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 Physicaland Mental Effects
of Psychoactive
Drugs

EighthEdition

Darryl S. Inaba, Pharm.D., CATC-V,CADC Ill

Director of Clinical and BehavioralHealth Services,Addictions Recovery
Center,Medford, Oregon
Director of Research and Education,CNS Productions,Inc., Medford, Oregon
AssociateClinical Professorof Pharmacology,Universityof California
Medical Center, San Francisco
Consultant/ Instructor, Universityof Utah, School on Alcoholism and
Other Drug Dependencies,Salt Lake City, Utah

William E. Cohen, CGACI

CNS Productions, Inc.™

Medford, Oregon
CNS Productions, Inc .™
Publisher: Pau l J. Stein b roner
11 Almond Street
Medford , OR 97504
Tel: (800 ) 888-0617 · Fax: (541) 773-5905
Web Site: www.cnsproductions .com
E-ma il: info@cnsproductions.com

Uppers, Downers , All Arounders, Eighth Edition

© 2014 Darryl S. Inaba
First Edition © 1989
Second Edition © 1993
Third Edition © 1997
Fourth Edition ©2000
Fifth Edition ©2004
Sixth Edition ©2007
Sevent h Edition ©2011

Editors: Ellen Cholewa and Eliza beth van Radics

Book Design and Illustrations: Impact Publications/David Ruppe , Medfo rd, Oregon
Cover Design: Don Thomas Illustration , Ashland , Oregon
Printing and Color Separations: Cedar Graphics , Cedar Rapids , Iowa
Co-writer , Chapter 10: Pab lo Stewart , M.O. , Clinica l Professor of Psychiatry,
Univers ity of California, San Francisco , School of Medicine

Special thanks to:

Add ictions Recovery Center , Medford , Oregon
Hassan Igram , Founder , Cedar Graph ics , Ceda r Rapids , Iowa

Disclaimer: The information in this book is in no way meant to replace

professional medical advice or professional counseling and treatment.

Publisher's Cataloging -in-Publication

Inaba , Darry l S.
Uppers , downers , all arounders: ph ysical and menta l
effects of psychoactive drugs/Darryl S. Inaba , William E. Cohen-8th ed.
p.cm.
Includes index
LCCN: 2014938512
ISBN: 978 -0-926544 -39-0
Psychoa ctive drug s-- Side effects . 2. Drug abuse -
Complications. I. Cohen , William E., 194 1-ll . Title

All rights reserved. No part of this book may be reproduced or utilized in any form , electronic
or mechanical , including photoc opying , reco rding, stori ng in any info rmation and retrieval system ,
or transmitting by any means without prior wr itten permission of the publisher.

Printe d in the United States of America

Uppers, Downers, All Arounders, Eighth Edition, is adoringly dedicated
to the creative genius of its co-author, William E. Cohen. Bill was
already established as a national Peabody- and Emmy Award-winning
video journalist when he teamed up with co-author Dr. Darryl Inaba
and producer Paul Steinbroner in the 1970s to create the educational
film Psychoactive. Like most professionals who are exposed to the
addiction field, Bill became immediately enchanted by the courageous
struggle and the miraculous recovery outcomes of those vulnerable
to the medical condition now known as substance-related and
addictive disorders. Most of all, Bill became fascinated by the evolving
science of addiction and recovery. He immediately went from that
first film to create the educational booklet by the same name, which
was the forerunner of this publication, now in its eighth edition. Bill
also became a Certified Gambling Addiction Counselor ( CGAC I) and
assisted several hundred individua ls struggling with this condition
into recovery man y decades before gambling was finally recognized
as an addiction by the DSM-5, published in May 2013. As clinicians
and educators fall in love with this field, William E. Cohen fell in love
with Uppers, Downers, All Arounders and dedicated his entire life to
promoting a better understanding of addiction and recovery

William E. Cohen
November 2, 1941-May 20, 2014
Key Phrase Highlights Key phrases are in boldface throughout the book
to emphasize the most significant concepts and to help the reader prioritize
the information . Chapter introductions and reviews, exercises, and most test
questions are based on these boldfaced phrases .

Study Guide and Glossary A study guide and glossary are available for
download from our Web site . More information can be found on the inside
front cover of this book.

Supplementary Material Visit www.cnsproductions.com for additional

content. Dr. lnaba 's weekly podcast, video blogs, a reader forum, useful links,
and other learning tools are regularly updated and available 24/7 . You can
access a video clip specific to each chapter using the QR (quick reference)
tags found on each chapter 's opening page.

Data and References Every effort has been made to incorporate the most
current and comprehensive information available at the time of publication .
Some of the research studies cited are conducted every 2, 5, 10, or in some
cases 20 years and are included to illustrate trends or because they provide
pertinent information that is not time sensitive . References are cited after
significant data presentations by numerical position in each chapter . These
are then available for download from our Web site by chapter where the
reference was cited .

Note: The registered trademark symbol ® distinguishes trade (brand) names

of prescription and over-the-counter drugs from chemical (generic) names.
Chapte r 1
PsychoactiveDrugs: Uppers
dassificationandHistory Introduct ion
::fi";':~~ ionofPsyd,oactiveDrugs C..nl!falClassification
General Effects
),fajorDrug< Cocaine
OtherDrug,andAddictions Smok>bl,Cocaine(crack . f=ba«,oxidado)
Amphetamines
~:i:c:o ~oactiv,, Drug s
Fh,eHi>toricalTh<meso/DrugU« t:t;.1~:i:~ ~!:'.:counter Stimulants
Prd>i>toryrndtheNrolithicPeriod Miscelbneou,PbntStimubnts
(8300 -i OOOB.C) uff<ine
Anci entCiviliz.:otion,(4000B.C. - A.D. 100)
TheMiddleAg<>(-400 - 1100)
TheR,nal,..nceandtheAgeofDi,;cov,ry ChapterReview
(1+00- 1700)
TheAgeofEnlight<nmentandtheUriy
lndu,;lrullR<volution(l700-1900) Chapter 4
TheTwenti<thUiltury
~::;;:,,";;,!omorrow
Downers:Opiates/Opioids
and Sedative-Hypnotics
Chapte<Review C..nl!falClassification -t.l
MajorO.pre,.,,mts i .l
MinorD<pT<Ssana
Chapte r 2
Prescription Drug Epidem ic
TheNeurochemistryand ~~i::~ ~o id,
the Physiologyof Addiction Cbmfication i.6
HowP!;yd,oactiv,,DrugsAffectl'eople Hi>toryofMethodsoll'« i .7
HowDrug,G<ttoth<Br>.in Twmti<th a ndTwmty-Fir>tCenturie,
The Nervous System Effect>ofOpioid,
Neuroanatomy Thaap,uticPainControlv. . Hyp,ralgesia
Phy,io logical R«pons«toDrug> Additiona!Complicatioru;C.us«lbyOpioid.s
FromExp,rimentationtoAddiction
~~ru1~:"::1ai:;E~~! didion Sp,cificOpioids
Theorie,ofAddiction Sed ative-Hypnotics
Her<dity. Env!ronment,P,ychoactiveDrug,
~:l:cation
~io~~~:;~~"' • ~~";'Mice
~!:~\~:! View of th< Addictive Proc<SS

Chapte<Review Oth<rSroativ<-Hypnotic, i .il

Druglnt<r.tctiom i .+4
PrescriptionDrug,andth<Phnmocrnticallndu,;tryi .+4
ChapterReview
Chapter5 5.0 Anticholinergic Psychedelics
(belladonna , henbane, mandrake, and
datura (jimsonweed, thomapple]) 6.20
Downers:Alcohol PCP, Ketamine, Salvia Divinorum, and
Overview 5.1 Other Psychedelics 6.21
Introduction 5.1 Marijuana and Other Cannabinoids 6.25
History 5.2 Chapter Review 6.46
AlcoholicBeverages 5.5
The Chemistry of Alcohol 5.5
Types of Alcoholic Beverages 5.5 Chapter7 7.0
Absorption,Distribution,and Metabolism 5.8
Absorption and Distribution 5.8 Other Drugs,Other Addictions
Metabolism 5.9 Introduction 7.1
DesiredEffects,Side Effects, Other Drugs 7.2
and Health Consequences 5.10 Inhalants 7.2
Levels of Use 5.11 Sports and Drugs 7.11
Low-to-Moderate-Dose Episodes 5.12 Miscellaneous Drugs 7.27
High-Dose Episodes 5.14 Other Addictions 7.30
Chronic High-Dose Use 5.17 Compulsive Behaviors 7.30
Addiction Heredity, Environment , and Compulsive Behaviors 7.31
(alcohol dependence,or alcoholism) 5.21 Compulsive Gambling 7.33
Classification 5.21 Compulsive Shopping and Buying 7.43
Heredity , Environment, and Psychoactive Drugs 5.23 Hoarding 7.44
Tolerance, Tissue Dependence, and Withdrawal 5.24 Eating Disorders 7.45
Directions in Research 5.26 Sexual Addiction 7.55
Other Problemswith Alcohol 5.27 Electronic Addictions 7.57
Polydrug Abuse 5.27 Conclusions 7.61
Alcohol and Mental Problems 5.27 Chapter Review 7.62
Alcohol and Pregnancy 5.28
Aggression and Violence 5.31
Driving Under the Influence 5.33 Chapter8 8.0
Injuries and Suicide 5.35
Epidemiology 5.35 Drug Use and Prevention:
Patterns of Alcohol Consumption 5.35 From Cradle to Grave
Population Subgroups 5.37 Prevention 8.1
Ethnic Populations 5.42 Concepts of Prevention 8.2
Conclusions 5.44 History 8.3
Chapter Review 5.45 Prevention Methods 8.7
Challenges to Prevention 8.15
Chapter6 6.0 From Cradleto Grave 8.17
Patterns of Use 8.17
All Arounders Pregnancy and Birth 8.18
Youth and School 8.27
Introductionand History 6.1
Love, Sex, and Drugs 8.34
Classification 6.3 Drugs at Work 8.46
General Effects 6.3 Drugs in the Military 8.49
LSD, Psilocybin Mushrooms, and Other Drug Testing 8.50
Indole Psychedelics 6.5 Drugs and the Elderly 8.54
Peyote, MOMA, and Other Phenylalkylamine Conclusions 8.58
Psychedelics 6.13 Chapter Review 8.59
Chapter 9 9.0 TargetPopulations 9.54
Men vs. Women 9.54
Youth 9.54
Treatment Older Americans 9.55
Introduction 9.1 Ethnic Groups 9.57
A Disease of the Brain 9.2 Other Groups 9.61
Current Issues in Treatment 9.2
TreatmentObstacles 9.62
TreatmentEffectiveness 9.6 Developmenta l Arrest and Cognitive Impairments 9.62
Treatment Studies 9.6 Follow-Through (monitoring) 9.63
Drug Abuse Treatment Outcome Study 9.6 Conflicting Goals 9.63
Treatment and Prisons 9.7 Treatment Resources 9.64
Principlesand Goalsof Treatment 9.8 Medical InterventionDevelopments 9.64
Principles of Effective Treatment 9.8 Introduction 9.64
Principles of Drug-Abuse Treatment Medications Approved to Treat SUDs
for CJS Popu lations 9.8 vs. Those Used Off-Label 9.64
Goals of Effective Treatment 9.9 Medical Strategies in Development to Treat SUDs 9.66
Selectionof a Program 9.10 The New Drug Development Process 9.68
Diagnosis 9.10 ChapterReview 9.69
Treatment Options 9.12
BeginningTreatment 9.14
Recognition and Acceptance 9.15 Chapter 10 10.0
TreatmentContinuum 9.18
Detoxification 9.19 Mental Health and Drugs
Initial Abstinence 9.20 Introduction 10.1
Long-Term Abstinence 9.20 Determining Factors 10.3
Recovery 9.21 Dual Diagnosis(co-occurringdisorders) 10.5
Relapse Prevention 9.21 Definition 10.5
Relapse Prevention Strategies 9.24 Epidemiology 10.6
Outcome and Follow-Up 9.24 Patterns of Dual Diagnosis 10.7
Individualvs. GroupTherapy 9.25 Making the Diagnosis 10.7
Individual Therapy 9.25 Mental Health vs. Substance Abuse 10.9
Group Therapy 9.26 Psychiatric Disorders : Pre-Existing
Treatmentand the Family 9.31 Mental Disorders 10.13
Goals of Family Treatment 9.32 Substance-Induced Mental Disorders 10.18
Different Family Approaches 9.32 Treatment 10.21
Other Behaviors 9.33 Psychopharmacology 10.24
Trauma-Informedand Trauma-Focused Care 9.34 ChapterReview 10.31
RecoveryCoach 9.34
Adjunctiveand Complementary References R.1
TreatmentServices 9.35
Glossary G.1
Drug-SpecificTreatment 9.37
Polydrug Abuse 9.37 Index 1.1
Stimu lants (cocaine and amphetamines) 9.37
Tobacco 9.39
Opioids 9.4 1
Sedative-Hypnotics (barb iturates and
benzodiazepines) 9.43
Alcoho l 9.44
Psychedelics 9.46
Marijuana 9.46
Inhalants 9.48
Behavioral Addiction Treatment 9.48
 Sean Assariti, an advocatefor legalizing marijuana, makes thefirst
purchase at a dispensary in Coloradoof an eighth of an ounce (about
$60.00). In 2012, the people of Colorado (and WashingtonState) voted to
allow sales of marijuanafor recreationalpurposes.Another 20 states
allow marijuanafor medical purposes with a physician-approvedcard or
license. The ramificationsof this action on the "War on Drugs" will befar
reachingin terms of less overcrowdedjails filled with people arrestedfor
possession,driving under the influence,drug-freeworkplaces, tax
revenues,and a more benign attitude toward all drugs.
© 2014 Theo Strogmer/Getty Images
 Psychoactive Drugs:
Classification
and History
Th,lirstpanofCh•pta!d .. ,ifi<Spsychoactivedrugsandb<havionladdic-
ti<m, by th<iTg<n<TIIIphysic • l • r.d m<n'11 eff«tsa OOS<oonduily by th<ir ch,mis-
try. Th< thr,e main divisionsu, uppen , down<n, md all • round= .
• The 0tt0nd p•n oF Chapter l <nmin« th< hi,tory oF psydtoactive drugs • nd
b<h:r.iorllladdictions,focusingon t h< impactth<><edrugsrndb<h•viouhav<had
onthe>oeial,eoonomic.andgo, ,emmen l.>llabricol50Ci ety

Diodoin-. B<cam<drugef- Definition

r«adqxndon•moun1,fr,.
quer.cy, rnddur.ttio nofuS< a,;
w<ll a,; the makeup of the "Ap"f<l.oac6.,M"tJi<o'"jwbotaoc,tl.it~ •l,,ovt;,ct.J01roo,ot
uS<r.r<action,topsychoac- [rflri><li>o>ci<n!if,:pop,r.·
; :,ubs wi c .. can varynd '- ,,_,.,,
,....,,_..._.,.
_D_""'"""-...,,_,,ea,~,.-.,,.
,ot:
~y:,:nmfr:m"::~o=n Ap,ychoactivedrugi,any,ubs12nttthatdirtttlyalttnth<nonn.olfonctionil\l!of
~inin:=.•;~~
!;:'.;'j tht«ntralneneous,ysttm(CNS)
!ncn=.
. A,theundenundingof•ddicth'<bfllinproc<...,•
this definition mightbeexprndedtoinduderompul,ivebeh0>ioB(<.g. ,
drug,onthe bodyoho uld h< g:,mblingorlnternetg • m< pl •) inr,)th>t also• lta the br.tin
uS<donlyasgeneralguide-
linesrndnot absolutes,and Drug< can b, cl=ified in many w•y,, e.g., by th eiT purpo<e of us,, by th<ir vuiou•
nomeo,byth<irdferu
;;;,;::~!,i~
:7ru: con
- ClassificationbyPurposeofUse
• ln•ncientEgyptthephar.tohlwn,eopaidhisWOTkenwithbeatokeepthembuild -
ingt hepyra mid,
• Spani>hronq ui,udor,pro,idedc oca l<>.= toPeruvirnruotiv<>tokeepthem slav-
·ng ·n·' 'lvam'ne,
• lnjectionsolmorphinewrn,gi,,.n1owoundedooldienonboth,ide,;ofth,U.S
CivilW u tor<elieve pain rndro inciden t.1.llyto ca11><ruphori>
• Amphet>.mine, " "'"" hrnded out like crndyto WoTld War II piloa toerable them to
•1>.y•w•keonnightbom bingrum
• Steroid> were ,u ppli«l 10 Ru..i rn weightlifters >I th e 19'>6 Olympie< to boost thcir
confu!enceand,trength
 1 .2 CHAPTERI

I
Marijuana can be examined (A) as molecule, (B) as an exotic plant, or (C) as a source offinancing for insurgencies.
Moleculargraphicimage producedusingthe MidasPlus ® packagefrom the ComputerGraphicsLaboratory,UCSF.Microphotographof a marijuanabud courtesyof the U.S.Drug
EnforcementAdministration.Insurgentin Uzbekistanguardingmarij uanafield © 1990 Alain Labrouse.

• Marijuana joints are smoked by AIDS patients to control Classificationby Effects

nausea.
A more practical way to classify these substances is by their
• Video poker machines have been legalized in most U.S. overall effects: stimulation, depression, and psychedelic
states to supplement state budgets. reactions. There are other drugs that don't fall neatly into
In recent years the popularity of new psychoactive drugs one of these categories, and those can be defined by their
has exploded due to new technologies, the Internet, and the purpose, such as delirium for inhalants, mental balance for
proliferation of street chemists and their customers. Drugs psychiatric medications, and enhanced performance for
such as bath salts (synthetic methamphetamine-like drugs) sports drugs.
and Spice (synthetic marijuana-like drugs) are continually
reformulated to induce a legal high and to stay one step Major Drugs
ahead of detection by drug tests. The media's sensational re-
porting of outrageous acts committed by people under the
influence of one of these "new" drugs creates the perception
that the effects of these drugs are unique and raise the profile
of obscure drugs such as Salvia divinorum and kratom. The
truth is that almost all psychoactive drugs are either an up-
per (stimulant), a downer (depressant), or an all arounder
(psychedelic).
There are also inhalants, sports drugs, and psychiatric med-
ications that have psychoactive effects and do cause depen-
dency but generally not as rapidly or as powerfully as stimu-
lants, depressants, and most psychedelics.

Classificationby Chemical,Trade (®), Uppers (stimulants)

and Street Names (" ")
Psychoactive drugs have chemical names, trade names, and
street names.
• Chemical names are used to describe the molecular
structure of a psychoactive drug, e.g., C2H 5OH for ethyl
alcohol; new synthetic substances such as methylene-
dioxypyrovalerone (MDPD), a "bath salt," and naph-
thoylindoles (synthetic marijuana).
• Trade names are given by the pharmaceutical manufac-
turers, e.g. Xanax ® is the trade name for the chemical
alprazolam, and OxyContin® is for oxycodone.
• Street names evolve almost daily among drug users.
Each commonly used and abused substance may have
20 or more informal names. Examples include: "chronic"
and "medibles" for marijuana; "oxidado," and "crack"
for cocaine; super coke and cloud 9 for bath salts; and
"cheese" and "smack" for heroin.
Uppers (CNS stimulants) include:
• cocaine (hydrochloride, freebase, crack)
• amphetamines (Adderall,® "crystal" meth, speed)
• amphetamine congeners (Ritalin, ® diet pills)
• plant stimulants (khat, betel nuts, ephedra, yohimbe),
look-alike stimulants
• caffeine (coffee, tea, colas, energy drinks, chocolate)
• nicotine (cigars, cigarettes, smokeless tobacco) and de-
signer stimulants (bath salts)
• psychostimulants (e.g., ecstasy and other phenylethyl-
amines which can have psychedelic effects in addition to
methamphetamine-like stimulatory ones (see Chapter6)
PhysicalEffects
The usual effect of a small-to-moderate dose of uppers is
excess CNS stimulation that results in energized muscles,

increased alertness, insomnia, increased heart rate and blood
pressure, and decreased appetite.
Frequent us e of th e stronger stimulants (cocaine , metham-
phetamine , and bath salts) over a period of a few days will
deplete the body's energy chemicals and exhaust the user .
If large amounts are used chronically or if the user is extra-
sensitive, heart, blood vessel, and seizure problems can oc-
cur. Although tobacco is a comparatively weak stimulant,
the long-term health effects of smoking can be perilous
(e.g., cancer, emphysema, and heart disease). The Surgeon
General states that , "tobacco is toxic to each and every organ
of the human body."
Mental and EmotionalEffects
A small-to-moderate dose of one of the stronger stimulants
can make someone feel more confident, excited, outgoing,
and eager to perform. It can also cause a certain rush or
high , depending on the specific drug and the physiology of
the user.
Larger doses can cause jitters, anxiety, anger, rapid speech,
and aggressiveness.
Prolonged use of the stronger stimulants can cause extreme
anxiety, paranoia, anhedonia (inability to experience plea-
sure), mental confusion, and an induced psychosis.
Downers (depressants)
There are four categories of downers, or CNS depressants:
• opiates and opioids: opium, heroin , oxycodone
(OxyContin ®), hydrocodone (Vicodin ®), buprenorphine
(Suboxone ®), and methadone
• sedative-hypnotics: benzodiazepines including alpra-
zolam (Xanax ®) and clonazepam (Klonopin ®); barbitu-
rates such as butalbital; Z-hypnotics such as zolpidem
(Ambien ®); and others, such as ramelteon (Rozerem ®)
• alcohol: beer , wine, and hard liquors
• others: antihistamines , skeletal muscle relaxants, and
over-the-counter sedatives
PhysicalEffects
Small doses of downers depress the central nervous system,
which slows heart rate and respiration, relaxes muscles, de-
creases coordination, induces sleep, dulls the senses, and di-
Psychoactive Drugs:Classification and History 1.3
I
minishes pain and controls diarrhea. Opiates and opioids can
cause nausea, constrict pupils, and induce constipation.
Excessive drinking and sedative-hypnotic , or opiate/opioid
use can disrupt physical coordination, slur speech , cause di-
gestive problems, induce sexual dysfunction, and create tis-
sue dependence .
Downers in large doses or in combination with other depres-
sants can cause dangerous respiratory depression, over-
dose, and coma .
Mental and EmotionalEffects
Initially, small doses (particularly of alcohol) act like stimu-
lants because they lower inhibitions, which can lead to freer
and sometimes irresponsible behavior.
As more of the drug is taken, the overall depressant effects
dominate, relaxing and dulling the mind, diminishing anx-
iety, and controlling some neuroses. Certain downers can
also induce euphoria or a sense of well-being.
Long-term use of any depressant can cause psychological/
physical dependence and addiction.
All Arounders (psychedelics)
All arounders-hallucinogens or psychedelics-are sub-
stances that can distort perceptions and induce illusions, de-
lusions, or hallucinations. There are five classifications of
psychedelics:
• indoles : LSD and psilocybin mushrooms
• phenylalkylamines : peyote (mescaline), and psycho-
stimulants (phenethylamines), e.g., MOMA (ecstasy or
"Molly ")
• anticholinergics : belladonna, mandrake, etc.
• cannabinoids: marijuana, hashish, sinsemilla, and syn-
thetic marijuana (e.g., K2 and Silver Spice)
• others : ketamine, PCP, Salvia divinorum, nutmeg,
dextromethorphan, bromo-dragonFLY, lion 's tail, and
Amanita mushrooms.
PhysicalEffects
The physical effects from this class of substances are not as
dominant as the mental effects with the exception of PCP
 1.4 CHAPTERI
I
and ketamine, which act as anesthetics. Most hallucino-
genic plants cause nausea (at higher doses) and dizziness.
Marijuana increases appetite and causes bloodshot eyes. LSD
raises the blood pressure and causes sweating. Ecstasy and
LSD act like stimulants.
Mental and EmotionalEffects
Psychedelics distort sensory messages to and from the
brain stem-the mind's sensory switchboard-so external
stimuli, particularly visual, tactile, and auditory ones, are in-
tensified or altered (illusions). This process resembles syn-
esthesia, where the brain causes sounds to become visual
and sight to be perceived as sound . The brain can also trigger
imaginary sensory messages (hallucinations) along with dis-
torted thinking (delusions).
Other Drugsand Addictions
There are three other groups of drugs that can stimulate, de-
press, or confuse the user: inhalants, anabolic steroids and
other sports drugs, and psychiatric medications.
Inhalants (deliriants)
Inhalants are gaseous or liquid substances that are inhaled
and absorbed through the lungs. They include organic sol-
vents, such as glue, butane, gasoline, metallic paints, gaso-
line additives (STP®), and household sprays; volatile ni-
trites, such as amyl, butyl, or cyclohexyl nitrite (also called
"poppers"); and anesthetics, especially nitrous oxide
("laughing gas").
PhysicalEffects
Use results in CNS depression, causing dizziness, slurred
speech, unsteady gait, and drowsiness. Some inhalants lower
blood pressure, causing the user to faint or lose balance.
Because they are depressants, they can cause stupor, coma,
and asphyxiation . The organic solvents can be directly toxic
to cells in the lungs, brain, liver, kidney tissues, and blood.
Mental/Emotional Effects
Small amounts can produce impulsive behavior, excite-
ment, mental confusion, and irritability. Some inhalants
cause a rush through a variety of mechanisms. Larger
amounts can cause delirium and hallucinations.
Steroidsand Other Sports Drugs
Anabolic-androgenic steroids are
the most common performance-
enhancing drugs (PEDs). Others
include stimulants (e.g., amphet-
amines, ephedrine, and caf-
feine), human growth hormone
(HGH), human chorionic gona-
dotropin (hCG), herbal and
nutritional supplements (e.g.,
creatine and androstenedione),
and some therapeutic drugs (e.g.,
painkillers, beta blockers, and diuretic s) .
PhysicalEffects
Anabolic steroids increase muscle mass and strength. Pro-
longed use can cause acne, high blood pressure, shrunken
testes in men, and masculinization in women.
Mental/Emotional Effects
Use of anabolic steroids often causes a stimulant-like high,
increased confidence, and increased aggression. Prolonged
large-dose use can be accompanied by outbursts of anger
known as "roid rage."
PsychiatricMedications
Psychiatric medications are used to rebalance irregular brain
chemistry that has caused mental problems, drug addiction,
and other compulsive disorders. These are the most common:
• antidepressants: Celexa,® Prozac, ® Luvox, ® Zoloft, ®
Paxil,® Cymbalta, ®and Pristiq ®
• antipsychotics : Seroquel, ®Risperdal, ®Abilify,®Haldol, ®
and Zyprexa®
• antianxiety drugs: Xanax,® Buspar,® Lyrica® (off-label)
and panic disorder drugs (e.g., Inderal®)
The number of new drugs developed for the modification of
behavior and the alleviation of symptoms is an indication of
how fast the field of psychopharmacology has grown and il-
lustrates the emphasis on medication as a treatment strat-
egy rather than psychotherapy. These drugs are prescribed
more and more frequently despite the fact that the national
incidence of psychiatric disorders has remained fairly con-
stant over the past 40 years.
 Psychoact
ive Drugs:Classificat
ion and History 1.5

PhysicalEffects
"I believethis is a 900d time
Psychiatric medications produce a wide variety of physical for a beer."
side effects, particularly involving the heart , blood , and Franklin Delano Roosevelt
musculoskeletal system. Side effects and other adverse or after the 1932 repeal
toxic reactions from antipsychotic drugs (also called neuro- of Prohibition
leptic drugs) are especially severe.

Mental and EmotionalEffects "Onceqou cross that linefromthe strai9htsocietq

• Antidepressants counteract depression by manipulating
to the dru9societq- marijuana,then speed,then
the brain chemicals (e.g., serotonin) that elevate mood .
it's LSD, then it's heroin,et cetera-t hen qou're
done. We've9ot to take a stron9stand."
• Antipsychotics often manipulate dopamine to control
Richard Nixon meeting with Chicago mayor
schizophrenic mood swings and hallucinations.
Richard]. Daley, May 13, 1971
• Antianxiety drugs also manipulate brain chemicals, such
as GABA, to inhibit anxiety-producing thoughts.
"Penaltiesa9ainstpossessionof a dru9should
not be moredama9in9to an individualthan the
, I support
use of the dru9itself Therefore
le9islationamendin9federallaw to eliminateall
federalcriminalpenaltiesfor the possession
of up to one ounceof marihuana. "
Jimm y Caner on U.S. marijuana laws, 1978

CompulsiveBehaviors
"We'vetakendown the surrenderpa9 and
Behaviors like eating disorders (anorexia, bulimia, and run up the battle pa9, and we're9oin9to win
binge-eating disorder), compulsive gambling, sexual com- the waron dru9s."
pulsion, Internet addiction, compulsive buying/shopping, Ronald Reagan in a 1982 radio address to the nation
on federal drug policy
and codependency affect many of the same areas of the brain
that are affected by the compulsive use of psychoactive drugs
(e.g., norepinephrine , dopamine , and epinephrine). 'When that ~rstcocainewassmu9Bledin
on a ship, it maq as wellhavebeena deadlq
PhysicalEffects
bacterium,so much has it hurt the bodq,
The major physical effects of compulsive behaviors are the soul of our countrq."
generally confined to neurological and chemical changes in George H. W Bush, Inaugural Address,January 20, 1989
the brain's survival pathway, also called the reward/rein-
forcement pathway or the reward control pathway. Eating
disorders are the exception because excessive or very lim- "WhenI wasin En9land,I experimented
ited food intake can lead to cardiovascular problems, diabe- with marijuanaa timeor two, and I didn't likeit,
tes, nutritional diseases, and obesity. and I didn't inhale,and I nevertriedit a9ain."
Bill Climon in a reply to a question about
Mental and Emotional Effects his drug use , 1992

The development of tolerance , psychological dependence,

and withdrawal symptoms exists with compulsive behav- 'When I wasqoun9and irresponsible,
iors. The compulsion to gamble or to overeat is every bit as I was qoun9and irresponsible."
strong as drug-seeking behavior. George W Bush in a reply to reporters
asking about his drug use, 2000

"Muchof the rootcausefor violencethat has been

happenin9herein Mexico,for whichso manq
Mexicanshavesuffered,is the demandfor ille9al
Introduction druasin the UnitedStates,"
Barack Obama , during sta te trip to Mexico , May 3, 2013

"[Prohibitionis] a areatsocial and economic

experiment,noblein motiveand far-reachin9 Although presidential attitudes toward drugs and alcohol
in purpose.
" in the twentieth and twenty-first centuries vary widely, the
Herbert C. Hoover in a lette r to William E. Borah, laws and the attitudes regarding substance use have as
February 28, 1928 much to do with the political climate at the time they were
I
lormul.ot«la,;theydowiththeactu•ldTectsofdrugsonth< an incnas<inth<crtttionan d th< abu!i<CoFpsyc!to=iv<
individua l and !iOCi<ty.The =ult : th< budget for tht U.S drugs (•nd romp u lsiv, bdw,iors) . The first two th<m<>u<
Wuon Drugs incre»ci From $3.7 million in l97l to $25.i inh=cnt in humEl beings. The Wt thr<< m, root«! in th <
billioninthe20Hbudg<t ,w ithS8%aimed atr<ducingth< mak<upofth,collur,
supp lyofdrugs•nd-U%atr<ducingthedemEldthrough
!:;'::'..~::n:::::nt .' Thi> figur<don not indudesute O H~n beings :a"'h;}u;,'."'•d. to ropt with their

Th,~in th<U>< olpsychoactiv,drug,since Pr<sidrnt Earlymanlivedin•cbng,ron,•ndmy,tuiou,environmmt

RichardNixonlaunch«lth,WaronDrugsinl971,ugg<>l5 Brut.ol w<>.thu. carnivorous pmi>ton , lif<-thrttt<ning phy,.-
thot>ttackingthe,upp lysideofdrugsthroughbwenfOTC <• ical di>a< .. , d<>potic rulen, and •ggre,•ive enemi .. cou ld
mentmd ' nfcfon h•• e ,,n tob<anunsucces' l wound , maim, OT kill Primiti>"< and e\"<ntu.olly chilized
stal<gy . Ex1rn,iv<r<5<1rchow,thepastl0to30y<2I'!lon hu monbeing,,hove• lw:1)"0..,. rchedfor way,; tocontro l or
how t hebnrin rnctstodrugsha,r<>u ltcdind<<p<Timighl5 run, out thesedongen. Ancientpeopl,o built the city of
intotherooaoladdictionaswella,rrrognition lhatd<- Juicho 10.(lOOy<>.ro•go,oth,ycouldgrow•nd control
Til2Ildrciuction(drug-abu., , rn,mtntandprn-<ntion) .. thcirfood,upply•ndprot<ctth<m .. N<>fromtheirmemi,o
a strategy is m<>Kdfective th•n •npply re duction(int<o- Theywor<hippedth<irgodo,pray!ngfordiv!neint<rvention
,·u· n,l•, • nd'ncarcer.u'on) tha1 would allow them to ,univ,. They fa,tro, chanted
medi t.ot<d. danced, practiced «lf -hypno.i,, inflicted pain
lnl013A11omeyGener> l EricH . HolderJr . • nnounced1hot
on them><h ... , wentwithout sl«p, rnd u .. d nondrug
low,levd . nonviolentdrugoffendmwithnotintogong>
methods to m:<iv, =d•tion, lrom the gods M B)' chance
orU.rge...,.Jedrugorga.niutionowillnolongerbechnged and b)' <Xp<riment>tion . theyfo undth>ting<Stingcerui n
withoffense,th> t iml"""O<V<T"<Trl2Il<U.tory=tmc .. pLl.ntscould,...,f,., and•nxi<ty,reducepain . tr<Ol!iOm<
(50'l;ol•llthoseinpru<>n • retherelordrugoffe=;oftm
illn<-,;,giveplearunc,md•pirituill)'corn><ctthnntoth<ir
thechargeim-olv<>po<><osionof<mall>mountsol • drug) god•. Ourmodemworldal!iOcrut<>f<n,,anxiety ,pa ins
illn<= . rndpainfulboredomthatc,nrompel•per!iOilto
-Yoo'""'"IA""rica"'8"'oloo• •"lljp,i>o"' fo,for u«p<ychoactivedrug,,tocontroltheirmv!ronmmt
too ""1j aM fo,""trulijsooJl""',ofo, w0<nt,,.,,.,.,
W,c.,nrot,.,,P"/pros,c"t,o,ioc oro:, raltowlWlj
roOfcon,;
"!l" "' /;,.., tion·
""'""""·
"'""">'I<""~--"
·"'"
Tofu ll)·•pp=:iot< theocopern d thei nfiuenceth>lp<ych o-
acth-edrug<•ndcomput.i, ,.l,eh•vi oroh>v,h>don<Oci<ty.
it i,n•~toeuminethehi>toryofth<><rnb< u nc .. •nd
beh>vion. Thi , i>the key to findingw:t)~ to treat addiction
onbothpe=iruolrndsock t.olle,,"<1'

FiveHistorica
l Themesof Drug Use

Proplethroughout history h>v,chowntoal t<rth<irpeo-

«ption 0Fr<1litywithp<ychoactiv, oub,tane<>wh<ther
u..dto• lt<r,t.otesofronoc iou,n, .. ,m:l ucepa in,fotj!<t
honh,urroundingo,• lt<r>mood . medic•t<•m<n l.Olilln<M
orenhanc e th esrn .. ,.Thekindofdrug . m<thodofu.se.oon •
,cq ,c<0, tr<C >tm<nt ,md ,ff · ,mt'onhave v.t·<d
lrom rultur<C to rultur<C and from cmtury to omtur)'
R,gardl<Moltheway,;th,drug,wueu..dorabu..d--beit Abo""""2nlnrMKal.i..,1i.5ow.1,Afti<4<mok01"""1)"""""i,l,o
6,000 ),.. " •go in M<SOpoLomi>(beer) or )... t<rdoy in New i,,,,,,l"r<-
YOTkCity (Lite• be<rl-- th, authors have noticed certain C>OO>
L,-.,a.,-~-"'"""""-
p•tt<rnothathave tr • nscrndedtim<•ndcultureandledto

Human brain chemistry can be affected by psychoac-
tive drugs, behavioral addictions, and mental illness in
ways that will induce an altered state of consciousness.
In fact, if psychoactive drugs and behaviora l addictions did
not affect human brain chemistry in a desirable manner (at
least initially), they would not be used. The chemistry of
individual psychoactive drugs has counterparts within the
central nervous system.
Drugs affect the primitive, or "old," part of the brain that
controls emotions, instincts, natura l physiological functions
(e.g., breathing and heart rate), emotiona l memories,
sensory perception, and physical or emotional pain. They
also affect the reasoning and decision-making centers of
the "new" brain, called the neocortex. Because mental
illnesses are caused by unbalanced brain chemistry, psycho-
active drugs have been used to try to control illnesses such as
depression and schizophrenia. The brain 's neurochemicals,
neurons, and structures evolved over hundreds of millions of
years, starting in invertebrate creatures such as insects and
snails and growing in complexity in vertebrate creatures,
especially Homo sapiens.
Discovery of the survival circuit (reward/reinforcement circuit), which
includes the VTA, lateral hypothalamus , amygdala , and especially the
nucleus accumbens, has helped researchers understand the roots of
addiction.
0 2012 CNS Productions, Inc.
€) Historically the ru ling classes, governments, and in-
dustry, along with crimina l organizations, have been
involved in growing, manufacturing, distributing, tax-
ing, and p rohibiting drugs.
The intensity of the demand for substances that relieve pain
and induce pleasure is matched by the struggle to control the
supp ly:
• monopolization of coca leaf growing by the Spanish
conquistadors in Peru to increase tax revenues
• excise taxes levied on whiskey, hemp, and tobacco to
finance the American Revolution
• sale of opium to China by Britain, France,Japan, and
other imperial powers to support their colonies
• drug trade by al Qaeda to finance terrorist activities
Psychoact
ive Drugs:Classification and History 1.7
I
The New York City deputy police commissioner watches agents pour
liquor into a sewer following a raid during the height of Prohibition.
Courtesy of the Libraryof Congress
• taxing of medical marijuana enterprises to offset
governmenta l budget deficits
• prohibition or restriction of alcohol, tobacco, opium,
and every other psychoactive drug by every country at
one time or another
• legalization of gambling in most states to control the
activity and raise revenues
0 Technologica l advances in refining, synthesizing, and
manufacturing drugs have increased the potency of
these substances.
Over the centuries cultures have learned how to:
• distill alcoholic beverages to higher potency (Arabia,
tenth century)
• refine morphine from opium (Germany , 1804)
• refine cocaine from coca leaves (Germany, 1859)
• use manufacturing innovations to increase production
(automatic cigarette rolling machine, United States,
1881)
• synthesize the stimulant amphetamine to create a re-
placement for ephedra (Germany, 1887)
• synthesize LSD (Switzerland, 1938)
• use the sinsemilla growing technique to increase delta-
9-tetrahydrocannabinol (THC), the main active ingredi-
ent content of marijuana (United States, 1960-1980)
• create cocaine/methamphetamine-like substances that
avoid detection (United States, 2009)
These and other techniques enab led drug users to deliver
more of an active psychoactive ingredient into the body at
one time . For example, the percentage of cocaine found in
coca leaves is 0.5% to 2.0%; in street cocaine it is often 60%
to 70%. Today marijuana contains up to 14 times more THC
 1.8 CHAPTERI
I
Hey,whats in this brew? It makes everything I draw a masterpiece!
© 201 I Dave Granlund
than did the street marijuana of the 1970s. 2 Research shows
that the more potent the psychoactive drug, the more rapid
the development of addiction.
0 The development of faster and more-efficient methods
of delivering drugs into the body has intensified the
effects .
Technological and pragmatic discoveries have taught users to:
• mix alcohol and opium for stronger effects
(Sumer, 4000 B.C.)
• absorb more juice while chewing a coca leaf by mixing
it with charred oyster shell (Peru, 1450)
• inhale nitrous oxide to become giddy and high
(England, 1800)
• inject morphine directly into the bloodstream (England,
1855)
• snort cocaine to absorb the drug more quickly
(Europe, 1900)
• smoke crack cocaine to intensify the high
(United States, 1975-1985)
• crush and inject time-release medications, such as
the opiate pain reliever OxyContin ®for a bigger rush
(United States, 2003)
• vaporize nicotine in electronic cigarettes
• vaporize alcohol and inhale the fumes
(worldwide, 2000s)
Societal and cultural changes play a role in new behavioral
addictions . Rapid-play poker machines, slot machines, and
online gambling have resulted in an increase in the number
of problem and pathological gamblers . Online games such as
Farmville, ®World ofWarcraft, ®and a thousand other digital
activities have captured the imagination of the Internet gen-
eration and created yet another behavioral addiction .
A close examination of the evolution of substance use finds
these five themes appearing time and time again . By studying
Electronic cigarettes deliver vaporized nicotine without unwanted tars
and smoke particles. Some smokers are using them to help them quit.
© 2014 CNSProductions,
lnc.
the recurrent yet progressive nature of drug use and abuse, it
is evident that solutions must change and adapt as society
changes and as science presents us with a clearer picture of
the reasons for craving and addiction.
Prehistoryand the NeolithicPeriod
(8500-4000 B.C)
Many of the drugs available today have antecedents in psy-
choactive plants that have been around for millions of years.
It is estimated that 4 ,000 plants yield psychoactive sub-
stances, although only about 60 are commonly used.
Opium poppies, marijuana tops, coca leaves, tea leaves, betel
nuts, khat leaves, coffee beans, tobacco leaves, and fruits or
other plants that ferment into alcohol have been the most
popular over the millennia .3
While there is some evidence that Neanderthals and early
man used plants such as ephedra (a stimulant) and alcohol
from naturally fermented fruits at least 50,000 years ago,
most of the evidence places serious use of psychoactive
drugs about 12,000 years ago at the start of the Neolithic
period. 4 This era, considered the last part of the Stone Age,
was marked by settlement into permanent villages, the use of
agriculture to grow crops, the raising of domesticated ani-
mals, and the transition from stone to metal tools.
The need for substances to subdue pain, heal illness, and
deal with fears of real and imagined dangers in the environ-
ment also spurred the development of spirituality and ulti-
mately civilization . This need to deal with the physical world
led to the development of Shamanism, which holds beliefs in
an unseen world of external and internal demons, gods, and
ancestral spirits who listen only to the shaman. The shaman,
a combination priest-medicine man, was the key figure in
these religions and functioned as a conduit to the super-
natural, using both naturally induced (e .g., fasting and
dancing) and drug-induced altered states of consciousness .
 Psychoact
ive Drugs:Classificat
ion and History 1.9

I
In his role as a healer, the shaman could perform the equiva-
lent of an exorcism or use some natural plant preparation to
expel what he perceived to be his patient 's inner demons . In
those days the "demon " might have been a mental illness ) lake not thyself helpless in dri nking in the
such as schizophrenia.
The use of psychoactive substances spread through tribal beer shop . For
l.-0°~f~f r~~t:f !g~
will no t the words of [thy ] report repeate d
migration. One assumption is that the earliest Native
Americans were Eurasians who migrated to the Americas
10,000 to 15,000 years ago over the frozen Aleutian Islands slip out from {
~ ~} withou
thy
::: t~{ ~~ :':1i~~
hast
}th)'. } {tha t thou
chain, bringing with them their customs, religions, and psy- mouth k.nowmg uttered them ?
choactive substances, like the hallucinogenic mescal bean
and sophora seed. 5 ,6
Falling down thy limbs will be broken, [an d]

AncientCivilizations
...JI.- = nnl.& lLJJ =o'<@
\\ 'J~i'!I o o I '-="'>
no one will give th ee{•h and [to help} as for thy
(4000 B.C.-A.D. 400) thee up]

Great civilizations grew and thrived where the land was fer-
tile, usually next to rivers such as the Tigris and the Euphrates companions in t he
r~~= r.~
. t--: 0

swilling of beer, they will get up -

in the Middle East (modem-day Iraq, Syria, and Turkey) and
the Nile in Egypt. The earliest crops were wheat and barley,
used to make bread and beer (beer was far more nutritious
in ancient times than it is today). 8 Asian civilizations used
rice as a staple food and to make wine (sake) . Some ancient
cultures cultivated the opium poppy and the hemp plant
(Cannabis) for medicinal purposes .
Alcohol
Throughout history alcohol has been the most popular
psychoactive substance . This food/medicine/drug has been
with us since prehistoric times. Perhaps hunger, thirst, or
curiosity made early humans eat or drink fermented fruits,
or perhaps they noticed the odd behavior of animals that ate
the spoiled fruit of the marula tree .'
The taste, the nutrition, and the psychoactive effects, par-
ticularly the drunken states that made them feel closer to
their gods , motivated humans to learn how to produce fer-
mented beverages themselves. 10 They collected honey to fer-
ment into mead, an alcoholic beverage; they cultivated grains
to ferment starchy foods into beer; and they cultivated grapes
and other fruits to make wine . These agricultural experi-
ments are the earliest signs of organized efforts to guaran-
tee a steady supply of a desirable psychoactive substance.
In 2004 and 2005, inJiahu, China, archaeologists uncovered
evidence of the use of alcoholic drinks 9,000 years ago.
Residue in ancient pottery vessels from this Stone Age village
in China 's Henan province indicated that a fermented bever-
age of rice, honey, and fruit was being made at approxi-
mately the same time that barley beer and grape wine were
being made in the Middle East_ll
The first written references to alcohol were found on
Sumerian clay tablets from 6,000 years ago (4000 B.C.)
that were discovered in ancient Mesopotamia (now Iraq and
Iran) . They contained recipes for using wine as a solvent for
medications such as opium.
Many ancient cultures considered alcohol, particularly
wine, a gift from the gods . According to ancient mythology,
n~ n:::: o
~ l !J~¥ ~th isl\
and say, "'Outside with
l'='i-L..ll
drunkard."
The Egyptian hieroglyphicfrom 1500 B.C. advised moderation in
barley beer drinking as well as avoidanceof other compulsive
behaviors. Written Egyptian referencesto alcohol that date back to
3500 B.C. have been unearthed.
TranslationfromPreceptsof Ani, WorldHealth Organization.
Osiris gave alcohol to the Egyptians, as did Dionysus to the
Greeks and Bacchus to the Romans. 12 In ancient Egypt a bar-
ley beer called heh was a valued commodity and was given as
a reward to laborers building the great pyramids. Beer was
the drink of the workers, and wine was the privilege of the
pharaohs as evidenced by earthen jars in King Tut's tomb,
which noted the vintage (year) of the wine and the location
of the vineyard.
Rice wine was the drink of the masses in ancient China and
later Japan, but grape wine was more highly prized. In about
180 B.C., a gift of grape wine served as a bribe to get a civil
service job_B For centuries Judaism has used wine in reli-
gious and secular celebrations , including circumcisions,
weddings, and the Sabbath .
Because alcohol caused not only the desired effects but also
side effects capable of creating social and health problems,
most civilizations throughout history placed religious, so-
cial, and legal controls on the use of alcohol and other
drugs. Many of the 150 biblical references to alcohol include
a warning.
"Givestrong drink to him who is perishing,and wine to those
in bitter distress;let them drink and forget their povertq, and
remembertheir miserqno more."
Proverbs, 31 :6-7
 1.10 CHAPTERI

I
One of the earliest attempts at temperance (limited drink-
ing) occurred in China around 2200 B.C., when the legend-
ary Emperor Yu levied a tax on wine to curtail consumption.
Centuries later, during the Chu Dynasty (1122-249 B.C.),
the penalties for drunkenness were severe for the lower
classes, while the upper classes were given a chance at recov-
ery, not unlike current realities. 14
In ancient India religious hymns (Vedas) cited alcohol as the
cause of falsity, misery, and darkness while its favorable as-
pects were dismissed. And though many ancient Greek po-
ets, philosophers, and writers, including Plato, Homer, and
Aeschylus, drank wine all day, every day, warnings about ex-
cess use can be found throughout Greek literature. These
were reinforced with cautionary tales of battles lost due to
drunkenness. 15 The temperance of later Greek society em-
bodied in Dionysus (god of wine and fertility) gave way to This statue of the Minoan Goddessof Opium was dated back to
orgiastic drinking in Roman society, encouraged by Bacchus, 1400-1100 B.C. when discoveredon the island of Crete south of Italy
a more liberal incarnation of Dionysus. in the Mediterranean.Note the three opium poppies sculpted into her
crown, which are thought to mean she affects sleep or death.
By the fourth century A.D., heavy drinkers in Rome were led lrakliouArcheological
Museum(Heraklion)
through town by a cord strung through their noses. Habitual
offenders were tied with the nose cord and left for ridicule in
the public square. The political and moral swings from heavy
consumption to temperance, to abstinence, and back con-
"[Helen] dru88edthe wine with an herb that banishesall care,
tinue to this day.
sorrow,and ill humour. Whoeverdrinkswine thus druggedcan-
Opium not shed a singletear all the rest of the daq, not even though
his father and mother both of them drop down dead, or he sees
The other psychoactive drug that appears early in history
a brotheror a son hewn in piecesbeforehis verqeqes."
(10,000 to 12,000 B.C.) is opium. Ruins of ancient poppy
Homer, The Odyssey,IV, 221- 226, 700 B.C.
plantations in what is now Spain, Greece, northeast Africa,
Egypt, and Iran (Mesopotamia) are evidence of the wide-
Hippocrates, the "father of medicine," recommended opi-
spread early use of the drug. 18
um as a painkiller and as a treatment for female hysteria.
The process of extraction involved waiting until the milky Galen, the most prominent medical physician/researcher of
white fluid from the fresh opium poppy dried and turned Roman times and perhaps all of history, chronicled the many
amber; it was then boiled until it turned to a sticky gum, uses of opium.
which was then chewed. It was also burned and inhaled, or
mixed with fermented liquids and swallowed. Opium was "~sists poison and venomousbites, cureschronicheadache,
used both for its medicinal properties of pain relief, cough vertigo,deafness,epilepsq,apoplexq,dimnessof sight, loss of
suppression, and diarrhea control and for its mental prop- voice,asthma, coughsof all kinds, spittingof blood, tightnessof
erties of sedation and euphoria. 16 Because it was ingested breath, colic, the lilac poison, jaundice, hardnessof the spleen
rather than smoked, its bitter taste and the moderate con- stone, urinarqcomplaints,fever,dropsq[edema], leprosies,
centration of active ingredients limited the abuse potential. 17 the troubleto which womenare subject, melancholq,and all
pestilences."
Around 4000 B.C. the Sumerians in southern Mesopotamia
Galen of Pergamon, Antidotes, A.D. 129-217
cultivated the opium poppy along with barley and wheat,
their basic agricultural crops. 18 They named it hul gil, "the
In Rome the drug was so desired in A.D. 312 that hundreds
plant of joy." Early Egyptian medical texts referred to opium
of stores sold it and the excise tax on the drug provided
as both a medicine and a poison. Parents fed it to crying ba-
15% of the city's revenue. 18 The best opium was "thick and
bies to calm their discomfort and fears. In ancient times
heavy and soporific to the smell, bitter to the taste, easily
healers at the Temple of Imhotep administered opium to
diluted in water, smooth, white, neither rough nor full of
mentally ill patients in an attempt to cure them by inducing
lumps." 19
visions, performing rituals, and facilitating prayer to the
gods. The close relationship between drugs and mental ill- Cannabis (marijuana)
ness is referenced, researched, and utilized in treatment
Historically, Cannabis was known in many countries and lan-
throughout history.
guages: kannabis (Greek), qunubu (Assyrian), qanneb
Other ancient civilizations also employed opium to alter (Hebrew), and qannob (Arabic). 2° Cannabis was prized as a
mental states (to self-medicate). In The Odyssey Homer source of oil and fiber, for its edible seeds, as a medicine,
spoke about an opium mixture, called nepenthe, given by and as a psychedelic . Archaeologists found traces of hemp
Helen of Troy to Telemachus to banish unwanted feelings. fibers in clothes, shoes, paper, and rope dating to 4000 B.C.

This saddhu (Hindu ascetic) is making a beveragefrom Cannabis
indica. He grinds the leaves into a paste, filters out the remains of the
plant by pouring water through cheesecloth,then drinks the resulting
infesion. He uses the drink as part of his religiousbelief system for
meditation and concentration.He is a follower of the Hindu god
Shiva. Shivites believe in the use of this intoxicant though many other
Hindus do not endorse the use of Cannabis.
© 2000 CNS Productions, Inc.
in Taiwan, although it had probably been cultivated since
the Neolithic era several millennia before .20 -21 According to
legend, in 2737 B.C. the Chinese emperor Shen-Nung used
Cannabis (ma-fen) as a medicine and recorded the findings of
his personal experiment. A medical herbal encyclopedia
called the Pen-Tsao, written in A.O. 100, refers to Shen-
Nung's study of 364 drugs (including ephedra and ginseng)
and lists Cannabis as a medication as well as a substance
with stupefying and hallucinogenic properties.22
Over the centuries Cannabis has been recommended as a
medication for constipation, dysentery, rheumatism, ab-
sentmindedness, female disorders, malaria, beriberi, and a
dozen other maladies, including as a treatment for wasting
diseases. The Chinese physician Hua To in A.O. 200 recom-
mended Cannabis as an analgesic (painkiller) for surgery_23
India also held a benevolent view of the psychoactive prop-
erties of Cannabis. Almost 1,500 years before the birth of
Christ, the Atharva-Veda (sacred psalms) praised Cannabis
(bhang) as one of five sacred plants that gave a long life, in-
duced visions (hallucinations), and freed the user from dis-
tress . Other texts from India listed dozens of medicina l uses
for Cannabis, including calming soldiers' nerves in battle_H
Initially, use of Cannabis and its psychoactive resin was
reserved for the ruling classes and the military; the
lower classes were allowed to use it only at significant
religious festivals .
Psychoact
ive Drugs:Classificat
ion and History 1.11
I
In about 500 B.C. the Scythians, whose territory ranged from
the Danube to the Volga in eastern Europe, threw Cannabis
on hot stones placed in small tents and inhaled the vapors. 25
'The Sc~thiansthen takethe seedofthis hempand, crawlinein
underthe mats,throwit on the red-hotstones,whereit smolders
and sendsforthsuchfumesthat no Greekvaporbathcouldsur-
with the vapor,shoutfor
passit. The Sc~thians,transported jo~."
Herodotus, The Histories, 4.75.1, 460 B.C.
Around A.O. 200 writings by the Greek physician Galen de-
scribed hosts offering hemp to guests to stimulate enjoyment
and promote hilarity. 26 The hemp was probably mixed with
wine to increase its potency . In most ancient civilizations,
including Greece, Rome, and England, hemp was used pre-
dominantly as a fiber.
Mescal Bean and San Pedro and
Peyote Cacti (mescaline) in Mesoamerica
The availability of dozens of hallucinatory plants in North
and South America provided cultures with natural materials
for complex ceremonies overseen by shamans, who held
the same positions of spiritual influence as did those in
Neolithic times in Asia. The psychoactive mescal beans were
roasted and eaten during sacred rites, causing a sleepy
delirium that lasted for days. Half a bean, ground, chewed,
and swallowed, is sufficient to cause the delirium .3 Later,
cacti containing mescaline (San Pedro cactus) became
another ceremonial hallucinogen of choice. Stone carvings
and textiles depicting images of this plant were found at a
Chavin temple in the Peruvian highlands and date back to
1300 B.C. Other South American cultures, including the
Nazca and Chimu peoples, boiled the cacti for up to seven
hours and drank the potion to produce hallucinations and
communicate with the supernatural.2 7 Evidence found in
caves in what is now Texas implies ceremonial use of the
peyotl, or peyote cactus (which also contains mescaline),
3,000 years ago. 3 •22
Psychedelic Mushrooms in India, Siberia,
and Mesoamerica
Sacramental use of psychedelic mushrooms dates back
about 7,000 years . Cave drawings from the Neolithic era
discovered in Algeria show shamanic figures enmeshed in
mushrooms (possibly Psilocybe mairei), suggesting early sac-
ramental use. 28 In 1500 B.C. the Vedas of ancient India sang
of a holy inebriant that proved to be an extract of theAmanita
muscaria mushroom, also called the fly-agaric mushroom .
The active ingredients are ibotenic acid and the alkaloid
muscimole. The hallucinogen was called Soma, the name of
one of their most important gods. More than 100 holy hymns
from the Rig Veda are devoted to Soma.
"It is drunkb~the sickman as medicineat sunrise;
partakingofit strengthensthe limbs,preserves
the legs
frombreaking,wardsoff all disease,and lengthenslife.
Then needand troublevanishawa~."29-30
 1.12 CHAPTER 1
I
These are a few of the 200 Psilocybe mushroom stone gods that
survived the concerted efforts of Catholic missionaries to wipe out the
culture that used psychedelic mushrooms in sacred ceremonies. Some
date back to A.D. 100.
0 2008 Paul Stamets
Though the Amanita muscaria also grows in North America,
it was the Psilocybe mushroom that was preferred by Aztec
and Mayan cultures in pre-Columbian Mexico. 22 There are
more than 30,000 different identified species of mushroom,
but only 80 produce psilocybin and psilocin, the main active
hallucinogenic ingredients. Of the many psychedelic mush-
rooms, Psilocybe cubensis is the most widely used. 3 ,28
Tobaccoand Coca Leaf in Mesoamerica
The genesis of the plants containing stimulant alkaloids
(e.g., tobacco [nicotine] and coca leaves [cocaine]) dates
back 65 million to 250 million years. The bitter alkaloids
were the plants ' defense against dinosaurs, other herbivores,
and insects.
"Some scientistsjoke that dinosaursbecameextinct because
the majorit~of ve9etationthat the~ used to sustain themselves
becameinedibledue to the bitteralkaloidsand that the~starved
to death, showin9far the ~rst time that cocaineand ci9arettes
willkill~ou."
It was not until approximately 5000 to 3000 B.C., in the
Peruvian/Ecuadorian Andes in South America, that humans
began using tobacco. Over the centuries they drank (in solu-
tion), chewed, snorted, and smoked tobacco for religious
ceremonies and for the simulative effects. 31 It was also used
This Colombian carving
depicts a user's cheeks stuffed
with cocada, coca leaf mixed
with powdered lime.
Courtesy of the FitzHugh Ludlow
Memorial Library.
as an enema and swallowed as a jelly. Smoking was the pre-
ferred method of use for rituals, and the tobacco was stronger
than today 's milder leaves, causing intoxication. 32 Tobacco
was used socially and recreationally by both the common man
and the elite. It was grown and used only in the Americas un-
til Christopher Columbus sailed to the New World in 1492
and discovered its use and brought word back to Europe.
During the same time frame, tribes in South America
chewed the coca leaf for stimulation, for nutrition, and to
control their appetite when food was scarce. 33 The coca leaf
also increased glucose, glycerol, lactate, and pyruvate levels,
enabling the chewers to survive at the high altitudes of the
Andes Mountains (7,000 to 10,000 feet). 33A Burial sites un-
earthed on the north coast of Peru dating back to 2500 B.C.
contained bags that held coca leaves, flowers, and occasion-
ally a wad of coca leaves mixed with guano or ash and corn-
starch. These pouches are called a cocada, and were used for
chewing . The coca was interred with the deceased to facili-
tate the journey through the afterlife. Cocada chewing was
so common in ancient Peruvian culture that it became a
standard unit of time and of distance: one cocada equaled
the distance a person could walk before the effects of a sing le
wad wore off (about 45 minutes). Recent discoveries in the
Andes dating to 3000 B.C. have found evidence of complex
societies that chewed coca leaves for spiritual and medical
practices. 34 The use of coca persists to the present day as
evidenced by the existence (since the third century B.C.) of
hundreds of stone and wood sculptures of heads with cheeks
bulging from a wad of coca leaves.
The MiddleAges
(400-1400)
Psychedelic"Hexing Herbs"
"Double,double,toiland trouble;
Fireburn,and cauldronbubble.
Filletof a Fenn~
snake,
In the cauldronboiland bake;
E~eof newtand toe of froe,
Woolof bat and ton9ueofdo9,
Adder'sforkand blind-worm's stin9,
lizard'sle9and howlet'swin9,
Fora charmof powe1ultrouble,
like a hell-brothboiland bubble."
William Shakespeare , Macbeth, Act I, 1606
Centuries before Shakespeare 's witches brewed their concoc-
tion of animal parts, a number of plants were used to induce
psychedelic effects. Members of the nightshade family
Solanaceae that contain the psychoactive chemicals atro-
pine and scopolamine were the drugs of choice. These sub-
stances date back to ancient civilizations and were feared
due to their poisonous nature and their ability to cause hal-
lucinations and delirium. In the Middle Ages, the nightshade
varietals were sometimes used by medicine men and women
who were lat er accused of witchcraft. 3
 Psychoact
ive Drugs:Classificat
ion and History 1.13

I
• Datura (thornapple) was often made into a salve and ab-
sorbed through the skin. 30
• Henbane was referred to as early as 1500 B.C. in Egyptian
medical texts. It was used as a painkiller and a poison. It
was also used to mimic insanity, produce hallucinations,
and generate prophecies.
• Belladonna-also known as witch's berry, devil's herb,
and deadly nightshade-dilates pupils, causes inebria-
tion, and can cause hallucinations and delirium. It has
also been used to treat a number of physical illnesses and
dysfunctional mental states. 30
• Mandrake, or mandragora, is a root that often grows
in the shape of a human body and was used in ancient
Greece as well as in medieval times. Its properties are
similar to those of henbane and belladonna, causing
disorientation and delirium . Mandrake was consid-
ered an aphrodisiac in the 1400s in Italy, and a century
later Niccolo Machiavelli wrote a risque comedy called
Mandragola about seduction and infidelity.

Psychedelic Mold-Ergot (Saint Anthony's Fire)

Another psychedelic that has persisted through the ages is
found in ergot, the brownish purple fungus Claviceps
purpurea, which grows on infected rye and wheat plants .
The active ingredient in the fungus is ergotamine, which
contains lysergic acid diethylamide, the natural form of the
modern synthetic hallucinogen LSD. Ergot and its effects are
referred to in ancient Greek (Eleusinian Mysteries) and me-
dieval European literature . It was recognized as a poison and
a psychedelic as early as 600 B.C.
"Suddenlqthis new and devastatingair of plague descended
down upon the water,or it nested in the fruitsof
the field. .. the entire bodq was reddenedbq burningsores,
as when the 'sacredfire' [ignissacer] spreadoverthe limbs.
Throughout the insideof a person,so that it burned
all the waq down to the bones;completelqconfused
condition with fear and melancholia.
Roman Poet Lucretius (c. 94-55 B.C.) (6.1125, 1166 ff., 118311)
Over the centuries there were numerous outbreaks of ergot
poisoning. The population of entire towns, particularly in
rye-consuming areas of eastern Europe, went seemingly
mad, occasionally with great loss of life. In A.D. 944 in
France, 40,000 people are estimated to have died from an
ergotism epidemic. There were outbreaks as recently as 1953
in France and Belgium. Hallucinations, convulsions, possi-
bly permanent insanity, a burning sensation in the feet and
the hands, and gangrene occasionally causing a loss of ex-
tremities-toes, feet, fingers, and nose-were common. Less
dramatic was the use of ergot in small doses as a medication
in the Middle Ages to induce childbirth.
One of the outbreaks in A.D. 1039 is responsible for naming
the affliction Saint Anthony'.s fire. A wealthy Frenchman and
his son became afflicted with ergot poisoning and prayed to
Saint Anthony, a fourth-century saint who protects believers
from fire, epilepsy, and infection. Both recovered, and the
father was so grateful that he built a hospital in Dauphine,
Thisfifteenth-century painting by Matthias Grunewald shows Saint
Anthony being assaulted by visions of sexual licentiousnessand
savage animals, visions similar to those caused by the ergotfungus,
found on spoiled rye or wheat cerealgrasses. Ergotism was oftenfatal
becauseit led to gangreneand extreme delirium.
Courtesyof the MuseeUnterlinden,Colmar, France
. Reprintedby permission.
All rights reserved.
France (where Saint Anthony was buried), for the care of
sufferers of ergotism .
From Medicine to Psychoactive Drug to Poison
Theophrastus, a Greek philosopher and naturalist, charac-
terized the plant datura as a medicine at a low dose, a psy-
choactive drug at a moderate dose, and a deadly poison at
a high dose.
"One administersone drachma [of datura], if the patient
must onlq be animated and made to think well of himself;
double that, if he must enter deliriumand see hallucinations;
tripleit, if he must becomepermanentlqderanged;give a
quadrupledose if he is to die."
Theophrastus, Inquiry into Plants, 323 B.C.
Datura, ergot, opium, and most other psychoactive drugs
follow this pattern. Opium sedates and suppresses pain at a
low dose, causes euphoria at a higher dose, and depresses
breathing to dangerous levels at a very high dose .
Healers and shamans were well aware of the dose-dependent
dangers of most drugs and would experiment with various
 1.14 CHAPTERI
I
substances to find the correct dose to heal a patient or induce
a trance state. They lost quite a few patients in the process. A
similar danger exists in the relationship between the amount
and frequency of use vs. the liability for addiction. The more
powerful the psychoactive component itself, the quicker
addiction will develop.
Alcohol and Distillation
Even though techniques for distilling seawater and alcohol
had been around for thousands of years , it was not until the
eighth to fourteenth centuries that knowledge of the tech-
niques became widespread. The evaporation process was
used to raise the average alcohol content of a beverage from
14% to 40% .30 An Arabian alchemist known as Geber Oabir
Ibn Hayyan, A.O. 721-815), called the "father of the sci-
ence of chemistry ," is credited with perfecting a wine dis-
tillation method that produced pure alcohol, which he de-
scribed as "of little use but of great importance to science."
Further research was done by the Arabian physician Rhazes,
who described the process in his book AI-Asrar (The
Secrets). He called the substance al-koh .3 1 It took 300 years
for the process to become common in Europe, around the
time of the first Crusades .
Technical advances in cultivation as well as in distillation
made a difference in consumption. In the early days,
Christians celebrated their faith at banquets featuring wine
and bread; but as alcohol use became more and more of a
problem, less and less wine was consumed until it was used
almost exclusively in rituals.
Limiting alcohol consumption became a moral cause. Saint
Paul condemned the relaxed behavior excessive drinking
caused because it led users away from God. Paganism and
the use of psychoactive substances to communicate with
the supernatural gave way to a demand that faith alone be
used to understand God .
IslamicSubstitutesfor Alcohol
In the Qur'an, the holy book of Islam , few references are
made to wine and intoxicants . Wine is not used in any
Islamic sacraments and drinking is frowned upon . The
prophet Mohammed simply chastised a drunkard for not
performing his duties. Mohammed's brother-in-law, Ali, set
the tone for alcohol in later Muslim societies.
"He who drinksgets drunk, he who is drunk, does nonsensical
things, he who acts nonsensical/~sa~s lies,
and he who lies must be punished."
AlilB
Muslims avoided alcohol, substituting alternative psychoac-
tive substances . Opium for the relief of pain, both physical
and mental, was seen as an acceptable substitute. It was used
in Arab society as a general tonic; it supposedly eased the
transition to old age. In later centuries tobacco, hashish
(concentrated Cannabis) , and particularly coffee were em-
ployed as substitutes for alcohol to provide stimulation,
induce sedation , or alter consciousness . These substances
were also used medicinally .
Khat, a stimulant permitted by some Islamic cultures, was
originally cultivated in the southern Arabian Peninsula and
the Horn of Africa. It was used for long prayer ceremonies to
help the congregation stay awake (much like coffee). In A.D.
1238 the Arab physician Naguib ad-Din distributed khat to
soldiers to prevent hunger and fatigue; an Arab king, Sabr
ad-Din, gave it freely to subjects recently conquered to pla-
cate them and quell their revolutionary tendencies. 35
Historically, for most religions, alcohol per se was not
shunned but rather what alcohol made a drinker do .
Through the centuries temperance gave way to prohibition,
and objections to the debilitating effects of alcohol and other
psychoactive drugs gave way to bans on any substance that
could make one forget religious and moral duties.
Coffee,Tea, and Chocolate (caffeine)
For centuries the coffee plant Co.ffea Arabica grew wild in
Ethiopia; by the fourteenth century, it was imported to
Arabia and widely cultivated. Initially, people simply chewed
the beans or drank bean-infused water. During the later
Middle Ages, people began to roast and grind the beans,
which made a tastier, more potent beverage. It was also used
medicinally as a diuretic, an asthma treatment, and for head-
ache relief. It was not until 1819 that caffeine, the active al-
kaloid in coffee and tea, was finally identified by the German
physician Friedlieb Runge .
Approximately 60 plants, including the beans of coffee
shrubs and the leaves of tea bushes, contain caffeine (e.g .,
the cacao , mate, kola, and yoco trees and the seeds of the
guarana plant) .
Tea brewed from the leaves of the Thea sinensis (chinensis)
bush was supposedly used in China 4,700 years ago, in 2700
B.C., but the first written evidence of it dates to approxi-
mately A.D. 350. The cultivation of tea in Japan and the de-
velopment of tea ceremonies occurred about A.D. 800. Today
tea remains at the heart of social and religious ceremonies in
Japan and in a number of other countries. 36
Chocolate, refined from cocoa beans that grow on the cacao
tree, can be traced back to the Olmecs of Mexico (1500 to
400 B.C.). The Mayans (1000 B.C. to A.D. 900) were the
second people to cultivate cacao on plantations throughout
Mexico and the Yucatan Peninsula, followed by the Toltecs
and then the Aztecs. The beans were ground and used to
make a stimulating, highly desirable though bitter chocolate
drink (with foam). They were prized and used for barter: 4
beans would buy a squash; 8 to 10, a rabbit. The average
daily wage of a porter in central Mexico was 100 beans. 37
The Renaissanceand the
Age of Discovery(1400- 1100)
As exploration, trade , and colonization broadened in the 15th,
16th, and 17th centuries, Europeans encountered diverse
cultures and unfamiliar psychoactive plants which were
collected and brought home . Some of the most notable sub-
stances were coffee from Turkey and Arabia; tobacco, cocoa,
 Psychoactive Drugs:Classification and History 1.15

I
and coca from the New World; tea from China; and the kola
nut (chocolate) from Africa. To a lesser extent, these European
explorers, soldiers, traders, and missionaries in tum carried
their own culture's drugs and drug-using customs to the rest
of the world; e.g., tobacco to China from Portuguese sailors.
Urbanization, wealth, personal freedom, and fewer religious
taboos also increased the use of these substances .

Alcohol
Laws passed during this period that limited the use of alco-
hol were the result of the effects of overuse, particularly of
high-potency beverages. Those in power wanted to limit
alcohol's toxic effects and confront the moral consequences
of lowered inhibitions. Switzerland and England passed
closing-time laws in the thirteenth century . Scotland and
Germany limited sales on religious days in the fifteenth cen-
tury.15 These laws were aimed more at temperance than at
prohibition because controlled sales of distilled beverages
produced hefty tax revenues.
Europeans were not the only ones with well-established
drinking patterns. Many African cultures brewed wine from
palm trees or beer from maize and used it in rituals, as a
foodstuff, and for social interaction. When slavers ripped
Africans from their villages and sent them to America, start-
ing in the 1500s, the tribes of Whidah, Ebo, Congo, and
Mandingo brought many of their brewing techniques and
drinking rituals with them. 38 Some rituals remained, but
more often the changed power structure disrupted those pat-
terns. Slave ships and ships transporting missionaries to Following a centuries-oldtradition, this coca chewer carries his
non-Christian countries brought rum to cultures used to leaves in a pouch on his shoulder.The poporogourd in his right hand
drinking only beer and wine. Rum's higher alcohol content containspowdered lime that is mixed in his mouth with the coca to
often led to a disruption in the drinking patterns that had increasethe absorption of cocaine.
evolved over centuries and had rarely led to alcohol abuse. Courtesyof the FitzHugh Ludlow Memorial Library

Colonists in the New World found alcoholic beverages made

from maize (corn), cacti, tree bark, and pulque (maguey or
agave plant) and in turn facilitated the widespread use of
rum and whiskey, creating severe alcohol-induced health
problems for Native Americans.
Coca and the Conquistadors
The interaction between the Spanish conquistadors who
colonized Peru in the 1500s and the native tribes' use of the
coca leaf is one example of how the economic and political
needs of a country transformed the way a substance was
used. When the explorers/invaders arrived, coca leaf was
used as a mild stimulant and as a reward; it was also consid-
ered a divine substance, a gift from the gods. Some people
chewed throughout the day, much the way Americans drink
coffee. The leaf was only 0.5% to 2% of the alkaloid cocaine
and not especially toxic . Coca use was restricted by the elite,
but under the conquistadors it became a commodity and its
production increased more than 50-fold, as did its addictive
liability.39 •40
'The~ carr~ them [coca leaves]from some high mountains,to
others, as merchandiseto be sold, and the~ barterand chan9e
them formantillas,and cattle, and salt, and other things."41
Monardes, 1577
The conquistadors supplied their subjugated labor force
with coca to keep them hard at work in the fields and in the
silver mines located high in the Andes. They controlled the
Incas' coca plantations and planted new ones to ensure a
steady supply of leaves to keep the natives chewing-and
working-throughout the day. Production from so many
coca shrubs occasionally caused a glut in the market. 42 As
coca chewing increased, so did revenue from the trade.
About 8% of the Spaniards living in Peru during the six-
teenth century were involved in the coca trade, and they had
their own lobby back in Spain."
Although the tax revenues from coca helped finance the
colony, many Spaniards opposed its use on moral grounds_44
Even the Catholic Church was conflicted because although
the revenue was necessary to pay for missionary activities,
the Church was repulsed by the exploitation of the Incas and
questioned how chewing coca could convert anyone to
Christianity. 45
TobaccoCrossesthe Oceans
In 1492 Columbus crossed the Atlantic and reached the
islands of the West Indies, including San Salvador and Cuba.
 1.16 CHAPTERI

I
He noted the natives' use of tobacco or, as he referred to it in emperor's court, then among the people, and then actively
his journal, "certain dried leaves." Natives chewed tobacco or propagated throughout Asia. Rulers, governments, and
placed chopped leaves or powder on the gums. Eventually, churches believed tobacco to be harmful to society and
they learned how to smoke it in pipes, cigars, and ciga- mounted sporadic attempts at prohibition, but its use spread.
rettes.46 In North America straight pipes (war pipes, peace
pipes, and pleasure pipes later called calumets) were common. of
'The use tobacco is growinggreaterand conquersmen with
The Quiche Mayans and the Cuban natives preferred cigars. a certainsecretpleasure,so that those who have once become
accustomedtheretocan later hard/~be restrainedtherefrom."
Tobacco was widely used in rituals for planting, fertility, fish-
Sir Francis Bacon, 1620
ing, consulting the spirits, and preparing magical cures.
Shamans in South America used the toxicity of tobacco to
The danger of fire, large gatherings in tobacco houses dis-
induce trancelike states to awe their tribesmen. 47 Tobacco
cussing radical political ideas, and the abuse of tobacco by
was also used as a medicine for a wide variety of ailments,
the clergy led to vigorous attacks by various authorities in
including headache, toothache, snakebite, skin diseases, and
Europe, including King James I of England.
stomach and heart pains.
"[Smokingis] a custome lothsometo the e~e. hateful to the
'The people took certainherbsto take their smokes.The~ lit
Nose, harmefullto the braine,dangerousto the Lungs, and
them at one end and at the other chew or suck or take it in with
the blackestinkingfume thereof, neerestresemblingthe horrible
their breath that smokewhich dulls their pesh and as it were
intoxicatesand so the~ sa~ that the~ do not feel weariness."
of
Stigian smoke the pit that is bottomless."
James I, 1604
Bartolome de Las Casas, editor of the journal of Columbus's travels in 1514 48

The king's crusade against tobacco had as much to do with

The Spaniards and the British exported tobacco from their
North American colonies to Europe, where it was received
enthusiastically, originally as a medicine and later as a
stimulant, mild relaxant, and mild euphoriant. Sir Walter
Raleigh introduced "tobacco smoking for recreation" to the
court of Queen Elizabeth l. 47 In France tobacco was called
nicotiana after Jean Nicot, who described its medicinal prop-
erties. Portuguese sailors introduced tobacco to Japan,
where its cultivation began in about 1605. The Portuguese
also introduced tobacco to China, where it was highly re-
garded as a medicine. It was carried throughout China by
soldiers, then banned, and then taxed . It was in vogue at the
his contempt for the indigenous peoples of the New World
as it did with the immorality of smoking. He regarded smok-
ers as no better than Devil-worshipping savages. 31 He did,
however, understand addiction: "As no man likes strong
heady drink the first day ... but by custom is piece by piece
allured."
Pope Urban VIII forbade Catholics from smoking under the
threat of excommunication; the use of tobacco was, at one
time, also forbidden in Turkey under pain of torture and
death; and it was banned by Czars Michael and Alexis in
Russia with equally dire penalties. 47 Widespread covert use

·.. :.:.:: : ... X •

@'
@

• ===~,,S
-d
~oe,,,s,::,e;;;~
ii '1•
The use of tobaccoin a
number offorms predated
4' the 1492 arrival of

m
=u. -:_~-;-;::c •~ • - - . M• •

t: • J:B~ ij Columbus in the Americas.

~!fil1 ~-- - &3 iThis drawing of reclining

mi
0 - ~ -- •
Aztec smokers who seem to
HG] • •
0

o···
0
:i be getting highfrom their
= · -------.\
-·.:
•

1· - -:).._.: = ·· cigars was done by Ariel

Baynes based on the
originals reproducedin

'
Lord Kingsborough'.s
Antiquities of Mexico
(1843-1848).
.
Courtesyof the ArentsCollection,
New YorkPublic Libracy
 Psychoact
ive Drugs:Classificat
ion and History 1.17

I
by clergy, commoners , and nobility , however , defeated all
attempts at prohibition. Over the centuries the craving for
tobacco fueled by the addictive qualities of nicotine has
overwhelmed most calls for prohibition.
The economic power of the trade of a substance that was
both pleasurable and habit-forming was immediately recog-
niz ed and resulted in tobacco 's becoming a large source of
revenue for many governments , especially Spain and later
England and the United States .

Coffeeand Tea ConsumptionSpreads

Coffee and tea originally were perceived as drugs and medi-
cations and secondarily as social lubricants . An early English
coffee advertisement promised that the drink: "Closes the
Orifice of the Stomack, fortifies th e heat within, helpeth
Digestion , quickneth the Spirits , maketh the Heart lightsom ,
is good against Eye-sores, Coughs, or Colds, Head-ache ."37

Because it is hard to separate the actual medicinal benefits

of a psychoactive drug from the desirable feelings engen-
dered by the substance, coffee and tea drinking became The preparationof theriac,the ancientcure-all, is depictedin this
widespread in Europe, first among the wealthy classes and sixteenth-centurywoodcut.FromH. Brunschwig, Das Neu Distill er
Buck, Strasbourg,1537.
then , as supplies increased and prices declined, among the
Courtesyof the National Libraryof Medicine,Bethesda,MD
middl e and lower classes. Coffee became a favorite alterna-
tive to alcohol. In Amsterdam and London and later Paris,
New York, and Boston, it was consum ed in coffeehouses that
were popular centers of intellectual , political , and literary In 1524 Paracelsus (Theo phrastus von Hoh enheim) re-
discour se and news circulation. Tea was not common out- turned from Constantinople to western Europe with th e se-
side of Asia until Dutch traders introduc ed it in Europe in cret of laudanum , a tincture of opium in alcohol (with hen-
1610 and in America 40 years later. As its popularity grew; bane juic e, crushed pearls, coral, amber , musk , and essential
afternoon tea soon became the center of social interaction oils added). Laudanum was used as a panacea , or cure-all
and a ritualistic part of family life , particularly in England medication , including as a simple way to soothe a crying
and the American colonies. 37 child. Inexpe nsive and readily available , it was soon widely
used (and abused) across every strata of society, unlik e th e-
The other major source of caffeine , chocolate, was brought
riac, which for centuries was reserved for th e wealthy.
to Europe by Hernan Cortes after he sampled a beverage in
Laudanum was found in most home remed y chests.
Montezuma II's court in the Aztec Mexican Empire. The bit-
Paracelsus believed and widely promoted the idea that pain
ter brew of crushed, roasted , and steeped cacao beans was
relief and sleep were part of the cure for any disease, and he
thickened with corn flour and flavored with vanilla, spices,
medicated man y of his patients with preparations containing
and hon ey.
opium .45 A medicine that could kill pain and make one feel
Opium Returns euphoric was highly prized in every society.
Durin g th e Renaissance in the fifteenth and sixtee nth centu-
ries , the use of opium in medicin al concoctions returned The Age of Enlightenmentand the
to favor after the works of the second-century Greek physi-
cian Galen and the eleventh-century Moorish physician EarlyIndustrialRevolution
Avicenna became widely taught as part of medical educa- (1700-1900)
tion .75 Theriac, an opium preparation mentioned by both
physicians, was prescribed for a variety of illnesses, in-
The increased potency of refined forms of psychoactive
cluding inflammation, diarrhea, madness , melancholy,
drugs, new methods of use, and improved production
headaches, pestilence, nosebleeds , and anything involving
techniques , along with governments ' and merchants'
pain. Seventeenth-century physician George Bartisch called
economic motives, led not only to more users but also to
theriac "a highly praiseworthy , imp erial, royal, and princely
more mental and physical problems, including abuse and
medicin e.49
addiction .
'ThisTheriac used dailq servesold, cold, and enfeebledmen. DistilledLiquorsand the Gin Epidemic
It awakenssexual appetite and intercourse.It stren9thens and
Beer and wine had long been part of the European diet for
increasesthe manlq nature and brin9sjoq and desire."
both their nutritional and mood-enhancing prop erties. Old
George Bartisch, 1602 World beer was denser than modern brews , contributing
 1.18 CHAPTERI
I
B vitamins and other nutrients to the daily diet. Wine when
consumed in moderation was considered beneficial to health
and had some food value. Distilled spirits (about 40% alco-
hol) had little nutritional content and were consumed to
elevate mood or cause inebriation.
Gin was first made in Holland during the 1600s from fer-
mented mixtures of grains flavored with juniper berries . It
became popular throughout Europe; and after the English
Parliament encouraged the production, consumption, and
taxation of gin, urban alcoholism and the mortality rate
skyrocketed during the London Gin Epidemic of 1710 to
1750. The class-conscious British objected to the lower
classes having easy access to gin because they were the pro-
ducers of England's wealth and if they were drunk, they
could not produce. 50 The upper class also believed that
women who drank heavily gave birth to weak children,
thereby threatening the supply of strong young men for the
army and the navy.
The novelist Henry Fielding wrote that gin was the principal
sustenance of more than 100,000 Londoners. He predicted:
"Shouldthe drinkingofthispoisonbe continuedat its present
height,duringthe next20 ~ears,therewillbe b~ that time
ver~fewofthe commonpeopleleft todrinkit."
Henry Fielding, Enquiry, 1740
At that time one dwelling in six was an establishment serv-
ing and/or making gin. Production went from 1.23 million
The Gin Epidemic devastated London from 1710 to 1750, as illustrated by these 1751 engravings by William Hogarth. Gin Lane depicts public
drunkenness and the neglect of children. The companion print, Beer Street, shows a happier group of drinkers and implied that beer was a way to
drive gin out of vogue.
CourtesyNationa
l Libraryof Medicine, Bethesda,Maryland
gallons in 1700 to 7 million gallons by 1751. The Gin Act of
1736 imposed higher taxes and fees but had little effect on
reducing consumption. It was not until the passage of the
Tippling Act in 1751, prohibiting distillers from selling gin,
that consumption declined to about 2 million gallons.
The Gin Epidemic is an example of how unlimited avail-
ability of a desirable substance causes excess use. Only
stiff taxes and the strict regulation of sales brought epi-
demic consumption under control.
In colonial America rum was the chief medium of exchange
in the slave trade and, along with whiskey, one of the eco-
nomic mainstays. A farmer could produce 2.5 gallons of
whiskey valued at $1.25 from a 25¢ bushel of corn . The
product did not spoil and could be shipped easily.51 Around
1790 per-capita consumption of alcohol was three to four
times what it is today. When the federal government enacted
a tax on liquor to help pay off the federal debt, farmers in
western Pennsylvania resisted, leading to the Whiskey
Rebellion. The protests continued for three years until
President George Washington sent troops to quell the in-
surrection. This early conflict was one of the events leading
to the formation of political parties.
Tobacco, Hemp, and the American Revolution
John Rolfe, husband of the Indian princess Pocahontas, in-
troduced tobacco growing to the Jamestown colony in 1612.
After he sent the first shipment of Nicotiana tabacum
(Virginia leaf) to England, it supplanted imports from Spain
 I
rndothucolonialoutpom ." ·" Soontobaceob<cam,afi. chloroform in 1831. Using inh•Wlts r<crntion•lly was
nancialmainstayfo r th<southuncoloni<sandresurrect<d rom id, r,dacc,publeby th,middl, andupp<rclass,s,
thtJ•111<Stowncolony. Tobaccowo,;so importanttoAm<ri ca •ndbo thm enrndwo mrnp • rticipat<din"g:,,frol ics"b< gin -
that tobacco 1,._.,. rnd Oovm, .,.,,. U>cd •••capitol m otif ninginth< 18305. Wand<ringlectur<nwouldholdpublic
toppingthecolumn,supportingthedomeolth<U.S.Capitol gathering, called "<th<r frolics." wh<r< m<mb<rs of th,
building . Tobacco, • longwithrum a OOcontinrntolcurr<ncy pub!icprovidedent<ru.inm<ntlorthernd irnarbyinholing
(which wa.s not wonh much), helped firuonc<th< Amerian dinhyl <th<r or nitrous oxide to demomtrat< th< mind -
RevolutioraryW..r . • lt<ringprop<rtiesofth,., • g<nts
Jn l76iKingG,org,lllofEngl•nds,ntaprocwrul t ionto L..t<rinth,ninet«nthcentury.ther<finem,ntofvorious
America,nrouragingtheplantingofh,mp(rnotherimpor • hydrocarbons(fo,oillu, l,)in10,olo til,sol,<ntsincI<Ca«d
tontcropinth,Americanro
rope . H,mpi,anoth<rram<
lonies)topr0>id,EngiaOOwith
lorCannabi> wti,a, •plant
:i::a
•:;;:~
~h\"fi,~~o~~;' i.:~':"i::.:.
tlat could be inh.tled,
with a highfib.erront<ntthatislowinp,ychoacti>ecompo,
n,na . A,ingle,hi po fthaterall>cd l.OOOyud, olh<mp OpiumtoMorphinetoHeroin
rop,torigth,,.il,rnds,cur,1hecatj!o . Grorg,Wa.shington Asth, AgeofEnlight<nmrnt•ndthelndu,lria l R..olution
cul1ival<dh<mpalhi<Moun1V,monplantationrndrncour • brough tfonhsci<ntific advan« mrnts , changesinm<thods
"!!<ditsproductionasadome,ticsourc,ofrop,and,ails of drug us,, aggKSsive «onomk polici,s, and political <X•
forth,Oedgling U.S.Navy.Untilth,Chi l War. h<mpwu
::~~:: :opial<>spr<adandoft<n <>ea!Oledinto
th,South'ss,rond -latj!<>tcrop,lxhindcotton,butit t ook 0
slawlabortogrowh,mp,soitcelirotob<aprofitabl,
cropafta,mancipation Scient ificDevi! lopmenl!i
ln\804th ,G<rmanphannacl.s1Fried richWxrt~m<Tdi s-
Ether,NitrousOxide,OtherAnesthetics,
cowr<d a waytonfin<nw,phiYm(morphin,)fromopium
and Other Inhalants H,wa.sthe/ir,;tp,rsontoisolat<analkaloidfromanypl.ant,
E1her(all,d",wu1vitriol")wo,disco,.,r,d!n ll7~byth< whichisimporta ntb<cau,ealkaloidsar<th<actiwingrcii•
Spani,hchemis1Raymundu,Lullus,bu1ittook• lmost3-00 <ntsinmonyplant•bas,dp,ychoactivedrugs( <.g .. cocain<,
)=rslorP•racel.su,todisco,uthedrug',hypnotic<ff«a nicotin<,andc•ITein<) , makingmor,-ronc,ntratedloIT115of
•nd a nother200yeanforG=nanph),icianFriedrich •numb<rol drug,po,oibl<. Morphine is about 10 tilll<S
HoffmanntodevdopandUS<Caliquidformof<th<r,called mor, poten t than opium a nd ther,/or, • mor~ectiv, pain
anodyn<,Hananesthetic(in lHO) . ltwa.salsoU>cd•• • r<li<V<r. Opium had U>cd ., • painkillu during th<
medicine,adrink ,rndani nha l.an1,o f1<nforintoxi cation Am,ricanR<,.., lutio noryW ar!nth erig ht<rnthc,ntury , but
b,aus,itw:il5thoughttob< l<>,harmfulth>n •lcoho! itwumorphinetlatwll5u.sedinth, nin<tttn lhcen tury,
mostnotoblyduringth,Crim ,.. nWar(IB~J-IB'i6)andth<
lnh•lingag:,,(••oppo<edto,moking a drug)~•m•popu ·
U.S.ChilWar(li361 - l86~)
l.ara fterJos,phPriestl,ydi=w<Tronitrou so, cid<. OT"l•ngl,.
ingps,"inl776 . lapopnl •ritygr,wi nth<arly lSOO..Jt<r Thehigh<rpol<n cyo fmorphi nel<dto •m or<•npidd<vd -
Sir.;umphry D»y ,n~<>ted_thatoth".:,could=<:t'°i..'.:' opmrnt oftol,nnc< •ndtissn<d<p,nd<nc,thanopium
•ndth,nfonagr<ot<rchanc,cof•ddiction c i1 a t.ornod,
g:,,esu><dloran«th<siawe,r,al,od,.dop«l,inc luding o,,udos, mor, commorL " " r wart'm< us, ol morph'n<

Fo!l.,..·Ult <l,, pot,1;,.,1,.. ojSfrH""'P"ry

0.:.,llle«•,d>«,Ch<m ,c,land
Ph,IMcph>cal., hl<flyconum "'&l'ilt.--
O~.it. •Odi1<R,spin1ioo.o M""''"'1dt
(•17"\!t•b" )Titlt«am,orni,< l•pul,4_:'

n_,,,__
f.,,1,..,,,Jo,,ie,
Oo.iX __ ""-'add
,.._ t pa"h
~..,-
eo.,_,.

d l'rndlb.,,.Muooumd--

--.,, .__::_ _ __J ~'7.:::;~,:::;~:::g;;.~

 1.20 CHAPTER 1

I
and the subsequent creation of scores of dependent users
generated the phrase "the soldier's disease." Some historians
believe that the scope of the problem was overstated.
In 1874 at St. Mary's Hospital in London, C.R. Alder Wright
chemically altered morphine into diacetylmorphine, a sub-
stance two to five times stronger than morphine and better
known as heroin. In 1898 the German chemical and phar-
maceutical company Bayer began marketing Heroin® as a
remedy for coughs, chest pain, and tuberculosis. At one time
it was considered a possible cure for morphine addiction and
alcoholism. Brochures promised, "Morphine addicts treated
with this substance immediately lose all interest in mor-
phine." Not surprisingly, the greater intensity of heroin
caused a more rapid progression to abuse and addiction. It
was not until the twentieth century that heroin abuse be-
came a problem worldwide.

Changesin Methods of Use

Opium smoking was first introduced to China around 1500
by Portuguese traders, but it did not become common until
1520. Smoking opium quickly delivered greater amounts
of the drug into the blood (via the lungs) and therefore into
the brain, increasing the intensity of the effects . Because
the lungs have such a large surface area, excessive amounts
could be absorbed rapidly. Smoking also saved the user from
experiencing the unpleasant flavor of ingested opium.
Repeated use and dependence developed more quickly
through smoking, causing a vast increase in opium use in
China.
Injection and infusion had been used since the 1600s, when During the second Opium War in 1859, the British and Frenchsent a
several experimenters noticed that injecting an opium solu- squadronof gunboats to attack Chinas Taku Forts and came away
tion into a dog stupefied the animal quite quickly. 58 But it with a victory.
was not until the reusable hypodermic needle was invented Courtesyof the Vinkhuijzen Collectionof Military Costumes,NYPublic Library
in 1855 that drugs could easily be delivered directly into
the bloodstream, causing more-intense effects and over-
loading the brain. Some believe that French surgeon Charles
Gabriel Pravaz invented the hypodermic needle, but most deficit due to massive tea imports, the British insisted on
give credit to Scottish physician Alexander Wood. Tragically, their "right" of free trade. In 1839 Commissioner Lin Tse-
Wood and his wife became addicted to morphine because of hau, who had been appointed to stop the opium trade, de-
his experimentation." Injecting drugs with a hypodermic manded that the traders surrender the tons of opium stored
needle bypasses the body's natural barriers (skin, mucous in their warehouses. "The Wars for Free Trade," as the British
membranes, lung tissue, stomach acids, and intestinal walls) called them, or the "Opium Wars" (1839-1842, 1856-
that protect it from infection. 1860), as the rest of the world referred to them, were fought
to enforce the British right to sell opium to Chinese traders,
Economicand PoliticalDevelopments who bribed government officials in order to sell the drug to
By the late 1700s, China was considered a potentially lucra- all classes. 60 ,61 -62 England was granted greater trade conces-
tive trading partner, with many national riches, such as silk, sions, an unacknowledged right to sell opium, and the ter-
jade, porcelain, and especially tea, all ripe for exploitation. ritory of Hong Kong, which became a British colony.
Colonial powers vied for the right to sell opium in China.
The resulting addiction of many Chinese, the indignities of
The British East India Company grew opium in India to
China's defeat, and the unequal treaties imposed by Western
trade to China for silver in order to buy tea to satisfy
countries after the Opium Wars continued to complicate
England's obsession with the beverage. This complicated
China's relations with the West for more than a hundred
method of trade occurred because the Chinese government,
years. 63
which controlled the tea trade, would accept only silver as
payment. From Coca to Cocaine
By the early 1800s, China banned the use and the import of The transformation of the coca leaf from a bracing tonic to a
opium because its use was causing increases in crime, cor- powerful stimulant is another example of how refinement of
ruption, and addiction. Burdened by an unfavorable trade a substance changed its use and addiction liability. Until

1859th<l<.afv.,.,ch<W«lOTchopp<dand•bsorb<donth<
gumo,crttting a otimul.otorydf«toimiLutotha1of=..erol
rup,;of«pr<S>O.Aft<rAll~nNi<11UJ1ni!i0lattdthtalka-
loid rocain< from th< coca luF. th< rdir.«I whit< powda
chong,dth,mild,xdt<TI1<ntintoaninl<n«rushfollow«l
by«,u ticf«ling,and • pow<rfulphy,ical,timul.otionpu -
ticubrlywh<ninj«l<d,,moked,mon«l,oraboorb«lonth<
gumo . Vuiouom<dicalandcomm<rdzlapplication•popu-
l•ri«dth<pownfulotimulant.
Dr. KarlKollafoundthotcocain,wu a .,rongtopical•n<
thtticthatrrad<<y<<UIJl<I)"p<l'Oibl,ch<wa>nicknom«l
"Dr . CocaKolla " lorhisdi>cov,ry
T~:m.'.'."h\lch~~t AngdodM .::;ii i:"ddl«l his cocain<
Sigmundfttndpubliohtdhistruti..,,Oi,,,Coca,,ugg<st - mov<ment)intoth<tw<nti<thcmtury
ingth<drugb<us«ltocontrola<thmo . tocalmgamicdi!i0r •
d<r>, a< rn aphrodi,iK.rndtotr<atmorphin<rndaicohol
addica ... Fnudp,er><>nollyus«lcoc ain<tot<li<V<dq,=
,ion(rndforth<ruoh).H,wrot< • bouthi , crav!ngforth<
drngandhisf,.,-ofb<ingwithoutit.allth,whil,dm)ing
rn)·addiction
Thoughth,m:rnufactor<andth,,. l,of rocawin<andpat •
mtm«lid=•prndrapidly.•longwithwid<>pl'<.:ldbing<
u« and dqxnd<ncy, th<r< wa,; littl< wnning of th< n<!l"tiv<
ron«qutnc<,thotrouldr«ultFromu,ingtht«produca
lttook th<hind,igh tof a gm<r.Uionof • bu.,.,/orth<addic -
tiv< nalur< of rocain< to b, =:ogniz«l a nd ia widespt<Cad
rn,ibbilitycurtail«l. Th<d<>..elopm<ntolc rackcoca in< in
th<l980strignit«lth<probl<mowithlh<drug
Temperance and Prohibition Movements
Th,unoontro ll«l ac«ssibilityofrumandwhisk<yinth<
Vnit«lS<at<>inth<<ight<mth a r.dnin<t«nthe<cntoriesl«l
toincr<><robouaoldnmkmn<M.violmc,.andpublicdi,-
ruption.Asar<<ult,th<lirstT<mpaanc<mov<mmtinth<
Unit<d Stat« was sun,d around l78~ by Dr. B<njamin
Ru,h,anol<dphysicianandrrlorm<rwho" .. m<dagainst
ov<ru«of•lcoholbutadvocat<du,inglimit«lamounafor
h<.altht<Casons. Th,disu><conc,p tof• lroholismw aslirst
rrl<r<nc«linhi,,arlywriting,. "
"Stro"8l"l""';,"""'J«tm:1r><tha.!h,"""'J_Tl,,<k<tm:
1mof,, ,,,;,p,riok:.1110<r.ra,alrol,,,/,,,r1,jt,io/lu•ra"/X'n
""""'"~~atallhmt,a.,di•allsta,oru;·
Th< firstn.otionalt<mp,nne<organintion,th< Am,rican
Temp,r.tnc<Sodety.wascre • t<dinl826:itwas•upponed
bybusin,ssm,nwhon«d«lthtirwork<r-stob<!iOber a r.d
ir.dustriou , .'" Dyl830ther,w<r<morethrnl,000t<I11p<r • eoen..,ot.,._"'-'"''""'°"""'
mc,,ocietie>,butth<mov<menthodlit~<dfectonaicohol
I
uS<.Consumptionp,ak«linl830withaynrlypa-apita
romumptionof7.lgallonsofpureairohol(vs.l.Bgallons
today) . Consumption.,,., <till at mall -tim e high wh en
newly <l«t«l Pr,sident Ar.dr<w Jackson wu inougu rat«l
in 1833.promptingthepr<SidentO,ufftomovethecrowds
rnmding th< ev<nt onto the Whit< Houx lawn lor far of
drunk<nr<velasd<>troyingth<inl<rior. •·
ltv,..,notuntill8 3 lthat).l•inepaSS<d th<lintprohi bition
l.ow. \1/ithinlouryear,one -thirdofth,,ut<,hadl•wscon -
.. trollingthesa l,andtheu«olaloohol,andronsumptionfell
by tw o-thirds . WhentheCh-ilWars<art<d,th<Prohibition
mov<mentwass<all«l"n,ome,tate,·but 'ath<wn,th<
Women> Cru .. d, . th< WollUil• Christi•n Temp,r.tnc<
Union.andth<Anti-Saloon L<ague (1893) l«lth< Tem-
p<r.tne< movement (which lat<r became the Prohibition
. The first facility to
trat a lcoholi,mwuoper.«linMassachas<ttsinlMl
"Proltibi-onl~d,;,,,dnml,-n.,,,b.l,tnddoona..Ju,tod,,rl,
pb,u,.a..d<l<>«notcu,,j!.or<Y<n<li.,.oi>hj!"
,................,..,,..,:,.,,,,,
..."".....c..,.,.__
...,,._.., ,
OpiatesandCocaine inPatentMedidnes
and Prescription Drugs
Th,originalsrt~a,inAm<ricainth< 1600s brought their
hom,rem«li<>!romEngland.ThefirstU.S.pat<ntr<lat«lto
m«licin<w•sisouedin 17 13 in Prnnsylvonla.hene<th<
tmnpa1rn,m,Jicin,.Onc,Am<ricansbegrncrttting•nd
><llingth<irownr<m«lies.palrntm<dicines,.tur • t<dth<
h,aithconsciou,n«•ofth<publicfromth< !870.toth<
1930.. " Th<ris ing •cc<ptane<ol!i< ime<toupbindise»<,,
r,gardl,sso/th<accurxy,,pur!ro•ru<htolormubt<trut •
m<nts and cur,s_ Hundmlsof m«lication, w<r< off<r<d,
!iOTil<byphy,ici•m,,om,bystr<etchrmists,md,omeb)·
quacks. ,.
Ova-th<-eoun t<r(O TC)m«licine,!iOldarour.dth<tumof
th< twmtirth cmtury hod imaginativ< nam<>. ,uch"' ).\rs.
Winslow's Soothing Syrup (opium). Rogds Cocoin< Pil<
-
Bt; ld,,..,.<Ml.<u<41y1"•~•..:l<0<oli ""•"'""Aflrnbory,p,lilill"
,.,,. oio<ddiamo.-plt,.,"""f""""1d,l,,-.I, _
"'
 1.22 CHAPTERI
I
Remedy, Lloyd's Cocaine Toothache Drops, McMunn 's Elixir
of Opium, and Forced March (cocaine, caffeine)-all loaded
with alcohol, opium, morphine, cocaine, and/or Cannabis. 70
Needless to say, patent medicines were very popular across
every strata of society and were used to cure any illness, from
lumbago to depression, much like nepenthe, theriac, and
laudanum centuries before. Until the Pure Food and Drug
Act of 1906, the manufacturers of these tonics were not
required to list any ingredients or back up any claims .
People took these tonics, thinking they were benign medica-
tions rather than potentially dangerous substances.
"It ma~ strike~ou as strangethat I who have had no pain- no
acute sufferingto keep down from its angles- should need
opium in an~ shape. But I have had restlessnesstill it made me
almost mad.. .So the medical peoplegave me opium- a prepa-
ration of it, called morphine, and ether- and eversince I have
been callingit m~ amreeta... m~ elixir."
Elizabeth Barrett Browning , 1837 71
SEARS, ROEBUCK & CO., (Incorporated)
HYPODERMIC SYRINCES.
Drug hits that often included vials of cocaine and heroin and a usable
syringe were advertised in the drug section of the 1897 Sears Roebuck
catalog along with dozens of patent medicines that also contained
opium, cocaine, and marijuana.
Courtesyof the FitzHughLudlow Memorial Library
One of the finest poets of the nineteenth century, Elizabeth
Barrett Browning became dependent on opium and morphine
in much the sam e way that other middle- and upper-class
European and American women of that era did . Their male
physicians overprescribed psychoactive medications, par-
ticularly opioids , leading them to addiction. This physician-
assisted process is known as iatrogenic addiction . In fact,
the majority of addicts in the Victorian era were women. 72
Prominent women addicts included the writers Louisa May
Alcott and Charlotte Bronte and the actress Sarah Bernhardt.
Laudanum compounds and patent medicines were pre-
scribed for anemia, angina, depression, menopause, and the
vague complaint of neurasthenia, or nervous weakness.
Between 1860 and 1901, U.S. imports of opium rose from
131,000 to 628,000 pounds. In the mid-1880s there were an
estimated 150,000 to 200,000 chronic opium users in the
United States_73
Cocaine was almost as popular an ingredient in patent
medicines as opium . Its ability to counteract depression
made it commonly recommended by doctors . In 1887 the
Hay Fever Association even declared cocaine its official rem-
edy. It was available in drugstores, by mail order, and in cata-
logs. From the time of its original formulation in 1886 until
1903, Coca-Cola ®contained about 5 milligrams (mg) of co-
caine, or one-third to one-half of a "line. " Originally, Coca-
Cola®was sold as a brain tonic and an intellectual beverage
that was also supposed to ease menstrual distress .68 Today
the beverage contains caffeine and a coca leaf extract from
which the cocaine has been removed. Coca-Cola ®is still the
largest single buyer of Trujillo coca leaf. 59 It still uses the
leaves (with the cocaine removed) as flavoring.
The TwentiethCentury
From Pipes and SmokelessTobacco
to Cigarettes
Businesses and governments exploited and taxed psychoac-
tive substances, especially tea, coffee, alcohol, and tobacco,
by making them more readily available to the public . Tobacco
use is an excellent example of how refinement and manipu-
lation of a substance led to more-intense use, which in turn
led to greater dependence on the drug and subsequently
more damage to the body.
Historically, people used only small to moderate amounts of
tobacco-a pinch of snuff for the upper classes and chopped
leaf in the cheek or in a pipe for the lower classes. At the
beginning of the twentieth century, the market for cigarettes
(a more efficient form of use) was vastly expanded due to:
• lower prices resulting from automation (particularly
the Bonsack automatic cigarette-rolling machine,
invented in 1884)
• the cultivation of a milder strain that enabled smokers
to inhale deeply
• a plentiful supply of the new leaf
• widespread advertising
 I
Thefir,t-ou,w•rn ing,in theUnitedState>ofthehealth
hu.ml, of smoking~ issued •round 1945 by the M•yo
ClinicandechoedbytheAmerica.nC.ncerSocirtymdvari -
ou, h<.>lth a nd ph)'si ci>m' org:,nizatiom throughout th<
1950s.T hetob=industryridiruledhealthroncnns •nd

;;::~:~ •'°,!t•:~~t;.::,t~r:::,;,~c~ A~':r.::e

tobaccocomp>ni<Sweredenyingth<h<>lthhllmH a ndth,

~;:':rn;;::\i:_~~;,.i~:·
;;.";~"";;;::::,!
~:
rachedthebninmor,quickiythamregubrnicotin< .t here -
foreaddictingsmokenmorequickly
They•lsoformedtheTobaccolnstitute .t heindu,try•chid
politicallobbylnl964andl967,theU.S.SurgeonG<cner.,J
issued upon,, that concluded , "C igarett e smoking i, a
;::,~1(,iu!861)dai01td0>1t<a,~ « Jo. ,..,.,lloo1td"" healthh.uard."SmokingintheUnitedStat<>decre.,edin
the 1960s.rose duringthe 1970.,and then began•longde -
eo.,,,,,. a1,-.. L.t<
.,,at<'.Dnpu dine thotrontinue, today. h tookothu natiom longerto
heedthewami ng,,and a,•resul tth ereis a higherpuc<nt -
:!;,:i: l!':,"b.c";Jubt ion, smoking cig>t<ll<> a nd using

JB . Duk<,•NonhC.rolinacigmettemanu!.cturu . ex- Drug Regulation

ploitedthese a ndmanyotheTinnovatiom . Aftufivey<>~ As!iOCietie,'rnitude,to,...rddru g,•nd•lcoho l variedfrom
hi, mmul ,a le,;exploded lrom 10 million cig:urtte> to
totalaccq,tane<totemper.tncetoprohibitionandback
H4 million . Othumanuf:acturus,uch a,; RJ Reynold,
ogain,,odidthe l•wsandmlorcement.Bythebt<lSOO.,
joinedforuswithDuk<andcruted a monopolyBy\910
phy,ici>munderstoodtheaddictiverndh<.>lthli>bilitie,of
thecartelcontrolled86%ofthecigarrttetrade,leodingto a
opi>t<srndcoc•ine . butittook a nothertwodecad<>before
hn•kupolthetobaocojuggernautintoitscomponentprn, ,erlou, U.S.regub tion w...in iti>ted. Th,Pu r<eFoodand
~:il ~~l:r:uica.n Tobacco; Reynolds ; Liggett & Meyer,; Drug Act (1906) prohibited misbranded and • dnltaated
foods,dri nks ,anddrug,moving ininters tat<commerce,•nd
R.J Re}nold ,,C.me! • J,,-:,nd pion«m:lth< "mild" ciga- itrequimi•crumel•belingolingrediena . Th<S moking
rrtl< . In the 1910, thi, brand wa,; m.orkrted to women, DpiumExdu,ionAct(l909)encour:,gedthegradu•lreduc -
young prople, • nd thos, wh o ,..nttd to~ weight tioninwor ldwideopiumproductionand<>,entuallybanned
Although,ale,rontinucdto,kyrock<t,,moking=deemed ,mokingthedrug . Th>t ,. m<)"<:UCongre,,bann edtheim -
h>rmlul . GermElscientistswrote•bout•nep idemiologica.l pona tion of op ium not intended for medical use. The
connection betw«n smoking and lung cancer back in !w-risonNarrotic,TuAct(l9H)controlledthe,aleof
!f::-;:;~~i~~~<rm tion to smoking cigarette> was opium!iOtho titrould bemo nit ored bythe federa lgovem -
m<nt ." Althoughregu latioru;elimin.otedOTC»-.ibbilityof
opi>t<s•ndrocain,i n theVnit<dState,,t h<tightcontrolof

3:;,~=i~~t::J:'tq~,:;d:~
t;"'"'8
u.u,.,,.,,t""'cotic>.tlu.d<8'"''owo;,p,,=m"""
•ll•n pplieoencour.ogedthed<Ydopmmtof
drugtrade
a hugeillicit -

lnaddi tiontoth ehe • lth•nd !iOCialli •bi litiesolopilte,•nd

"'1ControlL,bl,_/,"'/>bj""f'<"°"'"""'mol:,,ayrr,ttt>" cocaine . regubt ionofth<>esubs12ncubec•m< •politic • I
conc<rnuu.seinc=damongpoorandminorityu11>1n
popul.otions . Headlin<>w•medof"m.oriju.na-smoking b-
lmpiredbythe,ucc""ofProhibition . anti,mokin glon:o
borer,;." "drug-crued Negroes ." and the "Yellow Peril"(•
redoub ledtheiTdfon,.Stal<>p>ssedl.ow,iprohibitingciga - referencetoChine.,immigrrntus,o/opium).F,aringrap<
rrtte, . buttheywerelargelyunenforc<.>ble a ndwererepe•led
by the l.ot< l 920..Bythel9JO.t> xe,oncigamte,,...r< •"! ~x!l.l l promiscuity. ruo~ona~,and stat< l<gi,!atu~ wm,
provid ing a rich oourcr of revenue fo, ,ate and fedaal gov-
ernments. money lh>t w:o, greatly needed during the
1t20 Th, Volstead Act implemented the Eighteenth
DepressionandWorldWarll
Amendment prohibiting th< 11UJ1ufactur<e• ndthe
Hollywoodcon/em,d a cenalngl•mourto,mokinga,•ndi - .. 1,ofany alroho licbnenge
mc<> watched'""' ligh t up on...crem. Cignette• ""'"' lt n Prohibition and the Volstnd Act "'"" repeal ed
distribut«lfrtttowldierodurin gWo ridWarll a ndthe
Koncrn War. By midcentury smoking was entrenched in IH J TheM•rihu.naT:u Actbann«ltherultivationand
Ameri c>n><>eirty theus,,ofCannabis,ati,a.
 1.24 CHAPTER 1
I
1963 The Community Mental Health Centers Construction
Act provided the first federal assistance for local
treatment of addiction under the cover of mental
illness.
1965 Drug Abuse Control Amendments prohibited the il-
licit manufacture of stimulants and depressants.
1970 The Comprehensive Drug Abuse Prevention and
Control Act , better known as the Controlled
Substan ces Act, was a response to the proliferation of 1984
drug use that occurred in the 1960s. 76 The act
consolidated and updated most drug laws that had 1986
been passed in the twentieth century. The Drug
Enforcement Administration (DEA) was created in
1973 and charged with enforcing the provisions of 1990
the legislation. The key provisions are:
• classify and control all psychoactive drugs
• limit imports and exports
• define criminal penalties 2000
Five levels were created based on a drug 's abuse lia-
bility, value as a med ication, history of use and abuse,
risk to public health, and political considerations . 1996-present
• Schedule I: Drugs with a high abuse potential
and no approved medical use , e.g. heroin , LSD,
peyote, psilocybin , mescaline , MOMA, and mari-
2008
juana
• Schedule II: Substances with a high abuse poten-
tial even though they have medical uses ; e.g., co-
caine, meth , opium, morphin e, oxycodone, and
methylphenidate (Ritalin®)
• Schedu le III: Substances with less abuse poten- 2010
tial ; e.g., buprenorphine , anabolic steroids, and
Marino !
• Schedule JV: Drugs that have even less abuse
potential , e.g., chloral hydrate , meprobamat e,
fenllur amin e, diazepam (Valium®), and the other
benzodiaz epines
• Schedule V: Substances with very low abuse po-
tential because of very limited quantities of nar-
cotic and stimulant drugs; some are sold over
the counter; e.g., Robitussin AC® (DXM) and
Lomotil ®
The drinking age was raised to 21 years .
The Anti-Drug Abuse Act strengthened federal ef-
forts to encourage foreign cooperation in eradicating
drug crops.
Crime Control Act regulated precursor chemica ls ,
allowed the seizur e of drug traffickers ' assets, and
controlled drug paraphernalia and money laund er-
ing.
Proposition 36 in California required a treatment op-
tion for first-time nonviolent drug offenders (drug
court).
More than 20 states and the District of
Columbia passed laws legalizing the medical use of
marijuana (four states pending).
The Mental Health Parity and Addiction Equity Act
classified addiction as a medical disorder that theo-
retically makes it eligible for insurance coverage,
but as of 2014 regulations had not been fully imple-
mented.
Senate Bill 1449 turns the possession of less than
1 ounce of marijuana from a criminal misd emeanor
into a civil infra ction.
This political cartoonfrom
1912 shows PresidentWoodrow
Wilson, as a doctor,consoling
his DemocraticParty about the
loss of incomefrom opium
importation because it was
going to be severely limited.
Tariffs and taxes on opium,
alcohol, and tobaccowere very
important to the government
budget and economy back then.
Courtesy
of the Libraryof Congre
ss

2013 The sale of marijuana in Colorado and Washington
State for recreational purposes is legalized.
2013 The federal government does away with many man-
datory minimum sentences for nonviolent offenders
in federal prisons, mostly minor drug-law infrac-
tions; about half of all federal prisoners are there for
drug-law violations.
Alcohol Prohibitionand Treatment
Between 1870 and 1915, one-half to two-thirds of the U.S.
budget was funded by liquor taxes, a reality that created con-
flict for a political faction, known as the Progressive move-
ment, dedicated to social reform and eliminating corruption
in government. Many in the movement believed that
Prohibition would weaken the control of saloons by big-city
machines. The anti-alcohol movement claimed that there
could be no compromise with the "forces of evil." There was
great debate over whether alcohol abuse was the result or the
cause of poverty; the majority deemed it the cause .
It took 13 months to ratify the Eighteenth Amendment
(Prohibition) in 1920, prohibiting the manufacture and the
sale of any beverage containing more than 0.5% alcohol. The
Volstead Act implemented the provisions of the amend-
ment. President Woodrow Wilson's veto of the bill was over-
ridden by Congress. During Prohibition cirrhosis of the
liver and other alcohol-related diseases declined dramati-
cally, domestic violence fell, violent crime dropped by two-
thirds, and public drunkenness almost disappeared even
though people routinely disregarded the law and drank in
speakeasies or made bathtub gin and beer.
Prohibition, called "the noble experiment" in the United
States, was tried with little success in Iceland, Russia, and
parts of Canada, India, and Finland.77
After nearly 14 years of political wrangling, Prohibition was
repealed. Americans had not changed their opinions about
This illustration of the founders of Alcoholics Anonymous-Bill W
and Doctor Bob-making a call on an alcoholic who still suffers has
been used in AA literature over the years. At present there are more
than 2 million members of AA in more than 100,000 groups around
the world. Almost half the members are outside the United States.
Courtesyof Alcoho
licsAnonymous.
All rightsreserved.
Psychoactive Drugs:Classification and History 1.25
I
the benefits and the liabilities of alcohol; they had simply
discovered that although Prohibition helped control a num-
ber of health and social issues, it was responsible for other,
equally serious problems. Just as important, most drinkers
didn't want to give up their alcohol.
Prohibition provided the opportunity for a new coalition of
smugglers, strong-armed thieves, corrupt politicians, crooked
police, and Italian, Irish, and Jewish mobsters to develop
an illicit, lucrative trade in the smuggling, distribution, and
sale of alcohol. After alcohol became legal again, this coali-
tion turned to other illicit enterprises, including expanding
the drug trade that handled heroin and eventually cocaine.
After Prohibition was repealed, alcoholism again increased,
though it took 20 years for per-capita drinking to reach pre-
Prohibition levels. Higher levels of alcoholism led to the cre-
ation of an organization to help alcoholics recover. Alcoholics
Anonymous (AA), a spiritual program that teaches 12 steps
to recovery, was founded in 1934 by two alcoholics, Bill
Wilson and Dr. Bob Smith. 78 Over the years AA has proved
to be the most successful support/recovery program in
history 79 As of 2013 there were 60,820 groups in the United
States (including prisons) with a combined membership
of 1,332,494. There are another 53,818 groups worldwide
with 705,902 total members. 80 Other "Anonymous" 12-step
programs help narcotics addicts (NA), marijuana addicts
(MA), overeaters (OA), gamblers (GA), adult children of
alcoholics (ACoA), and sex addicts (SA). There are more
than 50 other types of major 12-step groups operating
throughout the world.
The success of AA and its cooperation with researchers, phy-
sicians, and organizations like the National Council on
Alcoholism -founded by Marty Mann, who in 1940 was the
first woman to achieve long-term sobriety in AA-were in-
strumental in convincing the public as well as politicians
that alcoholism is a disease and not a moral weakness.
Marijuana: From Ditchweed to Sinsemilla
Although Cannabis was widely used in patent medicines that
were ingested, marijuana smoking was not common in the
United States until around 1910, when its use in Texas,
mostly by Mexican workers, was noticed. The practice
spread throughout the Southwest and the West.
The fear of Mexicans who smoked marijuana was used to
ignite passions surrounding immigration. In the 1930s the
Hearst newspapers ran an anti-marijuana campaign, refer-
ring to Cannabis as marijuana to make the drug sound more
foreign and menacing. The pressure to ban the drug escalated
when Harry J. Anslinger, a federal alcohol-regulatory chief
in search of a new mission after Prohibition was repealed,
chose marijuana as his new target. Anslinger used the fear
of rape and debauchery to bolster his opposition to the drug,
and in 1937 the Washington Herald quoted him as saying, "If
the hideous monster Frankenstein [sic] came face to face
with the monster marijuana, he would die of fright. 21
By 1936 marijuana was added to the list of "most dangerous
drugs" in 38 states, and in 1937 the Marihuana Tax Act
banned Cannabis sativa. The ban on growing and using
 1.26 CHAPTER 1
I
marijuana occurred despite its use in numerous medicines
for more than 5,000 years. Growing Cannabis in the United
States for economic uses was also effectively prohibited ex-
cept for a brief period during World War II when hemp fiber
for rope, paper, and oil was needed by the military.
In 1939 Fiorello LaGuardia, mayor of New York City, com-
missioned the New York Academy of Medicine to conduct a
study of marijuana and its dangers on 77 inmates who vol-
unteered to participate.
"Marijuanadoes not chan9e the basicpersonalitqstructure of
the indi,idual. It lessensinhibitianand this brin9saut what
is latent in his thou9hts and emotions, but it does not evoke
respanseswhich wauld atherwisebe tatall~ alien ta him..
From the stud~ as a whole, it is concluded that marijuana
of
is not a dru9 addiction comparableto morphine."
The LaGuardia Committee Repon, 194 181
The findings were mostly ignored due to World War II and
then due to political considerations.
'This statement [LnGuardia R~art] has a/read~dane areat
damaae to the cause of law en orcement. Publico(Fcialswill do
well to d.isre9ard.
this unscienti c, uncriticalstudq and continue
to re9ardmarijuanaas a menace whereverit is purveqed. ."
The Journal of the American Medical Association,
attacking the LaGuardia Repon , 1941
Unfortunately, the net result was the cessation of serious
scientific research on Cannabis for the next 50 years.
During the 1950s marijuana was mostly confined to rural
areas and inner cities in the United
States. It was glamorized by jazz musi-
cians and in the works of the Beat
The 1950s saw dozens of pulp novels warning of the dangers of drugs. The Beat poets
and counterculture writers of the 1960s reversed this trend by praising the use of
psychoactive substances.
and writers, chiefly Allen Ginsberg, Jack Kerouac, and
Gregory Corso. By the 1960s the Baby Boomer generation
dismissed the demonic portrayal of marijuana by the gov-
ernment and the media and embraced it as a symbol of
youthful rebellion against parents and authority.
As marijuana use increased, more-creative growing tech-
niques were used. Bags of fertilizer, watering pipes and tub-
ing, window boxes, and grow lights became hot items. The
price of marijuana in the 1960s was law ($50 ta $100 per
pound) as was the average concentration of THC, its active
psychedelic ingredient. It was not until the 1970s that the
sinsemilla growing technique (which increased the concen-
tration of THC) became widespread and the price skyrock-
eted (about $50 for one-eighth ounce). It is estimated that
up to 224 million people worldwide have tried marijuana in
the past year; it is cultivated in more than 120 countries. 82
Amphetaminesin War and Weight Loss
In a search for medications to treat asthma and respiratory
problems, the stimulant amphetamine was first synthesized
in 1887 in Germany and methamphetamine was created in
1919 in Japan, but it was not until the 1930s that they were
used therapeutically. Amphetamine was first marketed as a
decongestant in an inhaler under the trade name
Benzedrine. ® A popular song of the times was titled "Who
Put the Benzedrine in Mrs. Murphy's Ovaltine?" Other forms
were tried for the treatment of low blood pressure, narco-
lepsy, epilepsy, schizophrenia, alcoholism, and barbiturate
intoxication. 82 Its appetite-suppressant qualities were soon
recognized along with its calming and focusing effect on
children diagnosed with what is now known as attention-
deficit/hyperactivity disorder (ADHD). Ultimately, it was the
stimulating effects of amphetamine on the central
nervous system that became widely
recognized and exploited. The drug
was often used nonmedically to stay
awake, to increase confidence, or to in-
duce a high. These qualities were ex-
ploited during World War II , as Ameri-
can, British, German, and Japanese doc-
tors routinely dispensed amphetamines
(speed) to the troaps to fight fatigue,
heighten endurance, and "elevate the
fighting spirit." 83 Illicit-amphetamine
abuse increased during the 1940s and
1950s among truck drivers, workers per-
forming monotonous factory jobs, and col-
lege students trying to stay awake to cram
for exams.
Internationally, amphetamine use in Japan
after the war led to widespread abuse and
thousands of cases of drug-induced psycho-
 I
sis,a.stomofthedrugw<r<leftoverlromthewar . Byl9 55 first <Vidrnt •mong the ""ight -liftingcomp<titorsat the
ther, W<T<l million u«n, prompting th<J•pan<« go,.,m - 195'40lympics. Theu«ofanabo licandrogenicsteroid,,
m<nl to mount m at<r ··,prev<ni nmdt=tmrnt C2ID• •mphewnin«, and other p,rformance-<enh2ncing drug,
paign to stem th< epidemic ."-'" M=iv< amounts of •mph<t - b,c,m,wid«pre•d.Swimmingw:oson,ofth<hotbro,of
•mines W<T< di,p,rlSro during th < Vietnam War---;almost illegoldrugu.se
ll5millionubl<tsofD<xedrin,. • Thep ublicity,urround -
ingmariji.uno a ndh<roinu«inVi<tra.mobocur<dinfonruo -
tion conc<ming the wid<>pr<ad u,, of • mph<wnine,_ .,
lnth<\950,thedrug\ a pp<tit<-,uppr<<Ynt<ff<ctsl<dtoth<
11USsiveu.,of•mphewninea,adi<tdrug.lnl970,llbil -
lion pilis . tablru, md c•p,nle, conuining legal •mph<t -
•minesw,r,uk<nby6%to8%ofth<Am,ricanpopulation
Amph,umin< •nd m<th>mph<tamin< us< •lso fueled th<
hippi<mov<lll<Tlt•ndthe "Sum111<Toflov, " inl967 . As a
ractiontothe,uddenapand<du.seofth,sedrug,,Congr<., By 1968 the lnt<rn.otion•l Olympic Committ« defined
pass<d the Compr,hensiv< Drug Abu"' Prev,ntion and p<rformE1e<-nihancingdrugu«,list<dbann<d,ubstonce,,
ControlActofl970.lniti.olly,th<l<gi.la1ion~ith>rder mdb<gandrugt«t ing, Th<Na1 ioruilColl<gillt<Athl<1ic
tomanu!.ctur<andpr<>erib<•mph<tamin,sintheUnit<d As<Ociationb<gondrug1<,ting!8)'<.,,la1u . Bythattim<
Sut<s, butsltt<t ch<mists<t<pp<d in to fill the demand th<prolifaationof,,.riousstuoids . oth<rdrug,,uchH
"Cro55top,," smuggled from Mexico, wer, the me<t popular, hnm>n gro"1h hormone • nd <XOg<nou, <f}1hropoi<lin
but m<th.,.mph<umin< in powder or crystal fonn ("cnnk " or (EPO) , m underground <t<roid/drug network in w<ight -
"cry,tal") wm, •iso aVllii.obk Surting in 1983 th< U.S. f,d . liftinggym,,th<growing<0phisticacionof<tr<<tch<mi<l5,
aal gov<mm<nt paS>ro law, prohibiting pos=ion ol pr, - md th< grm<~h of OTC nulrition•I ,uppl<m<nt<-includ ing
cu=m; md ,quipm<nl for the production of m<th>mph<t - mdr0<t<n<dion<, gammo •h)'droxybutyr.u, (GHIi), •nd
•mine, dri..-ing the manufacturing to <,q,md to Maico •nd cre,otine-hadmultipli<d . Butth<wontwa,y<ttocom<
Asia, wh<r< •cc,.. to the pr,cunon wa,; <2>i<r. With the in -
cr,.,ing popui•rity of ·cf}~U l" m<th, • mon smokable fonn
ofthedrug,0><inc=.,d•sdid•ssoci.ot<dmrntal•ndphy.-
Sedative-Hypnotics
and Psychiatric
Medications
ie1lproblem.s
foundth>tthcycouldsynthesi%<m<die1tionsrath<rthan
Sports and Drugs rdy on plant <><tracts. S«lative -hypnotics, such • • bro-
mide,,chlonlhydme.andparaldehyd<.g •v<waytobarbi -
Th< mci<nt Olympic G•m<> (776 B.C. to A.D. J9i) in turate,_Th,firsttob<m.ark<t<dwa.sV<ronol " (barbi tal)in
Gn<e<,W<r<athle(ccomp iti 15f' dan<nonnou,·n -
190J;ph<nobarbi tol C2In<l0yanla ter,andeventuallySO
Au<ne<onlh<politial.r<ligious. a nd,oci •llif,of th,c!ty -
barbiturat<swereavail • bletoinduce,l«pandcalmanxi--
,tote,,ucha.sAthrns•nd Sparu.tha1mad,upth<Gr<<k
<ty. Th<iru«p<ak<dinth, 1930.•nd l9'IO,_lnhi<l9J2
Emp ir<e.Victo~b,c,mepolitie1 l tools1oh<lpon<•tot< • <- futuristicr,ovd,Aldou,Huxleypm:!ict<dth<wid,sprad
«rt dominance over the others. Th< Grttk philo,oph<r
u«ofdrug,tohdpon<fitinlo50Ci<ty
Pla1onot<dtha1a.s a =nltof1h<imporunc,ofwinning,
,ictoryin,poru<arn<dathl<t,smonthanjust a laur<I
wrr•thmdadulation . Villa.s.uxa<mption,,l•rg<sumsol
mon,y,•ndmiliuryd ,frnn,n twereju<t a fewofth<p,rks
•ward<dto",urs ." As•r<<ul t,<OTI1<comp,titorstriedto
enluntttheir•thl<ticprov,., .. byingestingsubsunceslik<
utracts of mushrooms , donkey hoo,..es, sh«p testicle,,
plan1Sttds.ormas,h-e•mount<ofm,at ." Such "doping"
proctice,w•nedo,..ertim e a,didth<import.mc,ofathl<tic
oomp,t't"om . unt"lth<n "n<t«cnlh•nc' ti thce ntu · ,
when othl<t<> •gain wer,c highly ="trd<d. A, th< KWUds
incre><Cd, <0didthewin-at-any-costatt itnd<
Thedi<cov,ryinth<l930>thott<stost<ron<couldincrtt«
mu5Cl<mH5op<n<d a P•ndora\box . ultim.at<lyl,..dingto lnB, ... ·rNrwWo,fJRm,urd,writt<nl6yurslat<r,Huxlry
drug -taint<dcomp,titionsanda,t<ri<k<atuch<d to many upr<5«dhi<m=<mrntth>tth<ph>rnac,utic•l=lncion
,porureoord,,particuiorly inba«ball,bicycling,track, ,.,.,.Jr,odyinprogr<M.occurring600y<ar<<arll<rlhElpr< ·
""ightlifting,md,wimming dictedinhi,orig!nalnovd

;;:, ~!~ld~~~~~:.::~=~~ -:i:r:.:'.:n7n!'t;:isn :a: Barbiturat<>W<n m,npr«crib«l in th< !~and \960,, cr<-
• ing m addictio n md ov,rdos, li>bility Mild<r tnnquilizen
 1.28 CHAPTER 1

I
like Miltown ® and other anxiolytics were developed as sub-
stitutes. 86Within a few years, benzodiazepines (a class of
anxiolytics) dominated the prescription downer market
because of their potentially lower overdose liability.
Benzodiazepines include Librium, ® Valium, ® Xanax, ®
Klonopin, ® Ativan, ® and Halcion. ® During the 1980s, 100
million prescriptions were written annually for sedative-
hypnotics. By the 2000s prescription drug abuse had spread
to every level of society.
truth serums, and as chemical weapons to disrupt the ene-
my's thought processes. Still others thought these substances
would enhance human thought, emotions, and spirituality.
"Don'ttakeLSD unless~ouare,er~wellprepared,unless~ou
arespeci{:call~preparedto 90 out of ~ourmind.Don't takeit
unless ~ou have someone that's ver~ experienced with ~ou to
9uide~outhrou9hit."
Dr. Timothy Leary, How to Go Out of Your Mind: The LSD Crisis, 1966

The recognition of brain chemical imbalances as the cause

of almost all mental illnesses spurred the development of
psychiatric medications (psych meds) in addition to seda-
tives and hypnotics. The creation of antipsychotics (e.g.,
Thorazine ®), lithium, antianxiety drugs, and antidepres-
sants (e.g., tricyclics, monoamine oxidase {MAO] inhibi-
tors, and, later, selective serotonin reuptake inhibitors
ISSRis] such as Prozac ®) led to a dramatic change in the
treatment of mental illness.
Research into the connection between mental illness and
psychoactive drugs also led to the development of medica-
tions to treat drug abuse and addiction, including those for
detoxification, long-term abstinence, and relapse preven-
tion (anticraving). The pharmacological use of newer psy-
chiatric medications became extremely common due to
a lower addiction liability than that of standard sedative-
hypnotics.
LSDand the New Psychedelics
Pharmacological developments led not only to synthetic de-
pressants, stimulants, and psychiatric medications but also
to new hallucinogenic drugs (psychedelics). LSD-25, a semi-
synthetic drug derived from the alkaloid ergotamine, found
in ergot fungus on rye grain, was discovered in 1938 by
Albert Hoffman of Sandoz Pharmaceuticals. Its hallucino-
genic properties were not revealed until he accidentally took
about two and a half times a normal dose (250
micrograms, in 1943.
"M~Yisual(:eldwa,eredand ew~thin9
appeared deformed as in a fault~ mirror .
Space and time became more and more
disor9anized and I was overcome b~ a fear
that I was9oin9out of m~mind, the worst
partof it bein9that I wasdear/~awareof
m~ condition."
Alben Hoffman, 1943
Dr. Timothy Leary's mantra "turn on, tune in, and drop
out" was embraced by the youth of the 1960s while infuri-
ating the establishment. Hoffman, who called LSD his "prob-
lem child," disapproved of Leary's advocacy of drug experi-
mentation as a way to alter the mind and gain insight.
Beginning in the 1960s, a flood of synthetic psychedelic
drugs and rediscovered natural psychedelic substances
like MDA, DOB, DMT, PCP, 2CB, CBR (nexus), peyote,
psilocybin, Salvia divinorum, and particularly MDMA
(ecstasy) were tried. These drugs, combined with the coun-
tercultural attitude of anything goes, gave a whole new
meaning to the slogan Better living through chemistry.
Methadone
In the early part of the twentieth century, physicians ap-
proached addiction as a medical problem and prescribed
morphine and other drugs to control opiate craving in an
effort to treat heroin addiction. By 1918 the federal govern-
ment considered drug use a criminal activity and prose-
cuted physicians who provided that kind of treatment.
It was not until the 1960s in New York that medical treat-
ment was tried again, using a long-acting opioid called
methadone, a drug developed in Germany in the early 1940s.
"Methadone maintenance" substitutes a legal opioid (meth-
The hallucinogen LSD
made a media splash in the
1960s as the public
debated whether to accept
it as a possible
psychotherapeutic
medication or condemn it
as a dangerous mind-
altering drug.

Due to Hoffman's findings, various groups, in-

cluding the psychiatric community, started ex-
perimenting with LSD and other psychedelic
drugs like mescaline from the peyote cactus
and psilocybin from psychedelic mushrooms.
They were considered a potential treatment for
mental illness, particularly schizophrenia, and
as a way to examine and possibly gain insight
into hidden memories and emotions. The U.S.
Anny and the Central Intelligence Agency ex-
perimented with them as mind-control drugs, as
odone)fo r onU!eplone(hcroln1ndothcrdWe n «!oplold
prucriptlont) .Mc tl>odoru:ls lcsslntcructhanherolnt...,b
addic:ll•e,whichmakesltvuyddlicultto&Othmu&h..ith-
dr,...._l. Am,rd!ng to the Ccmtr for Subwntt Abuoe
T1tttmerit.lnl0ll then,,...,. !,ll5bdllticsln471tata
that..,pplymethodonctoobou1284,608hctolrvq,ioldad-
di<ts,l9 .000i nNtwYon:Cicyalo r.e." World....ide1hcr<are

:!:~:'.'~=~~~~ha~:=
malnt<nanceP'<'l"""SwithanmrollfllCfltofmortthan
M0.000...
Th<origmalplsofmc1hadoncmalntCNn«w<ntomn-
trol1heilltploctM1lcsond1hcocldl<1Mbt:h,,'1c>Tofthe
h<min addict popubuion . At pra<11p1lon "l'lold ab.aw
ill<t'nK"d.,...,.. uoers IP'"• up heroin r..- Vkodm. • Jo/910,Elri<f'><>l<y,..,__.,_ • .,...,i,,-.,....
OxyC,,n1in.• andot.bc r prua-ipllonopiold1 . Mcthado1><lo io..i,1tttp..-,,..,..j,ttf-_...,l, ...... lll,_..,,,
ahouoedforpraclipllOfloplolddclO>lfutlonandmaln,.._ """-"-""'"""-"""'"'I--AIJW-.1,...,._,,, ..
nanr:,:.Sinal000bupm>01"phln<ma1n1<1W>CCIIUO<dm,c,n:
,..,.W.,.-'.tp•.'-1-•-s...,n,,"""""~
.lh-"'"""·'l'oxmi<p.,i.,-w.. .. o...,,..•u,uolinl,jo

oftenthanmcthadonc .
l.!ethadon, main<manco II an example of 01><of the urliat
hum r<ductlon procnms '""' ,.... taf1Ct<d to bcn<:~l IOd-
ety .. -n .. the oddict, Bccausc mc,!,adoflc i1 odmlnl•«mi
orally.thehazardsaosoc ll ~wi1hn.ccdlelnjcc1ioD-4U<h•
HIV/AIDS, hcpotitlsC,andb,,:m \allnr«uon,ofthel>an,
,,.in<,andothc•bodyl lsl u.,.._ r<gr<adydlmlnlshed
Heroin and Vietnam
ln1hell tc 1960,. and 1970.,U.S.tmops lnV letnamwer<
expo>ed1<> a floodofmmju.anaandoplumfmm,heGoldrn
Tri>ng!e(Myanmarlllurma] ,Laol ,andThalland).J.!<>11sol-
dicr,lnV'ietnam , mok«!maliju1na,butthey 1loouoedhc,..
oinbecau"'it"'"" osava!il hlc1nd11a1y10gtt uak ohol.
Anew1roupofhcrolnoddicuwuona1tdd ul1n1Amcrla,'s
i""ol-,-ementlnthcwar,butlll'ID£<ly1ha1lnor<cutwuno<
malntai.,.daftuthcG lsa, mchome .Thou ghhalfthciOl -
dicr, In V«tnamuptrtmcnltd with hemlnand 10'-.ofthOK
becameaddicU:d,only5"00flUnucdusi"3afttttM..u
:.::-::.hcl"OUl-..-uanonswc,10thc1trHS,On.<ltty.and
Preventing and Treating Drug Abuse
Ewn """'&h a!eoholi>mand dru1 abw.c hod bttn ,ttog·
ni=l•problcmaticforom,urlcs,mostlybyindhidualo
orsm&ll"""psofpiofeoslonals,i1WM1>otUntilthemid-
twmtiell,c,n1ury1ha,la'!CO!pDIZlllonsandptn1mmll
ac:~thcm•Knll\llmedicalc:ondlllonsand
ddm.daddiotionuad-.
• In 19ll th< World llulth O!pnizatiOfl a,lkd akohol-
..... •JCrious rn,dical probltm .
• In 19)6 the Amcncan Medical A11od11lon(Al.!A)colkd
alooholismoUUllblo!II,... .
• lnlffl1heAmclicanPsy<hia1l1<Alloolallon(APA)
bepndcKribin1olooholllffl • • uu11ble dllasc ;oya r
iat<?th<AMA"l!,Tttd'"1th1h<APA .
Con"rtodcfl"orutotua1 1ndpu"'nt1ko~llomonddn:11
addic:lionbegan!n1hcl970s\n,upoructothcpmllfemlon
ofdrupond drugu .. n, but the ponlouilrfoc:Uiw•on
,_,..
.....
mc.......,.,i.1911.
...,_,,
>p<al( amphctamin,.andmethamph<tamlnc,) ,Thcoc,:ond
dn:1gofco ncern wa,marijuor12.
At t<mp1Stoaddrno1heprob l<truofobu .. , odd!c1!on,1nd
crimefocw.edon thr,e,u-ateg!u:
• :.. ~;-du<1ion - prcv<tHionac:1MUaoo upltdw!th
• ouppl y Tcduction - interdiclionof1upplioplu.om1<:ter
lo..-.roncerninguse
• 1>armr<ducti on-medicalor,o,:;io l tecl,niqu.,torcd11<:c
thephy,icaland""-"Wdomag,cauoedby abuscanddc•
pendence(e.g.,methadonemain~noc.f1ttnccdled! s-
tribution,andu:mpenne,)
."' In 197ltheU . S.gottmmentbunchcdtho •V.•arOfll>Np. "
,oinitially(and"'uthelong•t<nn)m1,>1ofthefcdcral
funds...uefwmtkdintosupplyr<du<1i0<1.0apUethcln •
~~n: .. dalicaltd1<1,:ombati"'dnJc •bus<.thcal·
kx:ationof-,r,ey...,..oh,nbned1110ttonpolillcalupcdl•
...._.,.thanonth<dlicacyolthenrio"'apprwobcs,
ow,- the"""'' thrtt decadle,, ,-uio ... demand rcduc:tion
.uatqxs-indudingrrinfotcingbord,n,proridin1mllu ary
aidtodrug~rtingrountrlcs,andavastcspontlonof
draglaw.andh<rn<r..,.t<ncingJUidelinet-didhavean
dl"ectonll,elewkofdrugalHHcandaddic:"°" . Thcdemand
fordmpffDWnedbigh,how ....... and""'"Urn,newmo,h•
od, of,mugling and IDOl'C-oophisticaled manWac:tulinc
anddi,u;butionchannel,Kpknioh,dthe ,upply.
Al=.an:h 6ndinp...-tt< rompikd ,1t>oh • tho diKov<ryof
bnti n chcmical,(e.g.,<ndorphino)tbai.octedHkcp,yd>o-
actiY<drup(opi>. tB),underwndingofU,•p«<es1ofod •
dktlongrn,anddemandnductlonbenmcomor<viablc
.Ualegy. Tratmrnt bcilit i.. expanded• alooholtsm and
o<heraddi<1iom,,,.,..,accep teda,illncssa.Thc1reotme ntof
odd ic:tlon became a med ical a, wc U •••oocta l Klcn«.
 1.30 CHAPTERI

I
Some of the treatment protocols developed for addiction • 11 million to 21 million inject drugs.
consisted of 12-step fellowships, therapeutic communities, • 1 billion use tobacco .94
new medical treatments in and out of hospitals, free-clinic
• About 180 million smoke marijuana each year. 95
approaches, and outpatient clinics.
• Depending on the survey, 30% to 60% of hospital beds
Cocaine, the Crack Epidemic, and are occupied by patients suffering from the medi-
Smokable Meth ("ice") cal consequences of drug and alcohol abuse . If food
addiction were included, that percentage would be closer
"B~ 1914the Atlanta police chief was blaming70% of
the to 80%.
of
crimeson cocaine, and the District Columbiapolice chief • There are 72 major medical illnesses in which sub-
consideredit the greatest drug menace."90 stance abuse, in all of its forms, is the primary con-
tributor.
Although cocaine has been used since the late 1800s and has
Events that occurred in the early years of the twenty-first
had flurries of excess use, it was not until the late 1970s and
century resulted in both good news and bad news for those
early 1980s that more-plentiful supplies, an excess of public-
in the drug treatment community and the world community
ity, social amnesia about earlier problems, and the develop-
ment of new ways to prepare and use the drug made co- The Bad News
caine fashionable and use became widespread . It was the
The drug wars in Mexico have claimed 60,000 lives since
first big cocaine epidemic .33
2006. 96
Snorting and injecting-the traditional methods of using co-
The development and the use of synthetic marijuana, syn-
caine-were supplemented by smoking a new preparation of
thetic methamphetamine-like substances (e.g., ivory wave
the drug, smokable cocaine, which is created by chemically
and white lightning), and other psychoactive substances
altering cocaine hydrochloride into cocaine freebase. This
(e.g., mephedrone, BZP, Naphyrone, 2C-I ["smiles"], and
form of the drug can be vaporized without destroying its
MDAI) continue. Since 2011 the DEA has redoubled efforts
psychoactive properties. Developed in the 1970s, it was orig-
inally known as "freebase ." The smokable crystals, made
with baking soda, were called "crack," and the process was
called "dirty basing." Use went from after-hours clubs, to
freebase parlors, to crack houses and individuals' apart-
ments, and finally to street dealers. 92
The ensuing crack epidemic in the mid- and late 1980s was
fueled by the rapid stimulating effects of the drug and hyped
by the media's heavy-handed news coverage. 93 Experi-
mentation and binge use were common in the suburbs; but
as the glamour of crack faded, use moved to the inner city;
and because a hit of crack was so cheap, heavy use became
more prevalent among poor minorities.
In the late 1980s, perhaps in response to the popularity of
smoked cocaine, a slightly altered smokable methamphet-
amine called "ice," "crystal" meth, "shabu," "L.A. glass,"
and "peanut butter" came on the scene. Its mental effects
were stronger and lasted longer than the common metham-
phetamines. "Ice" was first abused in Hawaii but soon spread
to the mainland. Most of the methamphetamine confiscated
by the Drug Enforcement Administration during that period
and even today is the form of the drug most often called
"crystal" meth.

Todayand Tomorrow
Psychoactive drugs have an enormous social impact on all
U.S. Anny Lt. Col. Burton Shields, commander of 4th Battalion,
aspects of society worldwide. 23rd Infantry Regiment, and his interpreter, Ali Mohamed, discover
• About 2 billion people drink alcohol. a pile of dried poppy plants in Badula Quip, Helmand province,
Afghanistan, Feb. 12, 2010. The soldiers are participating in
• 76 million people have an alcohol use disorder, and 2.5
Operation Helmand Spider
million die from the disorder each year.
U.S. Air Forcephoto by Tech. Sgt.EfrenLopez/Released
• 167 million to 315 million people use illicit drugs.

to keep up with the hundreds of new compounds by banning
many of the chemicals used to make synthetic marijuana and
bath salts .
Opium production levels peaked in 2012 despite a blight in
2010 that destroyed many of Afghanistan 's poppy fields. The
country is the largest producer of opium and accounts for
75% of the world's opium poppy acreage.
The battle over marijuana (legalization, decriminalization,
and medical use) is being fought at both the state and na-
tional levels. As of 2013 recreational marijuana is legal in
two states with more to come.
Illegal methamphetamine superlabs are flourishing in
Mexico and the United States, mostly in California.
Worldwide , methamphetamine manufacture is spreading
from east and Southeast Asia to laboratories in Russia,
Central America, and the Middle East. 97 •98 Use is increasing
in Africa and east and Southeast Asia.
Behavioral addictions like online gambling, electronic game
playing, and texting continue to increase as technology
evolves. More high-profile athletes have admitted to using
steroids, HGH, tetrahydrogestrinone (THG), or EPO.
Professional laboratories and street chemists continue to
look for new formulas that are not yet illegal or that avoid
detection through testing. Seven-time Tour de France win-
ner Lance Armstrong was stripped of his medals after admit-
ting to using sophisticated , non-det ectable, performance-
enhancing drugs .
Tobacco companies seek new methods of delivering nico-
tine: flavored cigarettes, new forms of smokeless tobacco,
and electronic cigarettes .
The Centers for Disease Control and Prevention (CDC)
predicts that by 2030 42% of Americans will be obese
(body mass index of more than 30). The increase in type 2
(obesity-caused) diabetes and cardiovascular problems
worldwide has focused attention on unhealthy and compul-
sive eating.
The Good News
More-complex neuroimaging techniques , such as diffusion
spectrum imaging [OSI], and diffusion tensor imaging (DTI)
complement established techniques (e.g., positron emission
tomography [PET] scans, single-photon emission computed
tomography [SPECT], and functional magnetic resonance
imaging [fMRI] to visualize the brain and confirm many ex-
isting theories of addiction and suggest new ones .
Genetic research using gene sequencing, DNA studies, and
insights from the science of epigenetics has helped research-
ers identify at least 89 genes that influence addiction , and
better understand how stress can alter genetic function . Nine
hundred other genes are suspected as having an influence .
Thousands of studies of the neurochemistry of addiction
have led to the continued development of medications that
can reduce craving , support recovery, and possibly vacci-
nate against using.
Psychoactive Drugs:Classification and History 1.l 1
I
Drug courts for first-time offenders along with more-realistic
drug laws have eased the burden on the justice system.
The World Anti-Doping Agency (WADA), created to limit
the use of performance-enhancing drugs in amateur and pro-
fessional sports associations, works to identify and detect
substances created by private laboratories that simulate ste-
roids and other PEDs.
Limiting spaces where smoking is permitted has steadily
reduced the use of tobacco in the United States and other
countries.
Better use of counseling techniques (e.g., motivational in-
terviewing and cognitive-behavioral therapies) has resulted
in better treatment outcomes.
A focus on treating dual-diagnosis patients ' problems si-
multaneously (e.g ., drug addiction and a mental illness) has
led to better outcomes
Geopolitics of Drugs
The monetary value of drugs has often been part of legiti-
mate and illegitimate governments' economic plans. It has
also involved terrorist organizations, crime cartels, large
and small businesses, and rebel insurgencies. Whether
it was a government-run monopoly on coca (conquistadors
in the sixteenth century), the profit from opium sales to
China in the nineteenth century, the excise taxes on whiskey
and tobacco, state-sponsored gambling in the form of
lotteries and slot machines (twentieth century), or an
insurgency-controlled drug trade to support terrorist and
revolutionary activities (twentieth and twenty-first centu-
ries) , the link is clear.
For insurgencies , heroin , cocaine , and marijuana have
been the principal mediums of exchange. For example ,
with the sudden popularity of cocaine in the 1970s and
1980s, the main communist insurgent group in Colombia ,
the 8,000 to 18,000 members of the Revolutionary Armed
Forces of Colombia (FARC), found they could fund their
© 2008 Jim Margulies/ eagle cartoons.All rights reseNed.
I
org:miutionmor,di ectivdybybecominginvoh'rointh< and th< 11><of f,nwiyl. • po"ulul opiate, u.,.,d to gi,., •
cocaine tr2de. About 60% of the coc•in< exported from boosttoth,balloono rpack<t of t h<drug . On,ofth,lat<>l
Colombiaiscontroll<dbyFARC. ' Theronflict a r.dmultipl< ov<rdosevictim.oinlOliwa,;PhilipS.ymourHoffm.n .1 h<
atl<mpts a lpncet.olkscontinu,a,;do,,thecocain<tnd< ,up,rb:octor . whodiedwithan<Ml<inhi>armand70pack -
<tsofh , roin a r.dotherdrug,!1Cltt<m:l a roundhi>hom<
Heroin
>l.rtttchem · acm ~' '" · n·" ,ro'na,,..,lla,oth<r
Th< • buo,cofo¢•1"andopioid,hHgrowninpansofAsi•
opioidshav< produced 50m< ,.,cydang erou,,ub.t.mcn
andAfriaprim•rily duttopr ucriptN>np•i nkillu s.Huoin
andopiumu><wor ldwid,, ,,,m,lairly,able,with••light On,, xampl<H "krokodil."ordeoomorphin<, a highlyad -
dictiv,morphin<d<ri vati>-<th.otorigin.,.t<dinrunlRu,si•
declir.<inEoropt .*'
and that. when improp<rly mm,, caUS<> •b.c= and gan -
Afgh•ni,tani,theworld's[.,geotproduc,rofopium,pro- gm><.l1511>< start<d in Russio about a dru,n y<2T!lago md
viding~,OOOtonsannually,withcultivationonthe-de - hH ,prud to neighboring rountri,s but hm hard y r<ach<d
,pitt th< ongoing mili11ry conflict. Cu=cntly, moot of lh<United>l.1t<sbyl01J. The ingredi<n tsar<ood<in<. io-
Europ,'shero in comufromAfglu.ni>'1nviaTurk<y.Muchof din<. andredpho,phoru,ar.d,ifpoorlyfflll.it ronains
theM idd leE.a<topiumandhuointndehasbeenrontrolled toxicbyproducaofth<procrs,thatcand ,u,ug,tltt,kin.
bytheT a liNilmd theprofil5~ tofirancdaoctiviti<> givingitagr«n.,ca!yappn.~.h<nceth<ruom<t...-odiL
Asia's heroin comes lrom Afgh.,.ni<Wl md the Goldm
Tri>.ngle . Politicalchangu in SoutheutA,ia,partirulll lyin Cocaine
Myanm.or. th< btj!<>lproducerofopiumin the Goldm lnr«<nl)'<ar•thecOCllin<mark<thHdeclineddmnat i<lllly
Tri • ngle,cutproductiontoh•lfwrultitwuinthel990o in Nonh Am<rica, th< 1.argut U><r (l7"1",of t h< world ', toal
butth<rei,anupwudtrend.Thoughth<r<eism<,q,ar.ding numh<Tofusa, , downfrom'49'1\ inl 001),wh il<itha,O..t -
int<m.alm.ork<tforh,ro ininth ,Asioncountri<>thotgrow l<n<dou1inEurop,(l -t% olth,1011l).V><ha•!ncru><d
and,mugglethedrug(abouton, -founhofth<tol.l!crop). ~rn!=tly in Latin Am<rica ar.d th< C.ribb<m, A,io. and
theprofi15,tillliein><llingtousa,inw<lllthi<rcountrin
Curr<ntly.M,xkanbWCklllan d.toalt...,,at<nt.brown Vinually a Urocainti,grmominSouthAlllffica:Drcil.

::.,w~i7nrr:: ~!~:'.ibias~~:,AFfi:i,~;: Bolivia, Colombio.andP<ru.Curr<ently,P<rulnd,inco-

caintproduction . &can><roca l<>.v<>ar<difficulttogrow
M,rican drug-trafficking organization,. ll<caU>< of th< oul5id,South Am,ricamdth << xlactionproc,..i ,&i rly
incrtt>ro supply . th< priceofh,roin hHdropp<d whil<il5 rompl<x,h ighlyorganiudColombioncrlm,cart<lsdev,~
purity!u,ru<n . lnth,UnitedS!1t«.th< av,ng<pricefora op<dinth< 1980stoop,nteth<cocain<tr2d<. lnr,crnt
balloonoftuh<roin(O.lgram lgml)HSlO . Aba lloonof yuB, hown<r, th< Mexican cartels took c~ of,mug-
whiteheroinHO.JJgm . Th<>< lowpri c«ha\'<l«ltom gling and now control the lion', ,hor,c of th < tr2d<. Abou1
incra><inh<roinabu><bythosewhofirstb<cam,oddicted ::.:r,~~•~.1~:::, u~~, °::o the United Sate, rom«
topr<e>criptionopioidsandop iot<S
Th< number of o,.,rd= Imm h<roin hH ru<n dram.oti<lllly
inrrc<nty<an.oftenfromthehigher purit yofth<h<roin ;;,;;~"';
.=:·~r::i:
~::::~1:!
.~..%:~:

U..o/Cocain,~,byc-gra,phy"

_....,.,,. .. . ~'/:It,

t...."'-'ol'ldt,,C..-, ll'lo

These three advertisementsfor rave partiesfrom the early 2000s used cartoon icons. Attempts are made to keep alcohol out of the events, but
many club drugs are available through individuals and dealers who sell ecstasy,nitrous oxide, bath salts, synthetic marijuana, GHB, and a few
other substances.Many of the drugs are actually looh-alihesand not the real drug.
of the cartels, who are often paid with drugs, develop their
own marketing networks in cities such as Nuevo Laredo.
Tienditas (drug shops) are springing up everywhere, fueling
violence, corruption, and addiction. More recently, other
Latin American countries are creating scores of cocaine ad-
dicts at home (Brazil has 17% of the world's users). Often the
cocaine preparation of choice in Latin America is an inter-
mediate product of the coca leaf to cocaine powder refine-
ment process called "oxidado" (previously referred to as "co-
caine paste," "pasta," or "basuco"). Many of the problems
occur because of the impurities such as kerosene which can
remain if the drug is not made properly.
HIV, AIDS, and Hepatitis C
The human immunodeficiency virus (HIV) that causes AIDS
came to the world's attention in the early 1980s when the
viral infection jumped from primates to humans, wreaking
havoc first in the homosexual community, then among IV
drug users, and finally in the heterosexual community
Society reacted in phases: ignorance, bewilderment, alarm,
and complacency. In the past 10 years, significant prevention
and treatment have greatly extended the lives of infected in-
dividuals and slowed the epidemic.
Worldwide AIDS has claimed the lives of more than 27
million people, while more than 34 million live with HIV
infection. The majority are in sub-Saharan Africa, with
growing numbers in Asia. Each year about 2.5 million peo-
ple are newly infected and 1.7 million die, down from 2.3
million deaths in 2005. From 2001 to 2012, the incidence of
new HIV infections decreased in a number of countries,
mostly in sub-Saharan Africa, where it fell by one-third.''
In the United States, an estimated 680,000 people have
died of HIV/AIDS, while an estimated 1.25 million are liv-
ing with the disease . 100 About 50,000 new HIV infections
are diagnosed each year, and 15,000 people die. Men having
sex with men still accounts for an estimated 52% of new
infections. Overseas, AIDS is spread primarily by unsafe
heterosexual sex and secondarily by contaminated needles.
HIV/AIDS is not the only major infection caused by the con-
sequences of drug use, particularly injection drug use. More
than 4.1 million Americans suffer from hepatitis C, a po-
tentially fatal liver infection. About 40% of those with the
Psychoactive Drugs:Classification and History 1.33
I
disease got it through injection drug use. Conversely, an as-
tonishing 80% to 85% of injection drug users have the dis-
ease. Until 1992 there was no test for hepatitis C, so the rate
of new infections was extremely high-about 300,000 per
year. New infections have dropped dramatically to an aver-
age of 17,000 per year. 100
Worldwide 150 million people have chronic hepatitis C
(from all causes), and each year about 350,000 die from
complications of the disease. There are 3 million to 4 million
new cases every year.
From Club Drugsto Spice to Bath Salts
Starting in the 1990s, "raves," dance parties, and "club
drugs" kept alive the tradition of mixing music and psy-
choactive drugs. In the 1920s it was jazz, cocaine, and boot-
leg liquor; in the 1950s it was the blues, heroin, whiskey, and
tranquilizers. "Weed, whites, and wine" in the sixties gave
way to hard rock, psychedelics, amphetamines, more mari-
juana, and more wine . Cocaine and speed were common in
disco environments in the seventies, while the raves of the
1990s and early 2000s featured heavy metal, rap, and elec-
tronic dance music, mixed with ecstasy, marijuana, nitrous
oxide, and occasionally ketamine and GHB-all defined as
club drugs and washed down with hard liquor.
Currently, raves are hotter than ever, often hosted by DJs
playing mostly electronic dance music and rap. Attendance
at raves can be 5,000 to 10,000 in medium-sized cities and
up to 50,000 in large cities and at many venues in Europe.
The main drug of the 2000s and teen years is still ecstasy
(MOMA, "X," "E," "Adam") although a purer form of the
drug called "Molly," is preferred." A recent variation of ec-
stasy is called "extreme ecstasy" or "meth x." It is made by
adding meth to ecstasy, increasing the potency and the ad-
dictive qualities of the drug. While these combinations
sound exotic, it is still basically an upper with some psyche-
delic effects .
Ecstasy users claim that the drug promotes closeness and
empathy along with a loss of inhibitions that can trigger a
strong urge to dance, socialize, and stay active. The other
popular drugs include cocaine, marijuana, pain pills, and
promethazine with codeine. To a lesser extent, bath salts,
synthetic marijuana, and even kratom can be found.
I
On, ,ub5tmc, that hll become extr=<ly popular in th<
r>V<<etr.<isthecom binationol•cough,yrupcont>ining
rodeine•ndprom<tlw:ir.e(anmtihisLamine),pom<dinto
Sprit~andco lom:lwithJoll)·R.oncher • candi<>.ltiscalled
·purp ledr.tnk ," ,iuurp,"",yrup ." "l<>.n."Thi,rombination
ha,;b<mpopularformanyy<>.Bwi thinthehip-hop!i<<n<
butha,spr,adtothee l«tronicdanc,mu,ic>crn<
Thetoy,ofthedectronicr<volution-).IPJplay<T!l,t>b lrts
>m>rt pho= . el«1ron ic g:,m<>. the lnt<m<t-coupled with
a fioodolJ>T=riptionopiol<> . medica l iruorij1UI1.1.,alcohol-
lxed<nergydrinks, a M1h<partyo«nehlll!l2de1heabu>.<
addiction . andrompul>ioncontinuum mor<<cl«tic. The
p,ndu lummovedawayfromu,ingdrugstoe,q,lor,one\
"?~iousn,s~ "''."'"d
, im ply g<tti ng loaded. Even th< mu-

Theotherdrugth.othllcomeonth<><:<t><i,,yntheticmeth -
ampheumin<,50ld .. bothultsor" p W\tfood ."Llkemrth -

:ri::::~:"<lf~~~::1:.".,:1~:~na~:,:d.::::;:~
Lu complications. The drugs (m<phedron<, MDPV. and r< ·
US state, •re continuing 10 evalu.ote medica l and recrte-
atioruol legalization
btedcath inonederivative,)werea\'aibblelor•numberof
ye>.Bin the United Kingdom until thqwm, banned in 2010 A,of201Jmniju.onarem.ainedthema,twidelyu,edillicit
aftersev=tldathswere.uributedtotheiru.e. " Mephedrone druginth,UnitedState>,Australi.o.c.n.b.Mexiro.South
wuNnnedintherestofEu~in2010andwillbebanned Afric•,•nddo,rn,ofothercountrie> . High•potencymari-
inmo<tothercountrie> . includingtheUnitedStates. "' ju.on•i•wi delyanibble a ndisuptoH tim<>><•trong••
varieties aVllil.o
bl einthel970. . High-potrncymnijuanaw••
Anotherpopubrdubdrugwasgamm.a-hydro,cyb utyn.te >lw•y,•Vllilablebu1no1veryplentiful .Jus1 u thertlinement
(GHB),asedotiv, _ 11,. .. ,NnnedintheUnitedStatesbe - ofroca le,.v,,;intococaineandofopiumin tomorphinemd
cau.eyouthswrn,u5ng't ua >ed.o" ,.to"nduceeu,.''
heroin ledtogruterabus<andaddictionli•bility,better,in-
andlo r i!> a nabolicormu,cle -buildingeffects.hwa.s a lso
..,milbc u ltivationtechniq_ue,h= increuedthecompul -
usedby><xu.alpred.otoBtoinduce•mne>i.ointheiT,ictiTru siv,li>hilityofm.ariju•na.MorethamJJ~,OOOclienl5(more
Datromtthorplun (DXM), found in many nonpre<Cription thonl8%of•llodm i55ion,)rnt<ringtratmrnt!ntheUn it<d
roughmdcoldmed icatioru.can inducepsychedelic•nd S.O..te>listedmariju.ona..,,heirprimarydrug. '°'
di>ooci.otiveeffect,whenused inbrgequontitin(I0to.30 Anodditiontotheclubdrug,cene.,yn1heticCannabi>came
times the norma l dose). Because of • buse . many states
=i~ ~rug, containing dextro~ethorp;;-,~ ,_o be stOTed
on the market in the early 2000. . Th< dTects mimicked
tha,e ofotj!mic Cannabi~ It""' sold u herb.I inceme !n
"head,hop,"mdg><< tatioruunderthetrodenamesKlmd
purch2ses•ndshoplifting Spice•mongothers. Thesedrug,didnottestpo,ifr,., for
marijn•namdweretouted»•waytogethighwithoutde -
Marijuana(Cannabis) and Health tection. M•n y •tat« and the feden.l gowrnmen t ar<ron-
On November 3, 2013. the states of Colondoand WHhington tin uing to look clos,er at ,ynthetic ma riju:m.o •nd have
voted to ltgoli« m.ariju•ruo for recreation.al pn?J>OS<• placed ham on many of the p roducts and the cbemicat.
Customers wen lined up for the first day of distribution •nd u,edtoma:nufacture th em . Newteotingtechniq_nes•r<try ·
manyofthedispen,aries/<ton:srmoutolproduct.Thepr ice ingtokeepupwithth,dozensofnewproductbeingcre>ted
,hotuptwo-orthredoldbnt••theneww•yofdistribution every few month>
takeshold a ndbw , govemingthe,pecific.olits,alemd
S)'Ilthetic•ndhigh-potencymniju.onauseh2srecrn tlybern
U><>r<Cl'Uled. thepricewillprobab lygobackdown
associ.otedwith•vomiti ng,yndrome-C"11nabi>hypa<me-
OnAugus11 . 20IJ . lllinoispassed • b.wto a llowmed icaluse •i••yndrome-1hatcmnotbecon1rolledwith1henorm.ai
ofmniju.ona . makingitthetwentieth,tateto•llowmedical , ti-vom't'ngmed "cat"oru . S'tt"ng ·n • 't,I · oneof
marijuan.o.Asof201Jmed icalm.ariju.onohadbttn~e thefewthing,thatrelievesthevomiting(beside,no1,mok -
ltgolinAbsb.Aruon.l. . Califo m i.o.Colo.-.do,Conne cti- ingmarijuano)
cut, Delaware, Hawaii. Illinois, M•ine . M.. ,achusett>
Michigan. Montaruo. N<V>do. N= lumpshire, N= Jervy . Dabbing:ConrentratedlliC
ConcentratedTHCinvo lve>refiningmar!jn•nanntilthe
::,~:~c;;,~e:;~o~~:ib~•~nf!/::;n:.;:;;:;1~ n!1:, roncentr:1tlonofTHCi,JO'l,ormore . Onetechniquethat
medical mniju.ona . notably Belgium, C.n2<1•, the Czech h2sberomepopubriscalleddabbing.Jnthismethod,bu -
Republic . l,rael,mdtheNetherbnds . Othercountriesmd tane.CO 1,Evadeu"'akohol.orothersolven t i,P"',ed
 Psychoactive Drugs:Classification and History 1.35

through twigs and leaves of marijuana (mostly shake), to
extract the THC. The resultant slush is filtered to remove
the plant matter and the butane or other solvent is purged
though heating. It is known as BHO or butane hash oil. The
residue, a waxy substance, is usually sold in gram weights
for $30 or $40 . One gram will supply about 10 hits. A hit,
a little waxy ball, is placed on a hot nail or other hot metal
surface to vaporize the substance and when inhaled, strongly
affects the user for four or five hours. These concentrates can
be up to 80% THC but usually range between 50 and 75%.
A slightly different process will end up with a glass-like
result that looks like shattered glass, either clear or amber in
color. Other names include wax, shatter, budder, or even
"err!," slang for oil.
Because these concentrated forms of marijuana are so po-
tent, regulating them is a problem. Legislators are wrestling
with this quandary and dozens of others that weren't full un-
derstood when the original law legalizing marijuana in
Colorado and Washington were being written.
Tobacco, Health, and the Law
In 2014, the Surgeon General of the United States commem-
orated the first "Report on Smoking" in 1964 by releasing
the 32nd report : The Health Consequences of Smoking-50
Years of Progress. It says that the number of past-month
smokers has dropped from 44% to 22 .1% in 50 years .
Unfortunately, since 2008, the number of premature deaths
due to smoking (including second-hand smoke) has gone
up 40,000 to a total of 480,000 in 2012. Even though
the report says that 87% of lung cancer deaths are due to
smoking and second-hand smoke, more people die from
cigarette-induced heart disease . The report added several
I
new diseases to the list of those caused or aggravated by
tobacco including diabetes, erectile dysfunction, rheumatoid
arthritis, macular degeneration, and impaired immune
function. Tobacco costs America $176 billion in healthcare
expenditures each year. 104
The decline in smokers began soon after the 1964 U.S.
Surgeon General's Report. Since then antismoking cam-
paigns, massive government lawsuits, printed warnings on
packaging, legislation prohibiting smoking in public places,
lawsuits against tobacco companies, restrictions on tobacco
advertising, and solid research presenting the dangerous
health effects from smoking-all have had an impact.
However, governments in general collect 500 times more in
tobacco taxes than they spend on prevention.
On November 20, 2010, the World Health Organization's
Framework Convention on Tobacco Control continued to
strengthen tobacco-control efforts worldwide and support
efforts to:
• regulate the flavoring ingredients that make tobacco
products more attractive to new smokers, especially
young people
• integrate smoking-cessation services into national
health systems
• establish an infrastructure and build capacity to support
education, communication, and training, thereby rais-
ing public awareness and promoting social change
Although 3,500 U.S. cigarette smokers quit each day,
approximately 1,200 others die prematurely from the effects
of smoking. A 50-year longitudinal study in the United
Kingdom showed that the average smoker's life is shortened
by 10 years ms

WARNING
CIGARETTES
CAUSE
LUNGCANCER
85% of lungcancersare causedby
smoking . 80%of lungcancervictims
diewithin3 years.
Health Canada

WARNING
TOBACCO
USE
CANMAKEYOU
IMPOTENT
Cigarettesmaycausesexual
impotence dueto decreased blood
flowtothepenis.This canprevent
youfromhavingan erection.
Health Canada

Health Canada has mandated serious warnings on cigarettepackaging. The United States has commissionedpublic service announcementsto be
createdfor broadcastmedia but the tobaccocompaniesare strongly opposed to the use of the type of graphic images on their packaging as has
been mandated by Canada.
I
Thetobacoorompan·,.co,J1u<tornf an<wg ,rafon ijuaruo, ti, "mpact on th,,n,'ronm<nt, law<' cmrnt
of,mok<rs by denloping product> that ddiva nicotine to andtI<C>tm<ntcrnt<r<hasb<rngr,.at
the body . Th<><einclud,C.mel ' Sticks,Camd " Orhs,md
In lOlJ U.S. law , nfore<mrntagrncies raid«! approximat<ly
Uffid ' Stripo-4llproductsthatdelh·erm,ok<less1obacco
11,000m,thlabor.ttories,manyofth<minth<Mldw..t
Theelectroniccigor<t tti>anothernirotintdeliv,ry,yst<m
(<.g.,Mis<onri•ndlndi>ruo) a ndinC:.lifomi>.Thi,figur,i,
thllt • lre•dy~Slbillionin .. tninlOIJ . ltddh ..,r,a
downfroml3.000in2011 .'°' 0r.tr<HOnforth<<,q>IOO,..,
n"rot'ne -lad m'stthrough , 'ri:ethao, i eo•w•t<r
growthinth<<arly.ZOOO.wa.<th< d<>1'lopm<nt by<lr«t
!iOlutionthatr<plx<Stobacoo,mokingwithinh.alingvap<>T .
ch<mlsLsofn<W<r . ch<ap<r,sotntWhatsaf<r . and mor<-
1ti,b<coming!i0popularthatth<btj!<Tlobaccocompani<>
<ffectiv,way,oFmanufacturingillicitm<thamph<umin<
,ucha,PhilipMorri>,ang,ttingintothebu,in<M
T heoimplestm<thodi,call«l "<hak<•ndbake ." ltin,ulv«
Am,·canandB "f htobacrooomp•n·,.confnu<tovt• puttingroldpill, a r.d,omenoxiouschemicalsinabottl<
p•ndfouignmark<ll,whu,t<>l>Kco11><i>,uhst.mti.ally andthenth,concoctioni,.Jwcrn . ltr,quir<>justafewpill,
high<rthaniti>inth<l'nit<dSute> . Untilr<c:=~y,<moki ng and,oi,hardutod<tectthroughroldpillpurcha<<r<eoub

;;,•u . H:'<V<f, :.= ~:unlri.•~~7

inde-.1' lopingrounlrieswasincr<.o,inga1
th~
ara1eo/J .i%p< r
r<cogniring,:h• toll
Mootolth<«irnr«>r<ol"cry,ta!"
,mokabl,formolth<drug.50Jd
and,pttd . A Ing< numbuolm<th
m<th.•mor,r<adily
inth<pasta,;"crank,"m<1h
labs ar, ,mall. mom-and -
thirdof a llm,ok<Bbut hnp!.oced a rigorou,antismoking
pop sto,,etop op<r.ttiom c•ll«l "n><erbbs." Amor< <ignifi-
campaigninplxe.withthegoa l olrrducingthemor<thm
cant portion of th< manu!acturingand thewhol<S>lingi,
1 million ,moking -nl.ot«l pr=lur< death, ach yar .
Worldwid<•boutoro< -thirdof>lladuli.m,ok<.>lthough
lh<pucrntag<lsmuchhigh<r>mongmales(< .g., 70%of
::·~:~:.~!::t:.fli,:~::!,~=~7',:,!:'t
lromM,,ticanc•nd-co
~:::
ntroll <dbbs
lndonesirn•nd60%ofChi""'m.al<><mok<)
Froml998tol010,admi .. ionstoU.S.drug t rtttm<ntfa-
In l\l96 m.ojo,- tobacro rompani« rolltttivdy agrttd to
cilit i«foramph<tamin<,;(m.oinlym<thamph<tamin<and
p"}'SH6billiontonriou,,tat<<ov<r>p<riodofHyun
<estasy)ros,fromS6,000inl998toapnkofl73,0iSin
inth, bigg«tc l>s, -octionbwsuit«ttl<m<nt<>,ertob<
hand«ldown . Th<><tt l<mrntm oncyv. .. ,tob<umltod< - ~OOS. thrn. down"'. 113 ,625 in 2010~ " ~"h;'fflphw.m.in<
vdopprog=mtop=1'ntt<<ruog,nfrom<moking•ndto
includingth<Philippine,andThailand.wh<r<smallm<th-
hdpd,fr ayth,m«licalrosi.llSOrult<dwithd~caus«I
ampl><tamin<pillscall<d"yaba".,-,atr,m<lypopubr
by,mokingorch<wingtobacro . Man)·<t.ota , hov.1'v<r,us«I
partirular lyamongyoungp<opl <. Mucholth< "),. ba"i,
• l>rg<p<TC<nt,.g<ollh,mon,ytod,fr ayothupartsofth<ir
,ruodeinMyanmarand,muggl«lthroughoutAsi a
budgm
Prev<ntionprogr:am>and•nti,mokingcampaignsdowork Other Stimulants
W•<hingtonStat<u>Mth<lawsu itmon,yforiLsint<nd«I T h< most popular ,timuWlt i, caffcin< . About 'H% of
purpo><, and ti>< <tat<~ <rooking rat< dropped 12% in just Am,rican,ov<rth<ag<oFIBron<nm<coff«<v<ryd"}';
lour )"""· Ln .. uin have focused on ,econdhand ,mok< worldwidethenumbtri,muchhigh<r.Th,vari<tyofcaf .
,mokinginpublicpW:«,androv<ringupth<factsthat
th<tobacrorompani«haV<knownfo,-t1UJ1yynrsthat ~~::d.,:r : h<d::~~":i ;.;:::~r:1~: .. ':'u~::'~Zi:
cigar<tt<,.,-,dang,rou,.ln•natt<mpttorontrolhealthin - cation,ofth<publicOd<>iuforcaffrin< . Th<r<>r< mor,c
•nrmot00>Ls,mor<mdmor<oompan' >r<r<qu' · ~•'cir thanll.89lroff«•hop,andkiook>inth<Unit<dS t.ot<>
<mploy,,swhosmok<toquit . !oom,di,;charg<th< <mploy - and th< numh<r< a r, growing by the da)'. St.orbuck, ha,
<«if<moking-c<ssation,ffortsf.oil l8, 000outl<L5in6lcounlrie,andi>aimingtodou bl< that
ov<rlh<natlOy,an .1'"
TheU.S.FamilySmoki ngl'r<v<ntion ar.dTob.aocoCon trol
Actwa,;~t<d!ntolawonJundl,2009 .'°' ltga,..,th<U.S Withnam«lik<R,dBuU, • Monst<r,• Rock,tar, • NOs, • FuJI
FoodandDrugAdminlstration(FDA)th<authoritytor,gu - Tnrott1<,•a r.dAMP. " thegrowthoFth,rn<rgydrink«g-
lat<th<manuf:tetut<.dlstribution, a r.dmark<tingoftobacco m<ntofth,h<v<ng,industtyi,asd.-.matic><th<growth
produci. toprot«lpublich<•lth•ndk «ptobacroprodu<t, ofroff«pnrv<y<>B.Dozensofn,wdrinksrnt<rlh<marl«t •
awayfromchildrm.Tobaccou«inth<L!nit<dStat,si,atiL5 place ach yar, but Red Bull" and Mon,ter" alor.t hav, 79%
low<>tpointin75yan. oflh<marl<<t . l.ac«lwithcafl'rir.t .•ugar ,vitamin,,minuals
aminoacid,(,.g.,taurir.t) . h<rbs,anddi<tary,upp l<m<nL5
Amphetamine-TypeStimulants (<.g.,gin«ngandglurosamir.t),th<drink,ar,,,q><ct<dto
g<n<r.tl<>n<>timat<d $1J.5 billionin,al<>b)'l01 S,upfrom
Ov<rlh<pastfrwyan , ther,ha<bttnan incr<a><dfocus
SJ.7billioninl006. '"' Theyrontain•bonttwic<lh<caffcin<
on amph<tamin<•typ< <limulants (ATS,) in th< Unit«!
u •n averag<rupofooff«•ndproduot a ,trongubrnz
St.ot<>and•ronndth<worid.An«timat«IJ.-lmillionp,o-
pl< us,ATS,worldwidt (much of it ecstasy) rompar«l Th,us,ofkhathase,q, and<d,omewhat.Th< leav<>ofth i,
withhalfthatnumbuwhou«rocain< ."° E,..,nthoughth< <V<rgr<<n<hrub(Calhacduli,, who« activ< ingr<dirnti,
actllllnumbusofu«nare lowoompa r<dwithu.s<r<ofmar - cathinon<)are,muggledintoth,Unit<dSt.ot<>inincr,a,ing

amounts . The real expansion is of a wide variety of synthetic
cathinones and methcathinones, which are used in the man-
ufacture of bath salt stimulants.
PrescriptionDrug Abuse
According to the Drug Abuse Warning Network, in 2012
there were more than 1 million visits by individuals to emer-
gency rooms for complaints involving pharmaceutical drugs
(pain relievers, tranquilizers, stimulants, or sedatives). This
compares with 1.25 million visits involving illicit drugs. The
number of pharmaceutical visits doubled in five years_ll0
This trend reflects a shift from the "Generation X" of the
rave and club drug scene to "Generation Rx"-cohorts who
share and mix their diverted and prescribed prescription and
OTC drugs at "pharming parties." Prescription drugs are
now involved in 30% of all hospital emergency room
deaths_ll 0
In 2012, 6.8 million people age 12 or older used prescription-
type psychotherapeutic drugs nonmedically in a given month.
Abuse of prescription and OTC medications by teens now
exceeds abuse levels for many of the media-hyped street
drugs like ecstasy and methamphetamine . m Some of the
following reasons for the increase in prescription drug abuse
in the 2000s have been suggested:
• increased airport and U.S. entry-point security decreas-
ing the accessibility of other drugs
• the availability of abusable drugs prescribed to adults in-
creasing 150% over 10 years
• the availability of prescription drugs over the Internet
• the practice of raiding medicine cabinets for prescription
drugs while visiting the homes of others
• increased prescribing of controlled substances to youth,
such as ADHD medications and psych meds , resulting in
greater diversion of these medications for abuse
The most rapid increase in diversion of prescription drugs
for abuse occurred with prescription opioid pain medica-
tions like OxyContin ® and Vicodin. ® By 2012, 12 million
Americans had used a prescription pain reliever illicitly at
some time in their lives. 103 The continuing abuse of
OxyContin ® illustrates how a technological change can in-
crease problems with an existing drug. OxyContin ® is a
time-release version of oxycodone , an opiate originally sold
as Percodan. ® Opiate addicts discovered that crushing the
drug destroys its time-release capabilities, which allows it
to deliver a powerful, almost heroin-like high when snort-
ed, smoked, or injected.
More recently, Opana® (oxymorphone) has come into favor
in the illicit opioid-using community . This occurred be-
cause the makers of OxyContin ® reformulated the drug,
making it more difficult to crush and abuse. The makers of
Opana ® did not include this safety measure , so the opioid-
using community switched. Numorphan ® is another trade
name for oxymorphone.
Hydrocodone (Vicodin, ® Lortab,® Norco, ® Anexsia, ®
Hycodan, ®and Tylox ®) is the most widely used and abused
Psychoactive Drugs:Classification and History 1.37
I
prescription opiate. Since 1990 there has been a 500% in-
crease in the number of emergency room visits due to hydro-
codone. Unfortunately, the crackdown on prescription opi-
oids has led to a large increase in heroin abuse because it
is cheaper to use . A balloon (single hit) of heroin is about
$10, whereas a single 80 mg tablet of OxyContin ®is around
$70 and a 30 mg tablet of Opana ®is $20 to $40.
Adolescent abuse of prescription sedatives like Valium®and
Xanax® as well as of prescription anabolic-androgenic ste-
roids, or "raids, " like Anadrol ®and Equipoise, ®has also in-
creased greatly. Another recent trend is the abuse and the
diversion of prescription methadone. In states such as
Oregon where methadone is used extensively for pain con-
trol rather than exclusively for methadone maintenance, the
number of methadone overdoses is surpassing that of her-
oin . Methadone is also responsible for the greatest number
of deaths from prescription drugs in the United States .
Pain and Hyperalgesia
A series of scientific studies have suggested a powerful new
way of looking at opioid abuse, chronic pain , and hyperal-
gesia. Hyperalgesia is a magnified reaction to pain caused
when excess opioid use oversensitizes nerve cells and
ends up causing much more pain than expected as the
drug leaves the body. After a while tissue or nerve damage
that was only of minor concern becomes so painful that the
person is driven to use more opioids, which in turn makes
the user even more sensitive to any pain, thus encouraging
more abuse. The conflict between compassionate pain care
and overregulation of opioid use is making the medical
community examine the reliance on opioids as the first line
of defense.
Other syndromes that occur with extended opioid use in-
clude hyperpathia, pain that can persist after the nociceptive
pain stimulus is removed or healed; allodynia, a painful re-
sponse to a normally innocuous stimulus such as a light
touch on the skin; and hyperkatifeia , which is hypersensi-
tivity to emotional distress.
An investigative report by CBS News in 2013 found that the
Veterans Administration is trying to stop the over-prescribing
of opioid pain medications, which often causes more prob-
lems than it cures for wounded veterans. 112 While the
number of patients has gone up only 29%, narcotics
prescriptions are up 259%. This is also true in the civilian
sector. As a doctor once said , "It takes 30 minutes to say no
but only one minute to say yes to a request for opioids or
benzodiazepines ."
Buprenorphine
One of the more significant changes in the opioid treatment
process has been the trend to get general practitioners and
other physicians more involved . The administration of bu-
prenorphine through a doctor's office rather than exclu-
sively in a drug clinic is one such change . Buprenorphine
(Suboxone ® and Subutex ®) is a drug that can block craving
for heroin, OxyContin, ® Vicodin, ® and other opioids. 113
Buprenorphine is safer to use than methadone, although it is
 1.18 CHAPTER 1

I
costly: $500 to $700 per month per user, depending on the
dose. 114 Methadone maintenance treatment is cheaper, about
$350 to $3 70 per month.
As of 2013 there were three times as many buprenorphine
clinics in New York City as there were methadone clinics.
Buprenorphine can be used for detoxification and for long-
term maintenance. The FDA has approved a new drug, a
mixture of buprenorphine and naloxone, called Zubso lv,®
made by Orexo. The mint-flavored medicat ion is taken un-
der the tongue, has lower amounts of buprenorphine and
naloxone, and is FDA approved with a mandated liver warn-
ing on the packaging.

Alcohol Hangs On
Eyeballing is the latest campus craze-taking in straight
vodka by holding a bottle up to the eye. Having started in
England, it is reported ly moving onto U.S. campuses and to
Las Vegas. Devotees say it is faster than drinking and more
potent because it passes easily through the mucous mem-
brane and enters the bloodstream directly through veins at
the back of the eye. It also stings like hell
Although cocaine, hero in, and marij uana have high pub-
licity profiles, the drug that continues to have the most
wide-ranging impact on society is alcohol. In the United
States, there are eight to 10 times as many deaths from alco-
h ol than from all other illicit drugs. What is impossible to
accurately measure is the profound impact that alcohol has
on families, relationships, and society.
The drinking trends of the younger generat ion include
mixed drinks, combinations of alcohol and energy drinks
(alcoholic speedballs), ultrahigh-proof alcoho ls, j ello-shots,
and microbrewed bee rs. Today's drinkers are even inhaling
alcohol fumes using carbon dioxide p ills, dry ice, asthma
nebulizers, vaporizers, or pressurized air pumps to turn
their alcohol of choice into an inhalable, hig h -p roof alco-
hol-rich vapor. Inhaling alcoho l vapor removes the d igest ive
system, especially the liver as a metabo lizing buffer and
delivers the vapor directly th rough the lungs, where it is
absorbed into the bloodstream and pumped directly to the
brain.
Today's young generation is more interested in getting drunk
Vaporizing ("vaping") alcohol with heat or dry ice and inhaling the
fumes gets the drug to the brain much faster than drinking the liquid.
Inhaling liquid nicotine in electronic cigarettes is also considered
"vaping."
0 2013 CNS Productions
The areas of focus include genetic compo nents of suscepti-
bility, neurobiology of satiation, pharmacological interven-
tions to re duce cravings, and refinement of treatment tech-
niques such as brief intervention and involving primary care
physicians in diagnosing at-risk patients.
Steroids& Sports
Suspicions about steroid and other drug use in sports con-
tinue, but the interest level was low until the late 1990s and
the early 2000s, when baseball was thrust into the spotlight
by the revelations of players, especially Ken Caminiti, Jose
Canseco, Mark McGwire, Barry Bonds, Roger Clemens, and
Jason Giambi.
"It'sno secretwhat's9oin9on in baseball
; at leasthalf
the9u~sareusin9steroids . The~talkaboutit. The~jokeabout
it witheachother.The9u~swhowantto protectthemselves
or theirima9eb~l~in9havethat ri9ht....I tr~to walkwith
m~headup. I don·thaveto hold m~ton9ue."
Ken Caminiti 117

than in enjoying the taste of alcohol Over the past few years,
The next generation of drug abusers in sports has ended up
commercials for hard liquor have increased on U.S. televi-
with 50- and 100-game suspensions for multip le pos itive
sion, reversing the ban on television advertisements for hard
tests. In 2013 Alex Rodriguez, Ryan Braun (2011 MVP),
liquor. Ads for beer, wh ich makes up the majority of imbibed
Jose Cruz, and 10 other players were suspended because of
alcoholic beverages in the United States, have never been out
their association with Biogenesis of America rejuvenation
of favor.
clinics, which provided the players with banned substances.
Used separate ly or in combination with other psychoactive
The sport most affected by the steroid scandal is bicycle rac-
drugs, alcohol directly kills more than 75,000 p eople per
ing. After years of innuendos and denia ls, Lance Armstrong
year in the United States and 2.5 million worldwide. 88 An
finally admitted that he ha d used performance-enhancing
estimated 17.6 million Americans have an alcohol use dis-
drugs during his reign as a seven-time Tour de France cham-
order; and though that figure is j ust 8.5% of the adult popu-
pion. He was stri pped of all of h is titles. He and his racing
lation, alcoholics make up 10% to 15% of those in hospitals
team went to extraordinary lengths to "juice up," using
and 10% to 20% of those in nurs ing homes. 116
semi-legitimate laboratories and street chemists to create
Research into the causes and the treatment of alcoholism and PEDs that were not detectible or that were not yet illegal.
addiction in general has intensified over the past 15 years. The 2013 Tour de France winner, Chris Froome, stated:
 Psychoact
ive Drugs:Classificat
ion and History 1.39

cording to the population studied, which mental illnesses

"/ knowthe resultsI 9et are not 9oin9to be stripped
are included , and the organization conducting the study
10 ~earsdown the line... Forme it is a bit o[ a personal
Approximately one-third of those with a mental illness
missionto show that the sporthas chan9ed.
have a substance-abuse problem, and one-third of those
Chris Froome, Winner of the 2013 Tour de France, July 22 , 2013
with a substance-abuse problem have a mental illness. The
Substance Abuse and Mental Health Services Administration
In track and field, Marion Jones, a world-class sprinter in the
(SAMHSA) supports the "any door is the right door" treat-
2000 Olympics had to give back her five Olympic medals
ment access policy so that those with co-occurring disorders
when her drug use was finally confirmed.
can find help for both of their conditions regardless of where
The continuing battle between the street chemists who try to they enter the system." 9
satisfy athletes' desire to win at any cost and the various reg-
Implementation of the "any door" policy requires a treat-
ulatory agencies that try to keep athletic competitions hon-
ment facility to rethink their perception of dual diagnosis
est has made the public cynical about the effectiveness of the
and be equipped to handle both conditions. Mental health
system. The World Anti-Doping Agency was founded in
facilities approach drug-abuse treatment from a mental
1999 to promote, coordinate, and monitor doping in sport
health sensibility, and drug-abuse treatment facilities focus
in all of its forms.118 WADA conducts research, offers educa-
on the addiction.
tion about and development of anti-doping capacities, and
supports anti-doping policies in all sports in all countries . Generally, the mental health treatment community relies
heavily on psychotherapeutic drugs such as antidepressants,
In 2011 the Court of Arbitration for Sport ruled that an ab-
antipsychotics, and, to a lesser extent, antianxiety drugs such
normal biological profile can be used to ban cyclists from
as the benzodiazepines. In the drug-abuse treatment com-
participating in sports even if a specific drug is not found .
munity, there is a reluctance to use medications except
The program follows the blood profiles of riders over time,
to ease dangerous withdrawal symptoms, halt an opiate
looking for abnormal levels of hematocrit and other sub-
overdose, or help block drug cravings. These two approaches
stances that indicate the use of external substances to im-
illustrate the nuances of balancing the neurochemistry of
prove performance .
dual-diagnosis clients. As many drugs are under develop-
As of 2014 the banned substances include steroids, peptide ment for drug addictions as for mental health issues.
hormones, growth factors, beta-2 antagonists, hormone and
Another current issue is the overuse of psychiatric medica-
metabolic modulators, and diuretics. Also banned are certain
tions, especially for children. In 2005 the FDA required label
performance-enhancing methods such as blood manipula-
warnings on antidepressants, such as Celexa,'" Paxil,'"
tion and gene doping.
Prozac,® Wellbutrin ,'" and Zoloft,® to include the potential
for increased suicidal behavior in children as a side effect.121
Co-occurringDisorders The larger concern is the possibility that reliance on psychi-
Estimates about the incidence of dual diagnosis (a sub- atric medications may limit the amount of psychotherapy
stance use disorder and a serious mental illness) vary ac- that is made available for such cases.

On thefinal day of the 2013 Tour

de France (July 21), 169 riders
race toward thefinish line in Paris.
This one-hundredthedition of the
3,500-kilometer race throughout
France was the most scandal-free
in several dozen years.
© 2013 CNS Productions,
Inc.
 1.40 CHAPTER
I
DSM-5™
DSM-5 is the fifth edition of the American Psychiatric
Association's Diagnostic and Statistical Manual of Mental
Disorders, published May 18, 2013 .121 It supersedes the
DSM-IV-TR, published in 2000. In the United States, it is the
basic tool for the diagnosis of psychiatric disorders, in-
cluding substance-related disorders . Treatment recommen-
dations, as well as payment by healthcare providers, are of-
ten determined by DSM-5 classifications . In other countries
the World Health Organization 's International Statistical
Classification of Diseases and Related Health Problems
(ICD-10) is used.
A new general heading, "Substance-Related and Addictive
Disorders," which rates each addiction on a spectrum of
symptoms rather than on more-specific criteria, was adopted.
Many people were hoping that scientific advancements and
criteria would result in a manual that divorced itself from
symptoms and sign-based diagnosis. It didn't happen be-
cause the costs and the practicality of using the current brain
imaging and genetic testing for more-objective diagnosis are
prohibitive; thus the DSM-5's diagnosis of addiction is still
symptom and sign based. This leads to several problems. For
example, under "Alcohol Use Disorder," a client can be rated
as mild, moderate, or severe, so a situational mental imbal-
ance, such as depression when a loved one dies, that causes a
spate of binge drinking can become a lifetime diagnosis of
alcoholism even if the person is going to grow out of it.
There was much debate about including behavioral disor-
ders (non-substance-related disorders), such as sexual ad-
diction, compulsive shopping, and electronic game playing,
but the only one included in the fifth edition is "Gambling
Disorder," which includes online gambling . The other
potential addictions are listed in a section that says, "for fur-
ther study." "Feeding and Eating Disorders" still has its own
category.
Another problem with mental health classifications is the in-
flation of mental health categories. In the late 1800s, there
were only three or four conditions, such as depression and
psychosis; now there are hundreds. Because many diagnoses
are handled with prescription medications, such as antide-
pressants, there has been a dramatic rise in the cost of men-
tal health medication over the past 30 years.
Criticisms of the new DSM are generally accurate, but there
are no clear-cut solutions; perhaps multiple revisions every
few years are called for as research fills in the blank spots in
the overall picture of mental health and addiction treatment.
The Mental Health ParityAct
In 1996 the Mental Health Parity and Addiction Equity Act
was passed, defining mental health as an actual medical dis-
order that should be covered by health insurance in the same
way that any other chronic illness such as diabetes, asthma,
or high blood pressure is covered. m Various members of
Congress fought to include drug addiction treatment as one
of the mental health illnesses to be equally recognized as a
full medical condition and covered by health insurance. As
a result, the Addiction Equity Act of 2008 defined drug ad-
diction as another chronic mental illness that required fair
treatment and should be reimbursed as is any other medical
condition; but as of late 2013, no regulations have been ap-
proved for the addiction portion of the act to finance it so it
can be fully implemented.
Many states are afraid of a dramatic jump in costs when the
act is implemented, but when compared with the overall cost
of healthcare for addicts, particularly emergency room over-
utilization and the cost of putting offenders in prison, a de-
crease in costs is projected.
President Barack Obama's Affordable Health Care for
America Act includes specific regulations to fully implement
the Addiction Equity Act. The vital legacy of the Mental
Health Parity and Addiction Equity Acts of 1996 and 2008
are their firm validation that both mental health and addic-
tion are full medical disorders and not vestiges of weak
morals or a lack of will power.
BehavioralAddictions
(e.g., compulsivegambling, eating disorders,
and compulsiveInternet use)
"I wasin a car accidentthis morningwherem~car was totaled,
but I managedto tweetthe accidentand sendpicturesright
a~er I called9-1-1. Prett~cool, huh?Thegirl that raninto
me wason hercellphoneat the time."
25-year-old female cell-phone tweeter
Technology has created a new batch of addiction problems
and possibilities, from texting and tweeting to games like
Angry Birds,® Farmville, ® World of Warcraft,® Call of
Duty,®and Black Ops. ®The federal government banned text-
ing by truck and bus drivers, and most states have banned
the practice for all drivers. Even so, many drivers, teens in
particular, continue to text while driving. While most who
text are not addicted, one part of the definition of addiction
is "continued use despite adverse consequences." The odds
of having an accident increase 38-fold for those texting while
driving. These newer behavioral addictions are in addition to
more-traditional behavioral addictions such as eating dis-
orders, compulsive shopping, sexual addiction, television
watching, and especially compulsive gambling.
"If I wonall the mone~in the world,I'd haveto moveto a dif-
ferentworld.If I wonall the mone~in the world,there'dbe no
action;there'dbe no game becausethere'dbe no otherpla~ers."
45-year-old compulsive gambler
CompulsiveGambling
In 2013 in the new DSM-5, defining various mental illnesses,
gambling was finally included as a full-fledged addiction like
alcoholism and drug addiction-something that the treat-
ment community has known for some time. This includes
online Internet gambling. 121 Interestingly, two years prior to
this inclusion, the Federal Bureau of Investigation shut down

Legitimatefood companies
figured out how to tap into the
brain'.sdesire to "krave" theirfoods
by loading them with refined carbohydrates(sugar,high
fructose com syrup, etc.) fat, and salt. These two products seem to
acknowledgethat thinking.
© 2014 CNSProductions, lnc.
the three biggest online poker Web sites and indicted 11 exe-
cutives, charging them with bank fraud and money launder-
ing; the amounts involved hundreds of millions and even
several billion dollars. 122 Today an Internet search for online
gambling delivers more than 86 million pages and thousands
of sites . In addition to state-run slot machines and casinos in
f:14VE'Gi/24Nlf/Nf)@www.dav.granlund .com
Psychoactive Drugs:Classification and History 1.41
I
Nevada and Atlantic City, there are multistate lotteries, off-
track betting, and close to 500 Native American gaming es-
tablishments throughout the United States.
As governments continue to run up huge deficits, they look
for ways to raise money, and gambling is an attractive alter-
native to raising taxes . The state of Oregon derives about 9%
of its budget from gambling, mostly from video poker and
slot machines. All but two states (Utah and Hawaii)
have some form of gambling as do dozens of countries
worldwide. Gambling has gone mainstream. At one
point in 2013, there were still a half dozen different
Texas Holdem and Omaha poker shows on television.
Teenagers host poker parties at home with their parents'
blessing, and bars have Texas Holdem nights.
Gambling is an addiction like alcoholism and drug
abuse. In states where gambling is legal, 2.5 million peo-
ple are classified as pathological gamblers, 3 million are
considered problem gamblers, and another 15 million are
at risk of problem gambling .123
EatingDisorders
In 2013, for the first time in 50 years, the child obesity rate
dropped slightly, raising hopes that the "fat" epidemic in the
United States might be slowing. Obesity rates for U.S. adults
20 to 74 years old went from 13% in 1962 to 36% in 2010
and are projected to be 42% by 2030. 124
Even though 40% to 60% of susceptibility for addictions is
genetic, environment plays a crucial role in eating disor-
ders and has created a nation of overweight citizens. As
countries become more affluent, fast food becomes more
available, much of it loaded with fat, sugar, and salt to make
,,
it more desirable or, as research shows, more addictive. Dr.
David Kessler, former director of the FDA (1990-1997) and
••
© 2013 Dave Granlund
 1.42 CHAPTER1
I
author of The End of Overeating: Taking Control of the
Insatiable American Appetite (2009), showed how food com-
panies make food something to crave rather than to con-
sume for survival or to simply enjoy. 125 Eating is a recre-
ational activity for many Americans.
Eating disorders include bulimia, anorexia, and binge-
eating . Compulsive overeating is a separate item in DSM-5,
but it seems the most widespread condition that makes
America and other countries obese. To try to counter the
environmental factors that distort people 's relationship with
food, government agencies and health organizations employ
tactics on several fronts: removing unhealthy foods and soft
drink machines from school lunchrooms , requiring fast-food
restaurants to post nutritional information , calling for more-
detailed labels on foods, and promoting health y nutrition
and eating habits at the school level. A study of obesity found
that globally as many people are overweight as are under-
weight .126 The obesity rates in Germany and Italy are higher
than those in the United States.
Electronic Media
Media research by the Nielsen Company estimates that the
average American spends 4.5 hours per day watching tele-
vision, but the largest growth is in social media like
Facebook, Linkedln, Twitter, e-mail, texting , playing
games, and viewing movies and videos. Many people look
upon these activities as distractions , but there are some who
believe they cannot live if they are not "connec ted."
How can abuse and addiction to electronic media be de-
fined when the actual expenditure on a day-to-day basis is
not a substance but rather time? Well, if the time expen di-
ture is interfering with a person 's daily functioning (e.g.,
studying, spending time with family and friends , sleeping,
eating, exercising, and making a living) , it could be defined
as abuse; and if the activity becomes all-consuming, it is an
addiction. If someone spends five hours a day on Farmville
or another multiplayer online game, that activity consumes
35 hours a week or one-fifth of his or her waking life.
"/ thinkmi wifemi9hthavea realproblemwithWorldof
Warcra~ -s he spends7 or 8 hoursa daqplaqin9;and
whenI mentionedthisto a friend, he askedme ifI thou9ht
I had a problemas well. I don't thinkso, I mean, I onlq
spendmaqbe4 hoursa daqplaqin9. " self and causes epigenetic changes that can last a lifetime .
35 -year-o ld male video game player
Court-ReferredTreatment
Drug policy has shifted over the past 35 years from a heavy
emphasis on supply reduction to an increased emphasis on
demand reduction. Court-referred treatment is part of that
shift. All 50 states, the District of Columbia, Puerto Rico,
Guam, and more than 70 tribal locations already use or
are planning to institute drug courts, where a first-time
offender can be diverted from serving jail time to treat-
ment . From the first court started in 1989 in Dade County,
Florida, the numb er has grown to more than 2,600 drug
courts; hundreds more are in the planning stages. 127 There is
controversy surrounding some aspects of drug courts, but
most experts agree that when they are successful, the savings
to society (financially and socially) are significant. These
programs are known as "coerced treatment" because many
addicts would not have voluntarily entered treatment had it
not been legally mandated . Coerced treatment has demon-
strated better outcomes than voluntary treatment, according
to David Deitch , director of the Pacific Southwest Addiction
Technology Transfer Center at the University of California ,
San Diego.
Conclusions
Whether it is the abuse of opium and alcohol 10,000 years
ago or the abuse of bath salts yesterday and computer games
today, throughout history abuse and addiction have altered
government policies , created new social structures as the y
destroyed old ones, and hijacked personal hopes and pri-
orities. Today research focuses on brain structure and neuro-
chemistry to find reasons for compulsion and relapse; and
researchers use that information to study ways to normaliz e
the genetic and neuroch emical dysfunctions caused by
chronic use of psychoactive drugs and compulsive behaviors.
Research aside, some historians have suggested that the drive
to alter states of consciousness is as essential to human na-
ture as the drive to survive and procreate, even if the means
used to alter consciousness is damaging to the human be-
ing. 128 This concept is tenable only with the understanding
that the use of psychoactive substances can create a compul-
sion to continue using that supersedes survival instincts.
The drive to alter one's consciousness encourages botanical ,
pharmacologi cal, and technological advances that increase
the concentration of the active ingredients of these drugs ,
which then overwhelms the brain 's ability to rebalance it-
It is crucial to continue neurochemical research while refin-
ing treatment methods such as motivational intervi ewing,
stages of change , behavioral modification, and especially the
use of anticraving and normalizing medications to decrease
the burden that drug and behavioral abuse and depend ence
place on society

Classificationof PsychoactiveDrugs
Definition
• A psychoactive drug is any substance that directly
alters the functioning of the central nervous system
(CNS). Psychoactive drugs can be identified by their
chemical name, trade name, or street name.
• This book uses drug effects for a classification struc-
ture: uppers, downers, all arounders, and other
drugs. Even when new drugs are developed , such
as bath salts (uppers) and synthetic marijuana (all
arounders), they still fall under these categories.
Major Drugs
• Uppers: Stimulants, such as cocaine, methamphet-
amine, designer stimu lants (bath salts), diet pills, and
ADHD meds; plant stimu lants , such as betel nuts,
khat , caffeine, and nicotine; and psycho-stimu lants
force the release of extra energy chemicals. The stron-
gest stimulants-cocaine, methamphetamines , and
bath salts-can produce an intense rush.
• Downers: Major depressants include opiates/opioids,
sedative-hypnotics , and alcohol. Minor depressants
include antihistamines , skeletal muscle relaxants,
and over-the-counter (OTC) depressants. They de-
press various systems, control pain, reduce anxiety,
promote sleep, and lower inhibitions. They can also
induce euphoria.
• All Arounders: Psychedelics (e.g., marijuana, LSD,
MOMA, and designer drugs such as synthetic mari-
juana like K2 and Silver Spice) alter sensory input
and can cause synesthesia , illusions, delusions, and
hallucinations; physically, they can cause some stimu-
lation, some depression, or a dissociation of normal
brain pathways.
Other Drugsand Addictions
• Inhalants (deliriants) include organic solvents, vola-
tile nitrites, and nitrous oxide and can induce the full
range of upper, downer, and psychedelic effects.
• Anabolic steroids, human growth hormone, and other
substances are performance-enhancing drugs (PEDs)
used to increase endurance , muscle size, and aggres-
sion. New non-detectable PEDs are synthesized every
month to avoid drug tests.
• Psychiatric medications include antidepressants, anti-
psychotics, and antianxiety drugs . They are prescribed
to rebalance the brain chemistry . Generally, most are
non-addictive (except benzodiazepines).
PsychoactiveDrugs:Classificationand History 1.43
• Compulsive behaviors , such as food disorders , com-
pulsive gambling , sexual compulsion, Internet ad-
diction, and compulsive shopping, affect many of the
same areas of the brain that are influenced by psycho-
active drugs.
Historyof PsychoactiveDrugs
Introduction
• Historically , most presidents had ideas about drug use
in society, some about the drugs themselves , some
about the politics, and some about social issues such
as Chinese and Mexican immigration.
• The budget for the "War on Drugs" (1972 to the pres-
ent) has increased from $3.7 billion to $25.4 billion
in 2014.
• Demand reduction is more effective than supply
reduction.
Five HistoricalThemesof Drug Use
1. Human beings have a basic need to cope with their
environment and enhance their existence through the
use of psychoactive drugs and behaviors.
2. Human brain chemistry can be affected by psychoactive
drugs, behavioral addictions, and mental illness in
ways that will induce an altered state of consciousness.
3. Historically , the ruling classes, governments , and in-
dustry , alon g with criminal organizations, have been
involved in growing, manufacturing, distributing,
taxing, and prohibiting drugs.
4. Technological advances in refining, synthesizing, and
manufacturing drugs have increased the potency of
these substances.
5. The development of faster and more-efficient meth-
ods of delivering drugs into the body has intensified
the effects.
Prehistoryand the NeolithicPeriod
(8500-4000 B.C)
• About 4,000 plants yield psychoactive substances.
The earliest uses of psychoactive drugs involved
plants and fruits whose mood-altering qualities
were accidentally discovered and then deliberately
cultivated.
• Shamans were the key figures in exploiting psychoac-
tive substances.
1.44 CHAPTERI
Ancient Civilizations (4000 B.C.-A.D. 400)
• Sumerian, Egyptian, Indian, Chinese, Sou th American,
and other ancient cultures cultivated wheat and bar-
ley to make bread and alcohol. Throughout history
alcohol has been the most popular psychoactive drug.
It was considered a gift from the gods but also recog-
nized for its damaging effects .
• Opium was used as a medicine for its painkilling, sed-
ative, and euphoric effects.
• Marijuana was prized as a source of oil and fiber, for
its edible seeds, as a medicine, and as a psychedelic.
• Other early psychedelics were the mescal bean, San
Pedro and Peyote cacti, psychedelic mushrooms, to-
bacco, and coca leaves.
The Middle Ages (400-1400)
• Psychoactive "hexing herbs," such as belladonna and
mandrake, were used by witches and shamans for
healing and spiritual purposes.
• Ergot mold poisoning had LSD-like psychedelic
effects.
• Any psychedelic substance can be a medicine, a psy-
choactive drug, and a poison, depending on the dose.
• Distilled alcohol, coffee, and tea were discovered and
grew in popularity in a number of countries.
The Renaissance and the Age of Discovery
(1400-1700)
• The use of alcohol, coca, tobacco, coffee, tea, and opi-
um spread along the trade routes. The ruling classes,
governments, and merchants controlled the trade.
• The conquistadores controlled the coca trade in South
America. Other explorers brought tobacco back to
Europe and Asia.
• There was a resurgence in the use of opium as a medi-
cine in a variety of concoctions.
The Age of Enlightenment and the Early
Industrial Revolution (1700-1900)
• New refinement techniques (e.g., distilled liquor,
morphine from opium, and cocaine from coca), new
methods of use (e.g., hypodermic needle), and new
manufacturing techniques (e.g ., cigarette-rolling ma-
chines) increased use, abuse, and addiction liability.
• Ether and nitrous oxide were discovered as anesthet-
ics but also as a form of recreation.
• Temperance and prohibition movements also spread.
• Many patent medicines were loaded with a variety of
psychoactive drugs.
The Twentieth Century
• Tobacco use, through automation, milder leaves, and
widespread advertising, increased smoking to the
point that millions worldwide die prematurely every
year.
• Drug regulation started with the Pure Food and Drug
Act in 1906; dozens of others were passed over the
years, particularly the Controlled Substances Act of
1970.
• Alcohol Prohibition and repeal led to more criminal
involvement in the alcohol and drug trade .
• Marijuana use was made illegal in 1936. Since then
society has had mixed feelings about the drug.
• Amphetamines were widely used in wartime, for
weight control, and as recreational drugs in the hippie
movement of the 1960s and 1970s .
• Cheating in sports with PEDs was fueled by the Cold
War.
• New psychiatric medications such as antidepressants
have expanded the prescription drug market.
• New psychedelics, designer drugs, crack cocaine, and
synthetic versions of regular drugs have flooded the
illegal-drug market.
• The U.S. "War on Drugs" has used demand reduction,
supply reduction, and harm reduction to stem the
flood of drugs.
Today and Tomorrow
• The geopolitics of drugs, from the glut of opium and
heroin controlled by warlords in Afghanistan to the
control of part of the cocaine trade by the FARC in
Colombia, is always part of drug trafficking. Increasing
control of the drug trade in Mexico, increased opium
cultivation in Colombia and Mexico, and the growth
of large methamphetamine labs have led to increasing
violence and 60,000 deaths.
• The AIDS and hepatitis C epidemics have slowed, but
27 million people have died from AIDS, while 4 mil-
lion Americans have hepatitis C.
• The club and party scene still has traditional drugs
like ecstasy, nitrous oxide, and marijuana, but it also
involves the new designer drugs, including bath salts
(synthetic methamphetamine), synthetic marijuana,
krokodil, and kratom.
• Medical marijuana is allowed in at least 21 states, with
more to follow. Marijuana itself is legal in at least two
states (Washington and Colorado), again with more
to follow. The higher-potency marijuana is leading to
more dependency and a new syndrome called hyper-
emesis, where some chronic users can't stop vomiting.

• Governments and citizen groups try to control
tobacco use; and while it has decreased in the United
States, most other countries have use rates more than
twice that of the United States. Other delivery sys-
tems, such as electronic cigarettes, have become big
business.
• A resurgence in uppers, especially methamphetamine,
ecstasy, and cathinones, leads to more chronic users
seeking treatment. Weaker uppers such as energy
drinks, potent coffee drinks, and khat extracts are
keeping America and the world awake .
• Prescription drug abuse produced "Generation Rx,"
which has led to the "Millenniums," which has led
to "Generation Z," a group heavily involved in social
networking and anything electronic, including com-
pulsive and addictive use of the Internet and electron-
ic gaming. Abuse of prescription drugs, particularly
opioid painkillers and benzodiazepines, has quadru-
pled the sale of opioids since the early 1990s.
• Better brain-imaging techniques and genetic research
have broadened our understanding of drug depen-
dence and expanded effective treatment protocols.
• Alcohol continues to have the greatest social impact,
as it has throughout history
PsychoactiveDrugs:Classificationand History 1.45
• In sports Lance Armstrong and a number of big-name
athletes admitted to using performance-enhancing
drugs.
• In terms of treatment, a new diagnostic manual, the
DSM-5; new appreciation of treating co-occurring
disorders (addiction and a mental illness); and the
Mental Health Parity Act have added to the treatment
community's effectiveness.
• Behavioral addictions such as compulsive gambling,
eating disorders, and obsessive electronic media use
are finally becoming recognized as legitimate addic-
tions.
Conclusions
Abuse and addiction have altered government policies,
created new social structures, and hijacked personal pri-
orities. Psychoactive drugs and compulsive behaviors
overwhelm the brain's ability to rebalance itself and can
induce epigenetic changes that can last a lifetime. By
studying the history of drug use, society can improve
treatment techniques that are compatible with people's
genetics, culture, and neurochemistry.
This illustration of a nerve cell and its associatedstructures shows
the complexity of the central nervous system, the part of the body
most affected by psychoactive drugs. This cutaway view of a
synapse between several nerve cells exposes the nucleus, Golgi
apparatus, and mitochondria.Dendrites of other nerve cells
terminate as synaptic endings (boutons) on the cell membrane.
© 201D Francis Leroy.Bypermission
. Sciencephotos.
 The Neurochemistry
and the Physiology
of Addiction
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Th< crntr•I ner.uu ••}~t<m (CNS)-the bnrin and th< spina l oord- ar, <nmir.<d
to introducetheph)-.iologicalfr.tmeworkforthecvolvingscienceoladdictionand
ncOOV<C'JlHow psycho>ctivedrug, md compukh., behaviors affect the brain's neu -
roch<mistrythroughneurotr.m,mitt<n,r<c:q,tors,and ,yn.opticlunctioninvol,ing
the<ei<ncesofq,igenetics,,yn.opticplasticity,andallasta.sisis,xplain<d.Th,,ur -
viv..Llr<infOTC<m<ntcin:uit(al>ocall<dthe="trdlr,infOTC<Til<ntcin:uit)ofthe
br>in'soddictionpathw,yi,detai!Mbecauxitisth<hartoltheaddictiv,proc=

Addictionispu«ntedumoma lie,ollo ur ar<.0sof th<oddictionpathw ay

brain \ .,fu · ' <men tc'rru't "nvol · ~•no,,eracfve"go"• 'tch "n•'old

adamag<dorund<IXtive">1op",wi1ch inthecontrolcirru itin1h,newhroin

'mpa'redrommun\ cati nb<tw<mth,setwok<yc'rru'ties
:'.:;;::8~;;:r •stopp<dbain•=•th.atrnH<r,oov,ry<xtr<mdydifficultfOT

Th< memory proc=, of craving •long with cognitive im p;airm<nt of deci,ion -

making in <>.rlyr,oov,ry i, p=ted to aplain th< br.tin proc= involv,d in
ca,ing,slil"' . •rulrelaps,,
Thisclu.ptaal50pr<S<nl>mddefin<>th<•p<ctrumoldrug11><b<h.avior,,lrom
exp,rlm<nt1tion1o•buS<1ruladdiction . Th,w;ayth<><be lu.vion•r,class ified1rul
:::::~dinthe20lJDS.'-f -l .,"Substance-R<lat<dandAddictiv<Dison:ler,"is

AOOc0>ued1rethethroriesofaddictionandhow,-u!ner•hilityto1ddictioni,a
romhinationofh<Tedi1y,<nvironmrntal51r<S50f'.5(troum.o . st~ . •lru.,.,. mdnulri -
tioruol imh1Lrnc<>),1nd<,q,c,our,todrug,orcen.incompulsiv<b<lu.,ionth.at
acJ,,.t<on <'s>"Ulner•hilitj,:
 2.2 CHAPTER2
I
"I think one of the keq things that both addicts and nonaddicts
must understand is that this condition known as addiction
(and related drua,_ disorders)is an actual biologicalillness.
There are real differencesin the brainsof some people that rob
them of their abilitq to control their use of drugsor alcohol or
compulsivebehaviorsand then conspireagainst them once theq
enter recoverq,creatingan overpoweringneed t~ resumeusing.
It is important for them to know that theq aren t stupid or crazq
but that their brain functionsand operatesdifferentlq."
Darryl Inaba, Pharm.D., Addictions Recovery Center, Medford, OR
Eighty years ago Dr. William Silkworth, a physician at a hos-
pital for alcoholics in New York City, suggested that alcohol-
ism [addiction] came from a combination of an obsession
of the mind coupled with an allergy/illness of the body. 1
"All these [alcoholics], and manq others, have one sqmptom
in common: theq cannot start drinkingwithout developing
the phenomenon of craving.This phenomenon, as we have
suggested,maq be the manifestationof an allergqwhich
differentiatesthese people and sets them apart as a distinct
entitq. It has neverbeen, bq anq treatment with which we
are familiar,permanentlqeradicated.The onlq reliefwe
have to suggestis entire abstinence."
William D. Silkworth, M.D ., Alcoholics Anonymous' Big Book, 1939
To Dr. Silkworth an allergy implied that some susceptible
individuals will automatically exhibit negative physiological
reactions to alcohol with no regard to their personality, will-
power, or morality. What is most remarkable about this view-
point is that the science of addiction was in its infancy in the
1930s, but over time Dr. Silkworth's observations and con-
clusions have been validated by modern neuroscience,
psychological studies, brain-imaging techniques, and, most
conclusively, the behaviors of those afflicted with a sub-
stance use disorder (SUD). In 2008 President George W Bush
signed into law the Addiction Equity Act, validating addic-
tion as a true medical disorder in hopes of ending the long-
term stigma and discrimination targeted at those caught up
in an addiction .2
"Me and her drank together, went out together, but she is the
normal one and I'm the one that has that allergq. I cannot just
have one. Over the qears I started becominga blackout drinker,
obnoxious,violent. I could not admit I had a problem."
38-year-old male recovering alcoholic
'The inabilitqto stop is the essenceof what addiction is.
Mq favoritedrug was more and all."
Anonymous
In the 1930s Bill Wilson and Dr. Bob Smith incorporated Dr.
Silkworth's theory into the creation of Alcoholics Anonymous
(AA), a 12-step nonprofit organization aimed at helping alco-
holies recover. AA has proven remarkably effective; and
although AA describes itself as a spiritual program of recov-
ery, it recognizes the need to understand the physiological
roots of addiction.
"Whq is it that laboratorqanimals, on whom social, economic,
and educational variablesare inoperative,voluntarilq(indeed
avidlq) self-administerthe same drugs that human beingsuse
and abuse and will not self-administerother drugs?This argues
compellinglqfor a profoundlqimportant biologicbasisfor
substanceabuse."
Eliot L. Gardner, Ph.D., National Institute on Drug Abuse,
Behavioral Neuroscience Research Branch
Over the years drug abuse and dependence have been exam-
ined from historical, sociological, psychological, moralistic,
spiritual, physiological, and now neurochemical perspec-
tives, which continue to confirm the wisdom of Dr. Silkworth's
perception of addiction and suggest the direction of future
research.
>
Alcoholism[addiction]comesfrom a
combinationof an obsessionof the mind
coupledwith an allergyof the body.
'To developmore-effectivepreventionand treatment strategies,
we must deepen our understandingof how drugs affect the
complex inner workingsof the brain.Thanks to remarkable
advancesin bioscience,and particularlqin the neurosciences
over the past decade, this is a realisticgoal."
Nora D. Volkow, M.D., Director of the National Institute on Drug Abuse
How DrugsGet to the Brain
Psychoactive drugs are natural, semisynthetic, and syn-
thetic substances that directly affect the neurochemistry
and the anatomy of the CNS, causing mental, emotional, and
physical changes. The subfield of physiology that determines
the drugs' effects and abuse potential is pharmacokinetics-
the process by which a drug is absorbed, distributed, metab-
olized, eliminated, and excreted by the body. These are the
key factors in this process:
• route of administration
• speed of transit to the brain
• rate of metabolism
• process of elimination
• affinity for nerve cells and neurotransmitters
The more rapidly a psychoactive drug reaches its target in
the CNS, the greater its reinforcing (addictive) effect. 3
Routesof Administrationand Drug Absorption
The five most common ways drugs enter the body are inhala-
tion, injection, mucous membrane absorption, oral inges-
tion, and contact absorption (Figure 2-1).

Snortingandmucosa!
exposure
Inhaling
Bloodcirculation
The speed with which a drug reaches the central nervous system and
begins to have an effect depends on the m ethod of delivery. When
inhal ed (and absorbed in the lungs), injected (in a vein, muscle, or
und er the shin), snorted (through the nasal or buccal mucosa),
«:>2014 CNSProductions,Inc.
Inhalation
When a person
• smokes marijuana/heroin/tobacco/cocaine/methamphet-
amine ;
• "vapes" vaporized nicotine in e-cigarettes, vaporized
THC extract from marijuana ("dabbing"), or vaporized
alcohol; or
• inhales nitrous oxide , airplane glue, or isoamyl nitrite,
the vaporized drug enters the lungs and is rapidly ab-
sorbed through capillaries lining the air sacs (alveoli)
of the bronchi (air passages). From the capillaries-
minute blood vessels that connect the arterioles and
the venules of the lungs-the drug- laden blood trav-
els back to the veins and then to the heart, where it is
pumped directly to the brain and other organs and
tissues of the body. Inhalation acts more quickly than any
other method of use (seven to 10 seconds before the
drug reaches the brain). This method , known as avoid-
ing the first-pass metabolism , results in more of the drug
being available to affect brain cells.
The physical characteristics of the inhaled substance (volatil-
ity, particle size, and fat solubility) have an effect on absorp-
tion . Only a small amount of the drug is absorbed with each
puff or breath, but because the effects are felt so quickly,
The Neurochemistry
andthe Physiology
of Addiction 2.3
Drugdeliveredto the brainby blood
swallowed (and absorbed by the small intestines ), or absorbed by
contact (with the shin or mucous membrane ), the drug enters the
bloodstream and eventually makes its way to the brain.
users can continuously regulate the amount of drug they
are receiving (titration) . For example, cigarette smokers
regulate the blood nicotine level by how often and how
deeply they inhale.
Although more than 60% of the THC in a marijuana joint is
lost when smoked, the tars and other substances are still
inhaled , so medical-marijuana researchers have developed
safer inhalation delivery systems: a deep lung aerosol spray
(available in Canada and Europe) and a vaporizer using the
purified form of THC called dronabinol (Marino!®). A nasal
spray that relies on mucosa! absorption is also available.
Medical-marijuana advocates have also developed a vapor-
ization technique that delivers cannabinoids from the
marijuana plant without combusting, which avoids the
respiratory hazards associated with smoking. The plant is
heated in a kettle or in a specially designed apparatus (e.g.,
Volcano,® VaporOne,® or any of 400 oth er commercial
devices) to a temperature of 155 to 218°C, and the patient
inhales the cannabinoids from the vapor produced . Studies
have demonstrated a drastic reduction in pyrolytic smoke
compounds , resulting in a safer delivery system.•
The recent explosion in e-cigarette sales and the evolving
vaporizing techniques used to inhale alcohol or THC are also
examples of this method of drug administration , known
 2.4 CHAPTER 2
as "vaping." 4 Purified THC is obtained by forcing butane,
pure alcohol, and even CO 2 through marijuana buds and
even leaves. A "dab" or drop of the resultant high-potency
THC slush is dabbed onto a hot metallic surface or in an
e-cigarette, where the inhaled vapor can seriously affect the
I
user for hours.
The fastestroute of
administrationfor drugsto
reachthe brain is inhalation.
Injection
Substances such as methamphetamine, heroin, cocaine, and
steroids can be injected directly into the body with a hypo-
dermic syringe by any of three methods:
• intravenously (IV, or "slamming")-directly into
the bloodstream by way of a vein
• intramuscularly (IM, or "muscling")-into a
muscle mass
• subcutaneously ("skin popping")-under the skin
Injection is a quick and potent way to absorb a drug; 15 to
30 seconds intravenously or three to five minutes in a
muscle or under the skin. Because intravenous use delivers
a large amount of the drug into the blood at one time, inject-
ing a strong psychoactive drug produces an intense rush (a
brief and very intense feeling of excitation and mental plea-
sure), exaggerated sensations, and a high (euphoria). The
slower routes of administration can also produce euphoria or
a high but not a rush; the drug effects build up more slowly.'
The rush is the main reason why some users prefer IV use of
heroin, cocaine, and methamphetamine . In addition, none of
the drug is dissipated , as is the case with side-stream smoke,
poor nasal absorption, or destruction by body fluids and liver
metabolism when taken orally.
The large bolus (concentrated mass) of drugs from injecting
can cause exaggerated reactions or an overdose if the identity
and the purity of the drug are unknown. Once it is injected,
there is no turning back; the drug is in an enclosed system
that goes only one way. Injecting is the most dangerous
method of use because it bypasses the body's natural
defenses, exposing the user to health problems like hepatitis
Band C, abscesses, HIV infection, and contaminants that can
cause embolisms, infections, and other illnesses.
A number of drugs have been reformulated to be injected
intramuscularly and released into the bloodstream over
time. Time-release drugs include Haldol ® Decanoate (an
antipsychotic medication), Depo-Provera ® (a birth control
medication, injected once every three months), and Vivitrol®
(naltrexone, to suppress cravings for opiates and alcohol,
injected once a month). A naltrexone injectable pellet is also
available that releases the drug steadily over three months.
Mucous Membrane Absorption
Certain drugs in powdered form-especially cocaine, heroin ,
methamphetamine, or ground OxyContin ®-can be snorted
into the nose (insufflation) and absorbed by the capillaries
enmeshed in the mucous membranes lining the nasal pas-
sages. The effects are usually more intense and occur more
quickly than with the oral route because the drug initially
bypasses digestive acids, enzymes, and the liver. A nasal
spray containing a tranquilizer is being used in Sweden to
calm cancer-stricken children undergoing chemotherapy. 7
An older method of mucosa! absorption involves placing a
drug, such as crushed coca leaves (mixed with ash or soda
lime) or tobacco, on the mucous membranes under the
tongue (sublingually) or between the gums and cheek
(buccally ); using this method, it takes three to five minutes
for effects to begin. A Cannabis extract spray (Sativex ®) is
sprayed under the tongue . For severely ill patients who have
swallowing difficulties or are too weak to take an oral dose of
a painkiller , morphine anal suppositories are used (effects
from this route begin in 10 to 15 minutes) . The drug is
absorbed through tissues lining the rectum or vagina. Some
users employ these last two methods for recreational/
abusive/addictive drug use .
Oral Ingestion
When someone swallows a 10 milligram (mg) tablet of
Vicodin ® or drinks a beer, the drug passes through the
esophagus and the stomach to the small intestine, where it
is absorbed into the capillaries enmeshed in the intestinal
walls. The capillaries transport the drug into the veins, which
carry it to the liver, where it is partly metabolized (first-pass
metabolism). It is then pumped back to the heart and subse-
quently to the rest of the body. When drugs are taken in this
way, the effects are delayed 20 to 30 minutes. About 10% to
20% of alcohol is metabolized by the stomach in men, who
have more gastric metabolizing enzymes than women, so
women generally have higher blood alcohol levels after
ingesting the same amount of alcohol. Drugs enter the cap-
illaries lining the walls of the small intestine through passive
transport (absorption) .
ContactAbsorption
Drug-saturated adhesive patches applied to the skin allow
measured quantities of a drug to be passively absorbed for
up to 7 days; it sometimes takes 1 or 2 days for therapeutic
effects to begin. This noninvasive transdermal absorption
method is used with nicotine patches to help smokers quit,
fentanyl patches to control pain, clonidine patches to reduce
drug withdrawal symptoms or reduce blood pressure, and
heart medication patches to control angina (heart pain).
Some opioid addicts chew morphine or fentanyl patches to
get a maximum rush from the drug, but this can lead to an
overdose if the user miscalculates the amount of the drug on
the patch.
Drug Distribution
Regardless of the way a drug enters the circulatory system, it
is eventually distributed by the bloodstream to the rest of
the body. The actual amount of drug that reaches the brain
depends, among other things, on the bioavailability of the
drug . Bioavailability is defined as the degree to which the
active ingredients of a drug become available to the target
tissues after administration. The drug may be carried inside
 lhe Neurochemistry and the Physiology of Addiction 2.5

The Blood-Brain, Blood-Cerebral Spinal Fluid,

The veins and the arteries of the circulatory system in an adult carry
an average of 5 to 7 liters (L, about 6 qts.) of blood to every part of
the body. Miles of tiny capillaries then deliver the drug-laden blood to
tissues , including the nerve cells. The circulatory system also carries
the drug away from the brain and other tissues by filtering 500 gal. of
blood per day through the liver and the kidneys.
0 2014 Shubhangi Kene. Permission by 123 RF.
I
and Placental Barriers
The drug-laden blood flows through the internal carotid
arteries in the neck toward the blood-brain barrier, which
protects the CNS, the most protected organ system in the
body. The walls of the capillaries of this barrier consist of
tightly sealed epithelial cells that allow only certain sub-
stances to penetrate (Figure 2-2). Blood plasma carries oxy-
gen, glucose, and amino acids to the brain and carries away
carbon dioxide and other waste products. Generally, danger-
ous substances such as toxins, viruses, and bacteria are
unable to penetrate this barrier.
One class of drugs that can penetrate the blood-brain bar-
rier is psychoactive drugs (stimulants, depressants, psyche-
delics, and inhalants). Psychotropic drugs such as
antipsychotics and antidepressants also cross this barrier, as
do most steroids and some muscle relaxants. Stress can dra-
matically increase the ability of drugs to cross this barrier.
Psychoactive drug use often involves stressful or emotionally
charged situations, which could speed absorption of the
substance and perhaps exaggerate its effects. 8
A key reason why psychoactive drugs, including nicotine,
alcohol, and marijuana, are able to cross this barrier is because
they are fat-soluble (lipophilic ) ; and because the brain is
essentially fatty, it readily absorbs fat-soluble substances.
For example, morphine is partly fat-soluble, so it takes longer
to cross the barrier than more-fat-soluble heroin .9

the blood cells or in the plasma outside the cells, or it might

hitch a ride on protein molecules in the bloodstream; but any
psychoactive drug eventually circulates and travels to and
through every organ, fluid, and tissue in the body, where it
causes a direct effect or an indirect effect, is ignored, is
stored (usually in fat cells), oris biotransfonned into metab-
olites or chemical variations of the original drug, some of
which are also psychoactive. 3
The distribution of a drug within the body depends not only
on the characteristics of the drug but also on a person's blood
volume. A child of l2 might have only 3 or 4 qts. of blood
to dilute a drug compared with the 6 qts. in an adult circula-
tory system. The effect of a drug on specific organs or tissue
also depends on the number of blood vessels permeating that
site. For example, veins and arteries saturate the heart mus-
cles, and because all drugs pass through these vessels, a drug
Bacteria
andviruses
like cocaine can have a direct effect on heart function. Bones containedbybarrier
have fewer blood vessels, so most drugs have less effect on
these sites.
What is most important is the time factor. Within only 10 to
The inset shows the wall of a capillary in the brain, whose cells are often
15 seconds after entering the bloodstream, a drug will reach surrounded lry astrocytes-neurons that help plug the clefts, pores, or
the gateway to the central nervous system: the protective gaps in the capillaries to act as a barrier to most substances. Psychoactive
blood-brain and blood-cerebral spinal fluid barriers. Once substances, which arefat -soluble, are still able to cross this barrier.
these barriers have been breached, a psychoactive drug will 0 2014 CNS Productions, Inc.
have its greatest effects.

I
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<nttrtn3thebrain . Alooholbbothl!J>Ol'hllkandhydro-
phlllc,tohenter>thebr.,lnn<lly.
The blood-o:ubr.d ,pin&I Huid bonie r helps p,ncnt
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wh,n,1hitOuidllows(,ubon,ohnoidspa:,,,V<ntrick>,and
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Metabolis m and Exaet ion
Afu, a d"'lproducrs effa.u, i< is dimlnaled from the body
throuchrncubolHIDandcx<tt<i,c,n .
• Melaboliom i,; the body\ mechanism fo< procnsin11,
uol.,..andinactivating&Fottlpoubotan«thathas
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• Excrttl,c,niotheproc<HDF<limlnotlnMthefoneip•ul>-
llonccand!tsmetabollteofromd1<body.
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body lluua. Dru&<a.na~ be!nactlnlcd by body fat.,,.
p<D1Cinsthat abootb and""" oubotanca to prn=t them
from acting on o,pm. The ltvu is th< Uf metaboli c
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aff«uthebodybchour,0<days.DNpijluomokableroam<
&ndnlt=olridecratra""'jo<dl"c:t~just•F ...
mlnu1.. andar<quitll)·eliminattd.thou,o;hother<Ubtle1ide
dfecu an last for day> or wttlei . A drtlJI~ half-life is • ma-
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~llmlnatcd by th< body. Fn>m • d!nlcll ,undpoin<. it taka
.i.ou101><ortwohaU-livnlorad!-111tobecom<im<:lrn.tcd
ond about 6V<half-liv"' foo-• dn11 10 be IOUlly Lliminatcd
ftomthebody.lfthehalf -ll£,ohdn11islhom,iti.,..,."""'-
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th<TJtCinmarijuami,lOtnlOh.oun;&ndthatofProzac •
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toA<the,.has•lwF-lileol.i.outl ., hour,
ThelHel'iolheprimarymetlbol",r;
OIJMLlhti!bdneys-lhepmwlry
ucnet,a,yorgan.

The liver deactivates a portion of the drug with each pass through the
circulatory system.
0 2014 CNSProductions,Inc.
Through word of mouth and experimentation, some drug
users have learned how to deliberately create metabolites
to extend the effects of many drugs by using them in com-
bination with other drugs. 3 It takes longer than five half-
lives for a drug and its metabolites to become undetectable
because even tiny amounts can be detected by urine, blood,
hair, sweat, saliva, and other testing methods long after a
drug stops causing measurable effects. Urine tests for cocaine
can be positive for 2 to 30 days, amphetamines for 2 to 5 days,
heroin or Vicodin ®for 2 to 4 days, and marijuana (one joint)
for 7 to 14 days or longer, depending on the type of testing
used, the drug potency, how much is used, how chronic the
use, and also if its unique metabolites are being tested for.
The half-life as well as the bioavailability of any drug varies
widely depending on the individual.
In addition to standard urine testing, some employers test
hair. Psychoactive drugs are deposited into hair cells and
can therefore be detected as long as the hair is intact. Hair
grows about 1 to 1.5 centimeters (cm) per month, so testing
1 cm of hair cut close to the follicle will detect drug use
within the past month.
for
"/ was appl~in9 a job in Ve9asat a casino and found out
for
the~ did hair testin9 dru9s, which uses a strand hair of to
check(ordru9usefor the last numberof months(or however
lon9the hairtookto 9row). So, I shavedm~headand since
I hadn'tusedfor a week,I 9ot the job."
23- year-old female cocaine and marijuana user
Here are other factors that affect the metabolism and the half-
life of drugs:
lhe Neurochemistryand the Physiologyof Addiction 2.7
I
This resin cast of blood vessels in the liver, imaged by a scanning
electron micrograph, shows how the vessels infiltrate the liver. They
supply it with blood; gases and nutrients are exchanged so the blood
is detoxified.
0 2009 Susumu Nishinaga/Photo Researchers,Inc.
• Age. After the age of 30 and with each subsequent year,
the liver produces fewer and fewer enzymes capable of
metabolizing certain drugs; thus the older the person,
the greater the effect. This is especially true with drugs
like alcohol and sedative-hypnotics.
• Race. Different ethnic groups have different types and
levels of enzymes. More than 50% of Asians break down
alcohol more slowly than do Whites, and they suffer
more side effects, such as redness of the face, than do
many other ethnic groups.
• Heredity. Individuals pass traits to their offspring that
affect the metabolism of drugs. Those traits include low
levels of enzymes that metabolize the drug, excess body
fat that stores certain drugs like Valium® or marijuana,
and a high metabolic rate that eliminates drugs more
quickly from the body.
• Gender. Males and females have different body chemis-
tries and different body water percentages. Drugs such as
alcohol and barbiturates generally have greater effects in
women than in men.
• Health. Certain medical conditions affect metabolism.
Alcohol causes more problems for a drinker with severe
liver damage (hepatitis or cirrhosis) than it does for a
drinker with a healthy liver.
• Emotional state. Anxiety, anger, and other emotions can
exaggerate the effects of a drug. For example, an angry
person using methamphetamine can lash out and be-
come violent.
• Other drugs. The presence of two or more drugs can
exaggerate the effects by keeping the body so busy
 2.8 CHAPTER 2
metabolizing one drug that metabolism of the second
drug is delayed. For example, the presence of alcohol
keeps the liver so busy that Xanax®remains in the body
two to three times longer than normal. This exaggeration
of effects when two or more drugs are taken together is
I
called drug synergism .
• Exaggerated reaction. In some cases the reaction to a
drug will be out of proportion to the amount taken. Just
as a person with an allergy to bee stings can go into shock
from a single sting, a person with an allergy to a specific
drug might lack the enzyme that metabolizes that drug
and could die from exposure to just a tiny amount .
• Other factors. The user's weight and level of tolerance,
a woman's monthly hormonal cycle, enzyme induction,
enzyme inhibition, and environmental factors like the
weather can affect the metabolism of a psychoactive drug.
The NervousSystem
The principal target of psychoactive drugs is the central ner-
vous system, so it is important to understand how this net-
work of an estimated 100 billion nerve cells and 100 trillion
connections communicates .
• The CNS is half the nervous system . It comprises the
brain and the spinal cord .
• The peripheral nervous system is the other half. It con-
nects the CNS with its internal and external environ-
ments. The peripheral nervous system is further divided
into the autonomic and somatic systems.
Peripheral NervousSystem
Autonomic System
The autonomic part of the peripheral nervous system con-
trols involuntary internal functions such as circulation,
respiration, digestion, glandular output, and genital reac-
tions. It consists of the:
• sympathetic division, which helps the body respond to
stress;
• parasympathetic division, which conserves the body 's
resources and restores homeostasis (physiological bal-
ance) by inhibiting or opposing the physiologic effects of
the sympathetic nervous system; and
• enteric division, which coordinates reflexes, controls
digestive functions such as peristalsis , and reports on
internal mechanical and chemical conditions.
The autonomic system automatically helps us breathe, sweat,
pump blood, release adrenaline, and digest food, and it per-
forms other involuntary functions to preserve a stable inter-
nal environment (homeostasis). Sympathetic nerves speed
up the heart in response to stress, whereas parasympathetic
nerves slow it down when the threat passes.
Though many cell bodies of the autonomic system are located
in the brain (hypothalamus) and the spinal cord, they com-
municate with the affected organs and muscles via the
peripheral nervous system. When psychoactive drugs cross
The
Nervous
System
I
Central Somat
ic Autonomic
L_ Peripheral
__J
The various parts of the complete nervous system function together to
transmit, interpret, store, and respond to information from the
internal and external environments. Psychoactive drugs affect not
only emotions and thoughts but many bodily functions as well,
especially respiratory and cardiovascular functions.
© 2014 CNSProductions,lnc.
the blood-brain barrier, they can speed up, slow down, or
disrupt these involuntary functions in addition to triggering
emotional and mental effects, which is why a stimulant such
as cocaine can raise the heart rate, constrict blood vessels,
and cause heightened sexual sensations.
Somatic System
The somatic part of the peripheral nervous system trans-
mits sensory information about the environment and limb
and muscle position through sensory neurons that reach the
skin, muscles, and joints . It then transmits instructions from
the CNS back to skeletal muscles, allowing the body to
respond appropriately.
Central Nervous System
The CNS receives messages from the peripheral nervous sys-
tem, analyzes them, and then sends responses via the periph-
eral nervous circuitry to the appropriate systems of the body:
nervous, muscular, skeletal, circulatory, respiratory, digestive,
lymphatic, urinary, endocrine, integumentary, and reproductive.
The CNS also enables us to remember, reason, create, and
think, to respond to any situation . The brain and the spinal
cord act as a combination switchboard and computer .
Psychoactive drugs can alter information sent to the brain
from the environment, they can disrupt messages sent back
to the various parts of the body, and they can disrupt think-
ing. Psychoactive drugs affect not only the CNS but every
other system, as well. They can affect them directly while
passing through the organ or tissue, and they can affect them
indirectly by manipulating neurochemistry in the CNS, caus-
 lhe Neurochemistry and the Physiology of Addiction 2.9

ing distorted messages to be sent back to the organ. For
example, alcohol can directly irritate the lining of the stom-
ach and directly damage liver cells. It can also indirectly slow
respiration through its effect on the medulla oblongata in the
brainstem, located at the top of the spinal cord.
supply quick energy for fight-or-flight responses. The instinc-
tual desire for sex ensured offspring, guaranteeing survival of
the species.
The evolutionary perspective also theorizes that psychoac-
tive drugs have an affinity for natural survival mechanisms

Although the CNS is better protected (skull, vertebrae, and
meninges {membranes]) than the peripheral nervous system,
it is still vulnerable to internal assaults by toxins, particularly
psychoactive drugs.
Old Brain-New Brain
The brain can be described in three ways:
• anatomically, by its component parts-spinal cord,
brainstem (medulla, pons, and cerebellum), midbrain,
diencephalon ("interbrain"), and the two cerebral hemi-
spheres
• by function-vision center, motor cortex, somatosen-
sory cortex, and hearing centers
• by location-hindbrain , midbrain, and forebrain
Some of the clues about how psychoactive drugs work and
what causes addiction can be found by looking at the brain
from an evolutionary perspective . The evolutionary perspec-
tive looks at physiological changes in the brain as survival
adaptations. 213 ,214 For example, the desire for sweet-tasting
substances evolved from the need to identify foods that could
I
and initially cause effects that promote survival. Because
potent psychoactive drugs are relatively new on the evolu-
tionary time line and are more powerful than most naturally
occurring substances, however, the body and the brain have
not had time to adapt to their effects, which has allowed psy-
choactive drugs to hijack and subvert the brain 's survival
mechanisms. Using the evolutionary perspective, the two
major parts of the brain can be defined as the "old brain" and
the "new brain."
Old Brain
The old brain, also called the primal or primitive brain, con-
sists of the brainstem, cerebellum, and mesocortex (mid-
brain) , which contain the limbic system (the emotional
center). The spinal cord is considered part of the old-brain
system . Most of the old brain can be found in most all ani-
mals, from a fish to a human being (Figure 2-5). The old
brain has three main functions:
• regulating physiological functions of the bod y (e.g., res-
piration, heartbeat, temperature, hormone release, and
muscle movement)

Evolutionof the NewBrain

Newbrain Oldbrain

Fish

Note:Partoftheoldbrainiscoveredbyt
henewbrain.

On the evolutionary scale, from a fish, turtle, and frog, to a rat, cat, chimpanzee, and finally a human , the new brain has grown much larger than
the old brain, but the old brain tends to override it , particularl y in times of stress. Only mammals have developed a new brain (cerebrum and
cerebral cortex) of any siz e. The brain of an adult human weighs about 3 pounds.
0 2014 CNS Productions,Inc.
 2.10 CHAPTER 2
• experiencing basic emotions and cravings (e.g., anger,
fear, hunger, thirst, lust, pain, and pleasure)
• imprinting survival memories (e.g., that green plant
tastes good; this bad odor signifies danger)
The old brain responds to internal changes and memories
I
as well as to sensory inputs from external influences from
the environment. When a person's mouth or throat becomes
dry, the old brain recognizes thirst and triggers a craving for
something to drink. If a deer hears a twig snap in the woods,
the old brain registers fear, triggers a desire to escape, and
sends a "go" message to the legs and the body to run. When
humans are in a sensual situation, they will often desire sex,
and the resulting hormonal changes will move them to act.
When an individual uses a psychoactive drug, most often it
is the old brain that remembers the experience and how it
felt. Those memories can be triggered repeatedly, encourag-
ing continued drug use. 15.l 6 ,17 Emotions, rather than objective
reasoning, often decide whether to continue using. 18 ,19
Addictive psychoactive drugs
hijack and subvert the brain's
survival mechanisms.
New Brain
The new brain, also called the neocortex (cerebrum and
cerebral cortex), processes information coming from the
old brain, from different areas of the new brain, and from the
senses via the peripheral nervous system. When a person is
thirsty and craves water, the new brain helps locate the near-
est water source. If there is danger, the new brain might come
up with an alternative to running. If an executive decision
must be made about the relative merits of several courses of
action, the new brain, given time to react, can usually come
up with an appropriate solution. When there is no time (e.g.,
an emergency situation), the old brain reacts instantly. It is,
however, the new brain that weighs the possible conse-
quences against the benefits of taking action, experiencing
something, or feeling an emotion.
The new brain allows us to speak, reason, create, remem-
ber, make decisions, and then act. The old brain simply
"The prefrontal
cortex is
involved in
higher mental
functioning , like
using a can
opener and
remembering to
feed you ."
reacts. Over millions of years, but particularly the past
200,000 years, the old brain folded into itself as the new brain
grew around it. The new brain expanded to accommodate
billions of new cells. 20 ,21 The farther along the evolutionary
scale, the larger and more complex the new brain became
(Figure 2-5).
The old brain is the senior partner; the new brain is the young
upstart. Whenever the two brains are challenged by a crisis,
such as fear or anger, there is an automatic tendency to revert
to the more established old-brain function. And because the
craving to use a psychoactive drug almost always resides in
the old brain, the desire for the pleasure, pain relief, and
excitement that drugs promise can be very powerful. Craving
can override the new brain's rational arguments of "too
expensive" or "bad consequences" or "there's a midterm
tomorrow, so don't party tonight." The old brain acts four or
five times more rapidly than the new brain, so an action is
usually well under way before common sense kicks in.
'The impactof that dru9,the impactof that sensationand how
it immobilizedme and made me incapableof dealin9with the
simplestrealitiesof walkin9to the bus, of 9oin9 into m~ o(r!ce,
of 9ettin9on the phone.and of pickin9up m~children.was
so fn9htenin9to me that I did not want to repeatit. I was,
however,ver~compelledto repeatthe use of methamphetamine,
whichI did for~ears."
34-year-old female recovering meth abuser
During intentional abstinence from a psychoactive drug to
which an individual was addicted, drug cravings evoked by
memory and emotions result in a virtual tug of war between
the new brain, with its conscious desire to remain drug-free,
and the old brain that seeks to resume drug use, mistaking
the craving as a survival need.
Memory
The old brain and the new brain carry out their functions
by creating, storing, and utilizing memories. Without
memories it is impossible to learn, to act and react, and to
survive. Even emotions and cravings depend on memories.
Some memories are stored on a conscious level (explicit
memory), and some are stored at an unconscious level
CORNERED 0 Mike Baldwin.
AmericanUniversal Udick by permission.
AHrights reserved.
 The Neurochemistry
and the Physiologyof Addiction 2.11

I
Purkinjecell
This light micrographof an actual row of Purkinje nerve cells from
of cerebellum
the brains cerebellumshows the complexity of nerve cells and their
dendrites. The cerebellum-the largestpart of the hindbrain-
controlsbalance, posture, and muscle coordination.
© 2009 Alfred Pasieka/PhotoResearchers,
Inc.

The basic building blocks of the CNS are nerve cells or neurons. They
come in different shapes and sizes. Most of the branches extending out
from the cell body are dendrites that receive messagesfrom the axon
Storage of Memories Most memories do indeed last a lifetime
terminals of other neurons. The dendritic spines shown in the photo
on the right grow on these dendrites. because they are actually solid bits of protein imprinted on
© 2014 CNS Productions,Inc.
the brain as microscopic memory bumps called dendritic
spines. 23 -24 These tiny memory bumps grow from the den-
drites of nerve cells when the nerves are stimulated by a
sensory input . They can also grow from the soma or the axon
hillock of the nerve cell. Dendritic spines are constantly
(implicit memory). Storage, activation, and use of memo- forming and re-forming ; up to 20% of the spin es turn over
ries are at the heart of the obsession to use drugs, which is every day, culled and replaced by new ones , but the majority
one-half of the addictive process. 22 Researchers believe that become permanent and remain for a lifetime ."
implicit (subconscious) memories play a more important
role than euphoria and explicit (conscious) memories in the
development of the obsession aspect of drug addiction. Dr.
G. R. Uhl and his colleagues in the molecular biology branch
of the National Institute on Drug Abuse (NIDA) believe that
the high and the desire to repeat that high may ignite the
addiction , but it is subconscious memories that maintain it.
Obsession is just half of addiction ; the other half is the
"allergy" or extra sensitivity that vulnerable individuals
have to a drug and the neurochemical/anatomical changes
it induces in the brain, which trigger automatic reactions to
the substance .
Creation of Memories From the moment one is born, one's
brain begins to store memories. Initially, they are of feelings
and emotions: a baby cries when she is hungry because she
knows someone will respond and feed her ; she learned that
sucking her thumb is calming. As the years pass, colors,
shapes, sounds, and smells are remembered . Then learning The protrusionsseen here are called "memory bumps," ''footprints
becomes more deliberate , and we remember where our of memory," or technically,dendritic spines. The bumps grow when
bedroom is, who our friends are, and that the square root of stimulated by a sensory input. Each spine measures less than
81 is 9. We also learn what makes us feel good or relieves 0.25 millionths of a meter.More than 90% of excitatory synapses
terminate on spines. These are actual microphotographsof dendrites
our pain (physical and emotional). We learn that a brisk
placed on a neutral background. Glutamate receptors are plentiful
walk will relieve a depressed state. Our first experience with on the dendritic spines.
alcohol may be intensely pleasurable or make us very sick.
Courtesyof the MenahemSegal Laboratory
, Departmentof Neurobiology,
We are more likely to remember the pleasure rather than WeizmannInstitute,Israel.
the discomfort of being sick.
 Thcftattan ,,nlmaud IOOblllionnavtttl11in th<cmtnl
ncrvoussyste:m.andadinruror,haanywhettfromon,1<>
I0,OOOdrnclrita;a.chd<ndri1ccanst1pponupto50spi,,..
per l0mlcromn<n(millionthsofarn<1cr)oll,,ig1h. n..
toiala....,itylomom10U>,,.\iffllttd01l0 " (I0trillion)
_,,.~Dn1$1,-t..,....._.1Whenpeopl<
..... psy,,hoioct~ dntp. -- of the~""'
impr\nt«lonthebr1in:whe,.lhtyplh,drug,thtraoon
,hoy IIMd 11, and wbal. r,dinp (ernollonal and ph),ia.JJ
resul!<d.Th<Rronger<h<psychotlCll.,.,dru&,tb<"'°"'

I
>pi1>C1 ."'' htaWl,OOOormore1plnHwOTkingtog<ther rapld1h<1V<""'hon dprolife ratlonofmemorybumps,ond
lo form a oln&k memory , and Heh mtmory hH a number lhcn:lor, the more d«ply lmpr1ntcd ,he memory. '° The
ofconntetlon,1oo th<rm1,inorio 1.Th<v• rlou,pansofa arlicrln lif<•pe =mh<ginous!n Kpsy<h<>Kth..:drugsor
m<moryatt<onnccttdbytheolt<rat!onofdcndritic,pin<S practkaaddkti,·ebehaviors, the long,rand,<rong<rthe
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=~11~ mou linb an, formc:11nd th< 1110nc
pemu. - btou.,thtlnlormationfromthoK-tod<alwilh

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""'"'°"'dttplylmprint«lthanevaydaymm.oriabtta...,
moK dtndritic ,pi,.,. att crtattd from Ilk- n-.nts and
theyartmuchlaIXffthantl>oo<cru<tdfromav,r.,ge= -
oorylnpu1.•Th<fo rmationof,moc lonal mrn1oriai,coor-
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Mcmol'Ult ntcnt> might include th< ptln of a =·•,.
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pleuurtolskil11&•p<rftttrun,lhecrodcstnsatiomd.1fir>t s-r,sowfuture~lhemore-,
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z=-~~d:.'~U:.~~~ tl>efi=cacalneorm<thamplu:ton,lnerush,lhefinlcom -
r;.::i..,~-:--"a...iifi...,~k.:-.r,,,,,1
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ln101 sl mllu,ltuotion.lfweha-.1m11hprohl,mto50lve, l\ls11<t!vat«lbylh,memoryol 1 d.,!rabl<<motionalexperi-
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W1cxper1<nc,io..,lwthe""'problem . 1r...,ha,.,ona,gu - 001,irbcu....,o£ncpti.,.,fttLinp(t.a. , bo«dorn.dq,res-
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whe1herlt ....,.,.,nniogout 1113d.1pologi2ing.,;lhlloW<B, byust1111111bu.aldrug.M<rnor1aofwithdr:1..,,[ondodid'
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-..ut1,,,,.~..,.ur-w.Wa(..,,._,T

The Addiction Pathway and Its Survival
Reinforcementand Control Circuits31 ,34
The area of the brain that encourages a human (or any
mammal) to perform or repeat an action that promotes
survival is called the survival/reinforcement circuit. Its
normal function is to reinforce an action that promotes
survival (e .g., eating , drinking, having sex) . It is also the
part of the brain most affected by psychoactive drugs .
Technically, this circuit is referred to as the mesolimbic dopa-
minergic reward pathway (Figure 2-7). This brain circuit is
located in the old brain.
This survival/reinforcement circuit, located in the old
brain, acts as a "go" or "more" switch . At the heart of the
circuit is the nucleus accumbens septi (NAc). The ventral
tegmental area (VTA), lateral hypothalamus, and amygdala
also play important roles .
The control circuit, located mostly in the new brain, acts as
a "stop" switch and is driven by the left orbital prefrontal
cortex . The "stop " switch works in conjunction with the
fasciculus retroflexus and the lateral habenula , which con-
nect and communicate information from the "stop " switch to
the "go" switch .
The "Go"and "Stop"Switches
Normally, the "go " switch does three things when activated:
• It tells us that what we are doing is necessary for sur-
vival, giving animals and humans a feeling of satisfaction
(a kind of reward) when th ey fulfill a need that has been
triggered by an instinct , a physical imbalance , a memory,
or pain. 30 The body and the brain strive to maintain bal-
ance (homeostasis), so the "go" switch steers them to
the appropriate behaviors.
• The "go" switch also tells us to remember what we
did to survive (e.g. , escape, find food, gain comfort, or
relieve pain) .
• It then tells us, "Do more of whatever you did--<l.o it
again and again until you are satisfied; it is necessary
for your survival. " The constant message increases the
importance of the action, so the desire is pumped up to
make us satisfy it more urgently.
When the need has been satisfied, the pain relieved , or the
imbalance rectified, the "stop " switch shuts down the "go"
switch and the "do it again" message ceases. 32 •35 The release
of glutamate from the prefrontal cortex reaches back to the
VTA and signals the cells to stop releasing dopamine, thus
shutting down the "more " or "do it again " message. 36 Though
usually an excitatory neurotransmitter, glutamat e also
decreases the saliency (prominence) of dopamine at the NAc
"go" switch, helping weaken it and shut it off.
Hijackingthe Survival/Reinforcement
and ControlCircuits
When a psychoactive drug activates this pathway, the result
is a feeling of satisfaction, a high, or physical/emotional pain
relief, which prompts the "go" switch to urge the person to
The Neurochemistryand the Physiologyof Addiction 2.13
Structures
oftheSurvival/
ReinforcementCircuitand
theControlCircuit
I
Prefron
tal
cortex--- --
Orbitofrontal
cortex
Nucleus
accumbenssepti
Lateralhypothala
mus
Amygda
la
Substant
ia nigra
The survival/reinforcement circuit of the brain'saddictionpathway is
really a combination of several structures in the old brain that are
activated when a person respondsto some emotion or f eeling that has
arisen, such as hunger, thirst, or sexual desire. The principal parts are
the ventral tegmental area, the nucleus accumbens septi, the lateral
hypothalamus, and the amygdala, The control circuit of this addiction
pathway is located in the new brain. It turns off the survival/
reinforcementcircuit when its needs are fulfill ed. Its principal parts
are the prefrontal and orbitof rontal cortexes along with connective
fibers:fasciculus retro-flexus and lateral habenula.
© 2014 CNSProductions, Inc.
"do it again, do it again ." For substance abusers who have
altered brain chemistry, the "go " switch is more powerful
than normal and the "stop" switch becomes dysfunctional
and does not shut off the craving , so the person continues
to use because there are no instructions to stop . The sur-
vival/reinforcement and control circuits have been hijacked ,
so the individual continues to use drugs, trick ed into sensing
that survival depends on it .
As chronic heavy use continues and the neurochemistry
changes, the "do it again " message becomes impossible to
ignore , resulting in drug-seeking/using behavior regardless
of the amount of pleasure the user experiences or the
destruction the use ultimately causes.
'Towardthe end of m~craz~ gambling , I remember
plafng cards
at two in the morning, just wishingI wouldhurr~up and lose
and go homebecauseI couldn't stop if I had an~mone~left.
I'd actual/~get pissedoff if I wonbecausethat meantI'd have
to sta~ longer.I wasnailedto that chair."
48-year-old male compulsive gambler
The "stop " switch is often totally disabled by chronic drug
use , rendering it useless to stop even a mild craving from
turning into drug use. The overriding message at a subcon-
scious level is "If you don 't do it again , you will die ."
 2.14 CHAPTER 2
I
The memory of drugs. These positron emission tomography (PET) scans show the brain of an addict after
watching a nature video (lejr) and after watching a video of cocaine and drug paraphernalia (right). The
emotional control center (amygdala) of the brain did not light up or get excited lry the nature video but memories
of previous drug-using activities were stimulated by the cocaine video, and the amygdala lit up, most likely
signifying phase I of craving.
Courtesy of Anna Rose Childress
"Cracktastes like'more';that's all I can saq.You takeone hit,
it's not enou9h, and a thousand is not enou9h. Youjust want
to keep9oin9on and on becauseit's likea 10-secondhead rush
ri9hta~er~aulet the smokeout, and ~audon't9et that effect
a9ain unless~au take another hit."
32-year-old recovering crack addict
When the brain's addiction pathway is activated by psychoac-
tive drugs, especially in susceptible individuals, the impact is
so strong that the drugs can imprint and reinforce the emo-
tional memory of euphoria or pain relief more deeply than
most natural survival memories, making repetition of the
behavior even more likely.37 Experiments showed that rats
learned behaviors more rapid ly when they were coupled with
drug acquisition and that unlearning a drug-related negative
behavior took long er than normal.3 8
To test the strength of the memories of drug use and their
ability to trigger craving in humans, re.searchers showed a
video containing information about cocaine use to a group of
cocaine users. Functional magnetic resonance imaging
(£MRI) scans of their brains (photo above) showed activation
of the memories and the subsequent craving in their brains,
as did their subjective reports of these feelings. When sub-
jects were shown nature videos, there was no trace of either
craving or activation of memories. The control group of non-
addicts were shown the same video containing visua ls of
drug cues and showed no activation or craving. 39
Additiona l fMRI research by Dr. Edythe London at the
University of California, Los Angeles (UCLA) demonstrated
that when recovering addicts go into a craving reaction, their
control ("stop") switch becom es deactivated while their
emotional memory processes ("go" switch) be come hyper-
active. This research also showed that an area of the brain
known as the posterior cingulate became hyperactive (like
the amygdala) during craving. The cingulate is associated
with emotional bonding that can develop in humans.
Cravings in addiction involve positive emotiona l memories
that encourage bonding with the addiction while losing
control over one's normal behaviors. 40
'When I starteddrinkin9, ever~thin9 wentblankin mq mindas far
as thinkin9, feelin9s,
emotions . So /, like,kindof started9ettin9
usedto it. I said,Well, that numbedme the ~rsttime.· I didn't
thinkof howI wasabusedor the sexualmolestation , so I just
continuedon, ever~da~.and then I 9ot usedto the alcohol."
42-year-old recovering polydrug abuser
The survival/reinforcement circuit's "go" switch can be acti-
vated by psychoactive drugs at several locations in the
brain and often through different mechanisms (depending
on the substance used). Alcoho l might activate the nucleus
accumbens via the globus pallidus, heroin through the VTA,
and cocaine directly through the NAc. 4 C42 It is the activation
of the core of the nucleus accumbens rather than the shell
that triggers intense craving and relapse. 43 Exposure to an
addictive drug or behavior is not required for activation; it
can be caused by a person's memories or craving cues or just
by thoughts of using.
"/ lovedto 9amble. I mean, I'vealwa~slovedto 9amble.
Oh, I spentever~hourof the da~ I could,9amblin9.
When I was~oun9,I'd rather90 out and9amblethan
havesex with a 9irl. I mean it was the truth."
SO-year-old male compulsive gambler
The greater responsiveness of the "go" switch to certain psy-
choactive drugs or behaviors in those who are addicted or
vulnerab le to addiction makes nondrug activities less plea-
surable, so a dependence develops for the substance or the
compulsive behavior that will deliver intense experiences.
The release of dopamine from other non-add ictive activities

is less intense and nol as effective al solving problems or
relieving pain, boredom, depression, anger, or anxiety.44 For
example, over Lime methamphetamine releases more dopa-
mine and norepinephrine in a meth addict's brain than does
the relationship she has with her children.
"Mqbrainwasconstantlqsaqin9,'just anotherhit, just another
hit,' and it scaredme. HereI was,pre9nant
, bi99iantbellq,
waddli"I)around,and I wanteda hit ofdope."
36-year-old female recovering meth addict
>
When drugs are used chronically, nondrug
activities are less pleasurable, thus further
increasing drug use .
Because the survival/reinforcement ("go") circuit is located
in the old brain, it is intimately connected with the physio-
logical regulatory centers of the body (autonomic sysLem).
Consequently , when drugs are used for intoxication or plea-
sure, they also affect physiological functions , especially
heart rate and respiration; stimulants speed up these func-
tions , and depressants slow them down. It is the effect of
depressants on respiration that causes most drug-overdose
emergencies and deaths. Stimulants commonly produce
very high blood pressure, arrhythmias, high body tempera-
ture, seizures, and rebound respiratory depression.
Psychedelics have a greater effect on the new brain, although
to a lesser extent they also affect physiological functions in
the old brain (e.g., LSD stimu lates and marijuana sedates).
Most psychoactive drugs also affect memory because they
cause loss of neurons in the hippocampus, which is a key
part of the amygdala, the area of the old brain that coordi-
nates working memories. This impairment leads to memory
lapses and distortions. ·0 •46 Emotionally tinged memories
involve the amygdala , which becomes hyperreacLive to addic-
tion memories.
One of the things that differentiates humans from other
mammals is that by the age of three or four the neocortex
(new brain) in humans becomes more complex and better
able to reason than it does in other mammals. Its value cen-
ters on problem-solving skills that aid survival, taught from
birth by parents, relatives, teachers, neighbors, and peers.
The new brain has a much greater density of neurons than
the old brain and, given enough time and learning, can over-
rule the more immediate and ini tially stronger response of
the old brain.
In most cases, as people grow up they continue to learn how
to integrate the drives of the old brain and the common
sense of the new brain. Some people, however, lose some of
this ability due to genetic learning abnormalities, a chaotic or
abusive childhood, and especially the use of psychoactive
drugs and the practice of compulsive behaviors. Psychoactive
drugs subvert the survival mechanism from the common-
sense integration of the new and old brains, resulting in
the irrational behavior of addiction, which relies on the
"wants" of the old brain rather than the rational "needs" of
the new brain. 47
lhe Neurochemistryand the Physiology of Addiction 2.15
"WhenI'mreallqtired, I wantto drink.If I'mreallqanarq,
I want to dnnk. If I'mreallqhappq, I wanta dnnk. And so
the addictioneclipseseverqthin9elseand so there'snot a
pursuitofeverqdaqstuff 'causeeverqthin9leadstohowam
I 9oin9to copewithit 'bqdrinkin9or bqdru8.'}in9mqsel(."
I
35-year-old male recovering alcoh olic
NucleusAccumbensSepti and the •Go" Switch
The most important part of the survival/reinforcement circuit,
the NAc, 17 was first identified in 1954 by Canadian biologist
Dr. James Olds." What Dr. Olds and others hypothesized,
and has now been proven, is that the nucleus accumbens is
a powerful motivator (reinforcer). It gives all mammals
(humans and animals) certain feelings that drive them to
actions that primarily ensure their continued survival.
Experimentally, Olds and his research partner , Dr. Peter
Milner, attached an electrode to a rat's NAc and then con-
nected it to a battery and an electrical switch. Once the rat
pressed the switch , activating that pan of its brain, it would
not stop. In fact, the action was so powerful a reinforcer that
the rat would press the switch 5 ,000 times per hour. It
would not eat, it would not sleep, and iL had no interest in
sex-it just continued to push the swiLch. Although eating,
sleeping, and sex also activated the NAc and are necessary for
a mammal's survival, direct brain stimulation of this nuclei
had a more powerful influence on behavior.
Dr. Robert Heath in Louisiana tried this experiment on
humans in the late 1950s. An electrode was implanted in the
subjects' NAc, and they were given a switch attached to a
battery that when pre.ssed stimulated that part of Lhe brain.
Like the rats, the humans pressed the swiLch again and again
and again. They commented on how good it made them feel,
but most often they simply felt this obsessive need to press
the switch repeatedly.
Olds, Miller, Heath, and other researchers found that the
psychoactive drugs that result in addiction stimu late the
mammalian NAc as powerfully if not more so than does
direct electrical stimulation. 49 When a rat pushed the lever
that delivered a shot of cocaine, the rat would push that lever
in much the same way it pushed the switch for the electrical
stimulation. In fact, the rats continued to push the lever to
the exclusion of everything else; they pushed it until they
died of thirst or starvation.
The actions of the rats are similar to those of humans who
use certain psychoactive drugs. Rats respond to the same
psyc hoactive drugs as humans, and the order of preference
is the same; that is, the more intense Lhedrug is to rats, the
more intense it is to humans. This indicates that the brain
reacts in a certain way not because of a negative environ-
ment or an abusive childhood or peer pressure or poor
morals but because of the way the brain is designed, espe-
cially the survival/reinforcement and control circuits that
compose the addiction pathway. Heavy use of a drug alters
neurochemistry, which makes the NAc far more sensitive
than normal to the drug and to relapse. 50
 2.16 CHAPTER 2

This does not imply that environmental surroundings, emo-

tional states, and peer pressure have no effect on drug use.
The effect of social/environmental factors has more to do
with the obsession to use and the desire to change how one
feels. The effect of altered brain chemistry has more to do

I
with the reaction to the drug itself-the "allergy" as first
proposed by Dr. William Silkworth in the 1930s.
As a reminder, the key parts of the medial forebrain bundle
in the old brain that play a major role in addiction (besides
the nucleus accumbens septi) are the lateral hypothalamus,
the amygdala, the ventral tegmental area, and the lateral
habenula. These five nuclei of that area of the brain consti-
tute the survival/reinforcement circuit in the old brain that
composes part of the addiction pathway.

"Stop"Switch: Orbital (particularlyleft) PrefrontalCortex

When the brain is functioning normally, a survival behavior
(eating, hydrating, sex) activates the survival/reinforcement
circuitry; and once the need is satisfied, the control circuit
activates its "stop" or satiation switch to tum off the "go"
switch. "5 1 The control circuit consists mainly of the orbital
prefrontal cortex (especially the left ventral area) along
with the fasciculus retroflexus (FR) and the lateral haben-
ula (Hbn), which is also part of the old "go" circuit. The FR
and the Hbn are fiber bundles of neurons that form a com-
munication network between the control and survival/
reinforcement circuits of the addiction pathway. In a person
who has crossed the line into addiction, the "go" switch is
overactive and the "stop" switch is either underactive or
unable to communicate the "shut it down" message back to
the survival/reinforcement circuit. The altered compulsive
user's brain gets stuck in a "do it again," "do it again" mode.
What happens to the addiction pathway after craving has been
activated? Are the changes to the "go" and "stop" switches,
disrupted by psychoactive drugs, permanent or reversible?
'Thereareswitchesthatallowchan9esin the wa~g,neswor/cthe~
canbe turnedon or turnedoff One of thethin9sthat alcohol
does is it turnson and turnsoff someaenes.And as it does
this,it chaneestheproteinsin thosecellsand theenz~mes
that
those proteinsfunctionas, and that chanaesthe communication
betweenthe celt ultimate/~leadin9to a chaneein thenetwork
of thecelt and ~auB't a differentkindof behavior
."
Dr. Ivan Diamond, director, Gallo Research Institute
The activity or function of a brain cell can change as addic-
tion develops. If an action is repeated five or more times
within an hour, it is more likely to be remembered; chronic
use leads to encoding a memory function in a neuron for
future actions. An intense stimulus can cause sensitization
with just one encounter. 52 This increase in neural connec-
tions results in heightened sensitivity to the drug, thus
increasing the risk of relapse even after drug use stops.
This process is called long-term potentiation.
There are a number of theories about how psychoactive
drugs affect the "go" and "stop" switches of the addiction
pathway.
0 2014 Dave Granlund. All rights reserved.
• One theory centers on the premise that because the feel-
ing of survival need or reward did not originate from an
essential need of the body but rather from hijacked "go"
and "stop" circuits, there is no satiation point, so nor-
mal operation of the "go" and "stop" switches does not
come into play.
• Another premise is that the signals from the "go" and
"stop" switches are willfully ignored, enabling the user
to continue to experience the euphoria or pain relief de-
livered by the psychoactive drug.
• A third theorizes that in addition to disabling the ability
of the "stop" switch to make decisions and send a "stop"
message, psychoactive substances also disrupt commu-
nication between the "stop" and "go" switches, so al-
though users know they should stop, that information is
not being sent to the old brain. 53
One conduit of communication that becomes damaged is
the fasciculus retroflexus, the cluster of neuron fibers that
normally communicates the "stop" message from the "stop"
switch to the "go" switch once satiation is achieved. In an
addicted brain, "stop" messages never reach the old brain. 54
Damage to the FR can occur very early in chronic drug use.
Young people who drink heavily can damage this nerve path-
way after just a few binges. Nicotine is especially toxic to
these FR neurons, destroying their communication ability
with each exposure. Another part of the "stop" mechanism is
the latera l habenula, embedded in the old brain and triggered
by the FR; it normally shuts off the "go" switch by limiting
the release of dopamine. 55 5 6
"Idon'tlikebein9stuckon stupid,like,tweakin9
all the time.When
I'mdoin9speed,I'mjustin thiswholelittleworld,can'tB't me
out of it, findin9somethin9,
nothin9,andever~thin9 in thedirt."
24-year-old polydrug addict

In an addicted brain, "stop" messages never
reach the "go" switch in the old brain, partially
due to a damaged bundle of nerves called
the fasciculus retroflexus.
Certain behaviors, such as compulsive sex, gambling, and risk-
taking, also activate the addiction pathway of the brain and so
are subject to addictive behavioral patterns. The disruption of
the "go" and "stop" switches due to a behavioral addiction
is very similar to that which occurs due to drug addiction.
The longer a drug is used or a behavior practiced, the more
the brain changes to try to protect the body (allostasis). The
changes are not necessarily beneficial, so it becomes harder
to restore the body to healthy, balanced functioning (homeo-
If changes persist until addiction has occurred,
stasis). 31·57·58
the brain and the body establish a "new normal," which is an
allostasis need to continue exposure to the drug or behavior
just to remain functional. This abnormal functional state
manifests in withdrawal symptoms when exposure to the
addictive drug or behavior is discontinued.
The Stay-Stopped Areas of Low Brain Activity
and Relapse
An overactive "go" circuit in the old brain, an impaired
"stop" circuit in the prefrontal cortex of the new brain, and
a lack of communication between those two centers are
three key factors that determine an individual's vulnerabil-
ity to addiction. Recent research is exploring the possibility
that different areas of the brain make some individuals more
vulnerable to relapse during their struggle to maintain sobri-
ety. These areas of the neocortex are the stay-stopped brain
areas. Abnormally low electrical activity in these cortical
areas determines an addict's risk of relapse during recovery,
with a predictability rate of almost 90%.
In 2005 scientists discovered decreased activity in five dis-
crete areas of the brain's neocortex (see below) that corre-
lated to a high risk of relapse in meth addicts who graduated
from a 28-day residential treatment program. 81,82
Functional magnetic resonance imaging was used to measure patterns of regional brain activity in recovering methamphetamine abusers when
they performed a decision-making task. These images show the areas that were significantly less active in those who relapsed than in those who
stayed in recovery.
0 2005 Tapert and Schuckit
lhe Neurochemistryand the Physiology of Addiction 2.17
In the study conducted at the University of California, San
Diego, 46 men who completed a 28-day recovery program
had their brains scanned with an fMRI scanner while perform-
ing two decision-making tasks and again while doing a non-
decision-making task. The fMRI scans and measures functional
I
activity in the brain. Thirty eight of the 46 men underwent
brain scans again up to three years later. The results were com-
pared with the initial scans. Eighteen men had relapsed, and
20 had not. The brains of 17 who had relapsed showed sig-
nificantly decreased activity in five distinct areas of the brain
associated with decision-making, specifically evaluation and
choice. The areas consisted of a distinct portion of the right
insula, right inferior parietal lobule, right middle temporal
gyms, left caudate/putamen, and left cingulate gyrus. In
those who had not relapsed, the five areas were fully active;
in essence their decision-making competencies-the ability to
make non-destructive choices-had returned.
Prospective application of this research demonstrated the
ability to predict with up to 90% accuracy a slip or relapse
occurring within a year for those graduating from treat-
ment programs if these areas had low activity. Thus, if an
addict discontinues rigorous treatment efforts before these
"stay-stopped" areas of the brain have fully returned to func-
tionality, the ability to remain in sobriety will be greatly
compromised.
Subsequent research conducted at Yale University in 2011
by a team headed by Dr. Kenneth Banda confirmed that
abnormally low electrical activity in the frontal and posterior
cortical area predicted relapse to alcoholism. 83
>
Scans of the "stay-stopped" circuit gives the
treatment community the ability to predict a
slip or relapse with up to 90% accuracy
More research is needed to predict which addicts will
potentially relapse after treatment (thus requiring more
treatment) and which will be able to maintain abstinence.
The question of whether the susceptibility to relapse is
caused by areas of the brain damaged by drug use, a genetic
 2.18 CHAPTER 2
component that makes these areas more vulnerable, a stress-
ful environment that altered these decision-making areas of
the brain, or a combination of all three will be examined over
the next few years. The goal is to identify those who need
more-intensive and prolonged treatment to allow their
I
brains time to regain the necessary decision-making abili-
ties before they return to dangerous, drug-trigger-filled
environments.
'Thoseof us involvedin addictiontreatmenthaveknown,or
~earsthat therearepeoplewhowillrelapsere9ardlesso how
oftenthe~90 throu9htreatmentandpeoplewhowillrespond
almost immediate/~and do what is requiredto recoverri9ht
from the start. Most clientsexist somewherein betweenthose
two extremes,so predictin9their levelof susceptibilit~is hard to
do. I've seen almost a half millionaddicts treated overa period
of 40 ~ears . and thisspectrumof susceptibilit~existsin all of
them. Mosttreatment professionalsbelievethat further research
willhelpzeroin on the 'sta~-stopped' predictiveareasof the
neocortex;and usin9less expensivetechniquesthan fMRJscans,
we will be able to tailora treatment plan forclients."
Darryl Inaba , Pharm.D ., Addictions Recovery Center , Medford, OR
Morality and the AddictionPathway
Throughout human history, primal urges, intense emo-
tional memories, and desires that primarily reside in the
old brain have been pitted against reason, common sense,
and morality, which mostly reside in the new brain. In his
writings Sigmund Freud explored the id, ego, and superego,
outlining how the superego tries to rein in the primal urges
of the id and how this conflict is the cause of many of the
mental abnormalities in human beings. 59 In many addicts
this conflict is more pronounced, but "the old brain rules!
usually."
"Ifit wasup to me feedin9m~kidsor9ettin9m~nexthit, mq
kids werenot 9oin9 to eat. If it was up to ~e to bu~ a 9allon of
milk,orpa~the rent. or pa~a bill. it wasnt 9oin9to happen.
It had to be me. I comeprst- that selpsh,self-centered,
self-
seekin9individualwhich is me."
34-year-old recovering compulsive cocaine user
But if these primal urges are activated by abnormal biology
aggravated by drug use or behavioral addictions rather than
normal desires, is it fair to cast addicts as merely being mor-
ally weak? 60
"It waslikeI wastwopeople.Mq innerselfwouldtr~ to
communicateto me that This is not ~au'; ~au know what
I mean? M~ outer self would communicateto me, This is
who ~ou have to be.' So I was cau9ht in betweentwo entities,
~ou know, the entitiesof what is900d to ~ou or what is
900d for~ou."
44-year-old recovering heroin addict
Trappist monk Thomas Merton wrote about the conflict
between desire and common sense in more poetic terms than
"old brain vs. new brain."
"As lon9 as pleasureis our end, we will be dishonestwith
ourselvesand with those we love. We will not seek their900d
but onl~ our own pleasure.Authentic love requirestimes of
self-sacrifice.It requiresthat people monitor the sensationsand
feelin9sand moods of others, notjust those of themselves."
Thomas Merton, 1955
Because the addiction pathway 's survival/reinforcement cir-
cuit is located in the emotionally oriented old brain, it reacts
more quickly and intensely than the more conscious and
analytically oriented control circuit located in the neocortex.
It takes a powerful conscious effort to override cravings
and desires from the old brain, especially when instincts
lead us to feel that ceasing drug use is antisurvival. Greek
philosopher Plato wrote almost 2,400 years ago:
"Passions
, and desires, and fearsmake it impossible
forus to think."
Plato, 400 B.C.
Every world religion and almost all theologies (including
atheistic ethical structures) teach the importance of resisting
most primal cravings (including psychoactive drugs) in
order to live a moral or fulfilling life. To some the idea
of original sin can be viewed as the existence of primal
urges in a newborn. Some religions consider these urges to
be sins that must be controlled and their existence forgiven
for a person to grow fully and be saved. The need to balance
natural urges with society's restraints and cultural mores
continues to challenge those who are vulnerable to substance-
related and addictive disorders.
Neuroanatomy
Nerve Cellsand Synapses
Understanding the precise way that messages are transmitted
by the nervous system is crucial to understanding how psy-
choactive drugs affect a user's physical, emotional, and men-
tal functioning. When a person steps on a sharp rock, a signal
is immediately relayed to the old brain and the cerebellum
in the CNS, triggering the reflex action of jerking the foot
away from the rock. A slower signal continues to the thala-
mus at the top of the brainstem, which identifies the signals
as pain and then forwards the message to the sensory cortex,
where the intensity and the location of the pain are identified.
The signal is also forwarded to the frontal cortex, where the
cause of the pain is identified and a course of action is deter-
mined. Nerve impulses might fire up to 1,000 pulses per
second at speeds approaching 270 miles per hour, depending
on the size of the nerve. 61
The building blocks of the nervous system, the nerve cells,
are called neurons (Figure 2-8). Each neuron has four essen-
tial parts:
• dendrites, which receive signals from other nerve cells
and relay them through the cell body
• the cell body (soma), which nourishes the cell and keeps
it alive
 )
The urochemistryand the Physiologyof Addiction 2.19

I
Nerve
termina
l

This is a stylized depiction of how

nerve cells connecr with one
another. The dendrites, cell bodies,
and even terminals receive signals
from the terminals of other nerve
cells. The transmitted signal then
travels through the axon to the next
set of terminals , and the message is
retransmitted. The process continues
until the appropriate part of the
nervous system is reached.
0 2014 CNSProductions,Inc.

• the axon, which carries the message from the cell body to Message
Arrives
the terminals
• terminals, which relay messages to the dendrites, cell --Presynaptic neuron
Nerveimpulse
body, or terminals of the next nerve cell

A single cell's terminals might have anywhere from a few

contacts to up to 150,000 contacts with dendrites and the cell
bodies of other cells. For example, a spinal motor cell might
receive 8,000 contacts on its dendrites and 2,000 on its cell
body. A Purkinje cell in the cerebellum might have as many
as 150,000 contacts available (Figure 2-6). It is estimated that
there are 100 trillion to 500 trillion connections among nerve
cells even though only a fraction of the synapses fire at any
given time. 62
The length of a neuron is determined by the length of the cell
body, dendrites, terminals, and particularly the axon, which
varies from a fraction of a millimeter (mm) between brain
cells, to one third of a meter (m) between a tooth and the
brain, to 1 meter between the spinal cord and a toe. Terminals
of one nerve cell do not touch the adjoining nerve cell because
microscopic gaps, called synaptic gaps or synaptic clefts, This is a simplified version of the synapse between nerve cells. The
exist between them. This gap is 15 to 50 nanometers (nm) electrical message (nerve impulse) arrives at the junction of two nerve
wide. (A nanometer is one billionth of a meter.) One million cells- the synaptic gap or cleft.
synaptic gap widths added together barely total 25 mm (just 0 2014 CNSProductions,Inc.
under 1 in.)
A message is transmitted electrically within the neuron, but
from whatever nutrients the body ingests. The neurotrans-
when it arrives at the synaptic cleft it almost always com-
mitters are then stored in tiny sacs called vesicles that
municates across the gap from the presynaptic terminal to
travel through the neuron to the axon terminals.
the postsynaptic receptor, not as an electrical signal but as
molecular bits of messenger chemicals called neurotrans- When a neuron needs to communicate with other neurons,
mitters (Figure 2-9). These bits of chemicals have been syn- the neurotransmitters are released from their vesicles to syn-
thesized within the neuron from protein and molecules apse (slot into appropriate postsynaptic receptors on adjacent
 2.20 CHAPTER2

then correlate almost all psychoactive drugs of abuse with

the neurotransmitters that they affect (Table 2-1). Some
200 to 300 endogenous neurotransmitters have been iden-
tified in the brain, and many others have yet to be identified.
Discovery of endogenous neurotransmitter correlates for

I
exogenous opioids implied that any psychoactive drug has an
effect because it mimics or disrupts naturally occurring
chemicals in the brain and the bod y that have specific recep-
tor sites. This means that psychoactive drugs cannot create
sensations or feelings that do not already have a natural
counterpart in the body. It also implies that human beings
can create virtually all of the sensations and feelings they
seek from drugs through natural nondrug brain experiences,
although man y of the experiences created naturall y are not
as intense as those generated by highl y concentrated drugs.
Here are some examples.
• Fright forces the release of adrenaline (epinephrine),
which mimics part of a cocaine rush.
• Runners experience a "runner 's high " through the release
of endorphins and enkephalins, similar to a modified
The elecrrical message from the terminal of the presynaptic neuron is
heroin rush.
retriggered in the dendrite of the postsynaptic neuron.
0 2014 CNSProductions,Inc.
• Relaxation and stress-reduction practices like yoga can
calm restlessness through glycine and GABA modula-
tion, similar to the effects of benzodiazepines or alcohol.
• A half hour of exercise has the same antidepressant effect
dendrites of other neurons); the chemical signal is then con- as Prozac ® or another chemical antidepressant.
verted back to an electrical signal. If enough synapses col- • Sleep or sensory deprivation can produce true halluci-
lectively create enough voltage (action potential) in the next nations through the same neurotransmitters and mecha-
nerve cell, the electrical charge can travel to the next synapse, nisms affected by peyote.
where it is again converted into a chemical signal for the next
synapse (Figure 2-10). Each group of synapses transmits 'When I used to cram for an exam, sta~in9up for two or three
the message between neurons until the message reaches the da~s, I heardclassicalmusic,usual/~Beetha,en'sNinth;the
section of the brain or body for which it was intended. soundwasso realthat I kepttrfn9 to ~nd the personwho was
pla~i"Bthe radiotoo laud until I realizedit wasall in m~ head."
Neurotransmittersand Receptors 28-year-old nonuser of psychoac tive drugs
Neurotransmitters were first discovered in the l 920s (acetyl-
choline) and the 1930s (norepinephrine), but it was the
discovery in the mid-1970s of endorphin receptor sites and
then enkephalins and endorphins that finally provided Psychoactive
Drugi
an understanding of how psychoactive drugs work in the Neurotransmitter
Relationships
brain and the body. For the first time, a body's reaction and
DRUG NEUROTRANSMITTERS
DIREffiYAFFECTED
addiction to psychoactive drugs could be described in terms
of specific naturally occurring chemical and biological Alcohol GABA(gamma-aminobutyric
acid),
met-enkephalin,
serotonin
processes.
Benzodiazepines GABA,
glycine
• Endorphins and enkephalins are called endogenous
opioids. Endogenous means "originating or produced Marijuana Anandamide, aradiidonylglycerol
(2AG),
within the body or organism." They are the body 's own noladinether, acetylcholine,
dynorphin
natural painkillers. Heroin Endorphin,
enkephalin,
dopamine
• Morphine, heroin, and other opium derivatives or syn- LSD Acetylcholine,
dopamine,
seroto
nin
thetics are called exogenous opioids. Exogenous means Nicotine Epinephrine,
endorph
in,acetylcholine
"originating or produced outside the organism." These
Cocaine
andamphetaminesDopamine,epinephrine,norepinephrine,
are externally produced painkillers. serotonin,acetylcholine
Once the existence of endorphins and enkephalins was con- MDA.MDMA Serotonin,dopamine,
epinephrine,
firmed, the search for other natural neurochemicals that are norepinephrine
mimicked by psychoactive drugs began in earnest. Over the PCP Dopamine,
acetylcho
line,alpha-endopsychosin
next 20 to 30 years, researchers were able to identify and

"A~er teachin9aerobicsfor four or five hours a daq, everqdaq
fora weekor so, I wouldactual/~90 throu9hwithdrawalwhen
I tooka fewda~soff-It waslikea mild,ersionof the opiate
withdrawalthat addictstalkaboutwhenthe~quitusin9heroin
or OxqContin.® A friendtold me that excessiveexercisestresses
the bod~, so the brainreleasesits ownpainkillers
."
44 -year-o ld female aerobics instru ctor
The major difference between natural sensations and drug-
induced sensations is that drugs have side effects, particu-
larly if used to excess, whereas natural methods have few if
any side effects. In addition, the more a drug is used, the
weaker the effects become (due to tolerance) and the harder
it is to reproduce the desired sensations. If the dose of a drug
is increased to reproduce the same desired effects, increased
toxicity and side effects result.
Psychoactivedrugs cannot create sensations
or feelingsthat don't already have a natural
counterpart in the body,
With natural sensations the opposite is usually true: the
desired effects become easier to reproduce and more pow-
erfully felt with practice. Another key difference is that
natural biochemical responses return to a normal homeo-
static state after the response is completed, whereas drugs
continue to affect biochemistry after a user stops using, due
to more-permanent neurochemical allostatic changes in the
brain that were induced by chronic unnatural functioning
with exogenous substances.
Neurotransmitter research indicates that some people are
drawn to certain drugs because they have an imbalance of
one or more neurotransmitters. These people have discov-
ered through experimentation and self-medication that a
specific drug or drugs help correct that imbalance temporar-
ily. For example, people who are born with low endorphin/
enkephalin levels or who have damaged their ability to pro-
duce these chemicals might have a propensity for opioid and
alcohol use. Similarly, people with low epinephrine and nor-
epinephrine (natural stimulants) or depression may be pre-
disposed to amphetamine or cocaine use . These drugs mimic
the deficient neurotransmitters and deceive the user into
feeling normal, satisfied, and in control.
"/ still remember
the firsttimeI 9ot drunk.I felt normal
forthe firsttimein m~life; I fit in, waslikeothers-
in controland satisfied."
28 -year-old recovering alcoholic
Major Neurotransmitters
Four groupings of neurotransmitters have been identified:
• monoamines (e.g. , norepinephrine, dopamine ,
histamine, serotonin)
• amino acids (e.g., GABA, glycine, glutamic acid)
• opioid peptides (e.g., endorphins, enkephalins,
dynorphins, substance P)
lhe Neurochemistryand the Physiologyof Addiction 2.21
• miscellaneous (e.g., acetylcholine, anandamide,
corticotrophins, nitric oxide, adenosine)
Monoamines (e,g,, catecholamines)
• Norepinephrine and epinephrine, the second neuro-
I
transmitters to be discovered, are classified as catechol-
amines and function as stimulants when activated by a
demand from the body for energy, particularly when the
fight-or-flight response is acti vated. Besides stimulating
the autonomic system, they affect motivation, hunger, at-
tention span, confidence, and alertness. Norepinephrine
has a greater effect on confidence and feelings of well-
being; epinephrine has a greater effect on energy. These
neurotransmitters are also known as noradrenaline and
adrenaline, respectively.
• Dopamine was discovered in 1958. This catecholamine
helps regulate fine motor muscular activity, emotional
stability , satiation, and the addiction pathway. Dopamine
is the most crucial neurotransmitter involved in both
substance and process addictions. It is often called the
"reward chemical. " Parkinson's disease destroys dopa-
mine-producing areas of the brain, which causes erratic
and limited motor movements. Excess dopamine causes
many of the effects of schizophrenia . Much of addiction
was once understood as a destabilization of just dopa-
mine, but research into other neurotransmitters, espe-
ciall y glutamate and GABA, sho ws that they are now
strongly implicated in the process.
• Histamine controls inflammation of tissues, local im-
mune responses, and allergic reactions. It also helps
regulate emotional behavior and sleep.
• Serotonin helps control mood stability, including de-
pression and anxiety, appetite , sleep, and sexual activity.
MDMA (ecstasy) forces the release of this neurotrans-
mitter. Many antidepressant drugs, including fluoxetine
(Prozac ®) and paroxetine (Paxil ®), are aimed at increas-
ing the amount of serotonin in the synaptic gaps by
blocking their reabsorption, thus elevating mood .
Amino Acids
• GABA (gamma amino butyric acid) is the brain's main
inhibitory neurotransmitter and is involved in 25% to
40 % of all synapses in the brain. It controls impulses,
muscle relaxation, and arousal and generally slows down
the brain. Alcohol has a strong effect on GABA.
• Glycine , an inhibitory neurotransmitter, is primaril y
found in the spinal cord and the brainstem. It is also
prominent in protein synthesis and slows down the
brain.
• Glutamic acid (glutamate and glutamine), an impor-
tant excitatory neurotransmitter, is present in 80%
of neurons in the brain. 63 It is one of the major amino
acids and plays a role in cognition as well as motor and
sensory function. Glutamate enhances the prominence
of dopamine's effects when it is released in response
to psychoactive drugs. It is also important in memory
reinforcement and is a precursor for GABA.
 2.22 CHAPTER 2
I
This is a colored transmission electron micrograph of a synapse in the
brain, magnified 50 ,000 rimes. At a synapse an electrical signal is
transmitted from one cell to the next in only one direction. The nerve
cells are colored red, with the presynaptic cell at the lower right and
the post.synaptic cell at the upper left Mitochondria supplying the
cells with energy are colored green. When an electrical signal reaches
a synapse, H releases tiny bits of neurotransmiHer chemicals from
vesicles (blue) at the terminal (end of the presynapric neuron) .
Courtesy of Thomas Deerinck, NCMIR/Photo Researchers, Inc.
Opioid Peptides
• Endorphins, enkephalins, dynorphins, and opioid pep-
tides are involved in the regulation of pain, the mitigation
of stress (emotional and physical), the immune response,
stomach functions, and a number of other physiological
functions. They are also intimately involved with the ad-
diction pathway.
• Substance P (tachykinin), a peptide found in sensory
neurons, was first discovered in 1931. It conveys pain
impulses from the peripheral nervous system back to the
central nervous system. Enkephalins block the release of
substance P, thereby subduing pain.
Miscellaneous Neurotransmitters
• Acetylcholine (ACh), the first neurotransmitter discov-
ered (in 1914), is mostly active at nervdmuscle junc-
tions (e.g., cardiac inhibition and vasodilation). It also
helps induce REM sleep and modulate mental acuity,
memory, and learning. ACh imbalance has been impli-
cated in Alzheimer's disease.
• Anandamide (N-arachidonoylethanolamine) and other
endocannabinoids, 2AG (2-Arachidonyl glycerol) and
2-AGE (Noladin ether, 2-Arachidonyl glyceryl ether),
were discovered in 1995. The THC in marijuana has
an affinity for anandamide receptor sites, which were
discovered three years earlier. These endocannabinoids
activate two receptor sites in the body-CB 1 and CB2-
which are found in a wide variety of locations within
and outside the central nervous system. In the CNS the
receptors are in the limbic system and in the areas re-
sponsible for the integration of sensory experiences with
emotions (often associated with a sense of novelty) as
well as those controlling learning, motor coordination,
and memory. Endocannabinoids can act as an analge-
sic or a pain reliever. There are many more cannabinoid
receptors in the brain than there are opioid receptors.
• Corticotrophins (CRF, ACTH, cortisone) are hormones
that also function as neurotransmitters. Corticotropin-
releasing factor ( CRF) is produced by the hypothalamus
in the brain and activates the pituitary gland to release
adrenocorticotropic hormone (ACTH) during stress. As
neurotransmitters, CRF and ACTH induce an uncomfort-
able fight-or-flight response. ACTH then causes the release
of cortisone by the adrena l glands that tum off the CRF
and ACTH release to complete the human stress cycle.
These aid the immune system, healing, and stress control.
• Nitric oxide, a gas, is invo lved in message transmission
to the intestines and other organs, including the penis
(erectile function). It also plays a part in regu lating emo-
tions. When mice are bred without nitric oxide, they ex-
hibit aggression along with bizarre and excessive sexua l
behavior. 64 Nitric oxide (NO) should not be confused
with the anesthetic nitrous oxide (N 20).
• Adenosine functions as an autoregulatory local hor-
mone. Most cells contain adenosine receptors that, when
activated, inhibit some cell functions. As a neurotrans-
mitter, adenosine has an inhibitory effect on the CNS.
Caffeine's stimulatory effects are due partially to its abil-
ity to inhibit adenosine, which resu lts in enhanced dopa-
mine and glutamate effects in the brain.
In addition to these neurotransmitters, mo re than 100 others
had been discovered by 2010. Advances in neuroimaging
enabled researchers to actually measure the density of various
neurotransmitters with single-photon emission computed
tomography (SPECT) radio tracers, positron emission tomog-
raphy (PET), and functional magnetic resonance imaging. 65
Neurotransmitter communication networks can also be
imaged with diffusion tensor imaging (DTI) techniques.
>
The most important neurotransmitters for
psychoactive drugs are dopamine , endorphins ,
serotonin , GABA, and glutamate.
Receptors for Neurotransmitters
A neurotransmitter is designed to bind with a compatib le
receptor site. The neurotransmitter serotonin will bind with
any one of 13 serotonin receptor sites (e.g., 5-HTlA, 5-HT4);
a dopamine neurotransmitter can slot into five different
dopamine receptor sites (e.g., Dl to D5). Receptors exist on
dendritic spines, on dendrites themselves, on axons, and on
cell bodies. The several dozen receptor subtypes explains
why the same drug or medication can have very different
reactions in different individuals.

Each nerve cell produces and sends only one type of neu-
rotransmitter (except those epinephrine nerve cells that also
produce norepinephrine), but a single nerve cell can have
receptors for several different types of neurotransmitters,
and it can have thousands of receptors. A serotonin receptor
site will not accommodate dopamine , but a single nerve cell
can contain dopamine and serotonin receptors. In addition,
the release of one neurotransmitter usually has a cascade effect.
For example, the release of serotonin from one neuron will
trigger the release of enkephalin in another neuron, which
then triggers dopamine from a third neuron in the brain 's
emotional center, which results in a feeling of well-being .
Advanced Neurochemistry
Message transmission (Figure 2-11) occurs when the incom-
ing electrical signa l O forces the release of neurotransmitters
$ from the vesicles e and sends them across the synaptic
gap O. On the other side of the gap, the neurotransmitters
slot into precise and complex receptor sites 0 . These recep-
tor sites are structural protein molecules that, when activated
by a neurotransmitter, cause an ion molecular gate 0 to
open, allowing sodium, calcium, potassium, or chloride
ionic electrical charges $ to enter or exit.
• Excitatory neurotransmitters increase cell firings by
opening the gate and allowing positive ions like sodium,
potassium, or calcium into the neuron .
• Inhibitory neurotransmitters reduce cell firings by allow-
ing negative ions like chloride into the neuron, pushing
..
• : \ Incomingnerveimpulse
Positiveionspumpedintothecell create
anaction potential across thecell membra
resultingin an electricalwavetraveling
alongtheaxonor dendrite.
. ...
.
Nega tive ion,- - - -
typically chloride
. ....
•0•• : .
,,..... ·
. $
., # , •
rj;
- ••- •- e Vesicle
® Autorecepto ..
...
0 Reuptake
port
.../;:,1/
. ..0 . . ... .. . ..
.
.. ... . .. . ....... . .. .... ... .....
.. .. . . . .... .. . . .. ... .. .... .. . . . . . . ...
The Neurochemistry
andthe Physiology
of Addiction 2.23
positive ions out. When enough excitatory neurotrans-
mitters cause sufficient movement of the positively
charged ions and the total voltage reaches a certain ac-
tion potential (about 40 to 60 millivolts) , it depolarizes
and fires the signa l $ . The electrical-charge sum of all
I
the activated receptor sites can cause the cell to reach its
action potential and fire off the signal. If enough inhibi-
tory neurotransmitters keep the voltage below the action
potential, the cell is inhibited from firing .
• The process whereby the neurotransmitter directly affects
electrical transmission in the receiving neuron is called
the first messenger system .
• If the received neurotransmitters cause other biologi-
cal and chemical changes that then affect the electrical
transmission (e.g., G-protein coupled receptors), it is
called a second messenger system .42 -6 6
• As neurotransmitters complete their job in the recep-
tors , they are released back into the synaptic gap and are
reabsorbed by the sending nerve cell membrane (reup-
take ports 0 ) and returned to the vesicles, ready to fire
again . The reuptake pons use special molecules (trans-
port carriers, or transporters) as part of active transport
pumps to move the neurotransmitters through these
membranes . Some of the neurotransmitters do not make
it back to the reuptake pons of the sending neurons and
are metabolized by enzymes surrounding the nerve cells .
• The amount of neurotransmitters available for message
transmission is constantly monitored by autoreceptors
® on the sending neuron . If there are too many neu-
rotransmitters, the cell slows their synthesis and re-
lease. If there are too few, it speeds up the process .
In addition, the number of receptor sites on
the receiving cell is altered to compen-
ne sate for variations in the number of
neuro-transmitters. This consists of
two processes .
Neurotransmitters
....
Synaptic
gap
This illustrates what occurs neuro-
chemically and electrically at the
synaptic gap. To visually depict the
full complexity of what happens
would require dozens of illustrations.
© 20 14 CNS Productions,Inc.
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it is po,,ib leto,,,ehow=yi tis toinduce,ignificmt
chang<> inbrainfunction by moking,m.ailchmg<>to • Th<y can inhih it anen,ymethothtlp,•ynth<0iun,u -
th,nonruo l molecu lorproc<>.,.ofrommuni cation rotrammitt<1>l odo wth<nw,,eoell'sproduction ol neu -
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,ff ,fn<nrotransm 'ttena?'<call<d•gon· to of , ti n<urot ra n, m 'tl<I' •• : hamp':.m ·n, 'nh 'b"t,
• Drug,thatb indtorrcq,tonbutdon\octivat<thtmand mon oam in< oxi<W< and cot<cho !-0- m<thylu-:,ru;f,,-., ,
therebyblockn<nrotr.onsmitter• arec•lltda:ntogonists <nzym<> thotm<tobolinnor<pin <phrin < •nd<pinq,h -
• Drug,t hatbind tor<cq,tor,andpottlym imic t h<<ffecl5 rin<. Th isi,1h ,ru ,onwhyth<stimulon 1dFect,ofm , th -
ofneurotrm,mitters a r< call<dp.anialagonists amph ru. min e la, tmuchlong<r tha nthoo, o/ cocain<
• Drug,thatbindtor,cq,t on a nd , ubiliu th<r«<ptorin • Th<ycanint<rfer,withth<r<np to k<andth<•torag<
't, '=t\ ,e stat< by hyp,rpoloi 'ng "t sothat 'tcmnot of nrnrotnnsmittttl , allowing th,m 10 !i<<p ou t of
rac t a r< calledinwrv•goni•to vesicl<>• ndb<rom<d <grad<d,thuscau. ing a ,ho ru. g,

of those particu lar neurotransmitters. Stimulants result
in a depletion of stimulant neurotransmitters, resu lting
in less and less ability to cause intense excitation with
pro longed use .
• They can perform a combination of these interactions .64
Sometimes the disruption of neurotransmitters is useful
(blocking pain messages), somet imes desirable (releasing
stimu latory chemicals), and sometimes harmful (blocking
inhibitory neurotransmitters that control violent behavior).
A stimu lant like cocaine forces the release of norepineph-
rine (a stimulatory chemical) and dopamine (a pleasure-
inducing chem ical) from the vesicles and then prevents them
from being reabsorbed. The net result is that more of both of
those neurotransmitters is available to exaggerate existing
messages and stimulate new ones (Figure 2-13) . The user
remains active past norma l exhaustion and feels alert until
the neurotransmitters start to become depleted , resulting in
weaker and weaker effects from the same amount of cocaine .
A depressant like heroin acts like a second messenger by
mimicking enkephalins and slotting into opioid (enkepha-
lin) recepto rs, consequently inhibiting the release of sub-
stance P, a pain-transmitting neurotransmitter (Figure 2-14 ).
This is the reason why heroin and opioids lessen pain. Heroin
also acts as a first messenger by slotting into substance P
receptor sites on the receiving neurons , thus blocking the
pain-causing substance P. Finally, it attaches itself to certain
receptor sites in the addiction pathway, inducing a euphoric
sensation; this too is a desired effect. It also attaches itself
CocaineForces
Neurotransmitter
Release
Cocaineforces the release of extra neurotransmittersand blocks their
reabsorption,thus increasing thefrequency and therefore the intensity
of the electricalsignal in the postsynapticneuron.
© 2014 CNSProductions, lnc.
The Neurochemistry
and the Physiology
of Addiction 2.25
HeroinInhibitsSubstance
P
PainMessage
I
-Seco ndary
terminal
containing
endorp hins
SubstanceP
Nosignal
transmitted
Acting as a first messenger,heroininhibits the releaseof substanceP
and also blocks most of the neurotransmitter that does get through,
so the electrical signal is greatly weakened and the pain is controlled.
© 2014 CNS Productions, Inc.
to the breathing center, depressing respiration, which is a
dangerous effect. 67 •68
An all arounder (psychedelic or hallucinogen) such as LSD
releases some stimulatory neurotransmitters but mostly just
alters the user 's perception of messages coming from the
external environment; sounds may become visual distor-
tions, and visual images may become distorted sounds. This
subjective sensation of a sense other than the one being
stimulated is known as synesthesia . Other psychedelics
cause hallucinations by blocking the action of acetylcholine .
The use of an excessof psychoactivedrugs
tricksthe brain into believingthat there is no
need to produceas many of its own similar
neurotransmitters.This causesthe user to
increasethe dose to achievethe same effect.
SynapticPlasticity,Allostasis,and Epigenetics
The concepts of synaptic plasticity, allostasis, and epigenetics
represent the direction of much of today's research in the field
of addictionology and also provide clues to the process of
addiction and relapse. The findings also serve as points of
departure for more-effective treatment methods and med ica-
tions that support recovery.
SynapticPlasticity
Synaptic plasticity describes the ability of a synapse to
change in strength and function when that pathway is
overused or underused, often as a result of the intake of
psychoactiv,drugs,thepractic,cofrompulsiv<bdw,iors .. stress . toxim , drugs . orrompul,iv<bduvioBill<ctth<
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u<>o,u•longp<riodoltim e, thebodyisforc,cdtoclung<
Thestudyofepij;rn<tics a l,oincludesex:aminingthew:ay and•d•pt,devdopingtoler.tnc<totherontinuedinputol•
genesbelw.e(gene expressions ) when<tresscdbyrnviron-
mrn taleve nt<and,ub,tantt> («~ia llytoxi ns•nddrugo) :,~~",,.':~,n:·.Zn~:.::!~h~ha~:!~.:'d larger
Epig<n<ticc hange,result in•lt,r:,tion, ing<n<<,q,ression,
that= 12st fOTw«ks . month,, or)' U r>. Some ofth« e
change,can . infac1 . bepa,>«lontooff<pring.Epigrn<tic
d u ng esd onot alterthe«q urnacofthegen eiudF . only
·::r,;:;
pow~"
:;:x--/;
::.
!':m:~ft·.:t:.:},71:J
I 1,,,Jto.lri,,h, .,,,d,"""' ro,wit f«/ ""!th"'9-
thewayth.atiucompon<nt<r<act. "'" (Formoreinforma - a!JJa~""1:i
Youbtow.jt """'~k, / ...,, Jn.1nl -
tion0«w ,..,,._rn,producfiorts .corn/pJf/<pigrn<tin.) "
DNAisthe"rookhook"tha t ronuinsthe"ndpes"for
every cell in the body:itis resi,unttomu ta tion. Every
perso n has•rompl<t<srtolg,n«fromhlsorhermother ::7rt!':~;::~~;!i~~:~·::~::~~:i:~tori:
andfather . Thebodychoosesfromtha t mixwhichgrn<will sy,t<ms.To the l=iu<n tn><T,thi,•cbpt.otiondimini<t-.e.1h,
bedominant.Apersonmightgetthemoth<r',blueey<>md drug',,ffectwitheoch,ucceedingdoK . Dn<do>eolm<thon
thefather'sbrownh.air . Hemightg<t a nonruolKtofdopa - thefirstcbyofn><<n<Ij!iz« a U><Tandtriggen a euphoria
m'ne neurotransm "tt<n and rec, , ' m h', mother or• tha1will takelOd os«tomo1chonthehundredthcbyofuK
mu t.otedgrnefromhi< father . Whenepigrn<ticfactonsuch (Figure2 -l~ )
 The Neurochemistryand the Physiologyof Addiction 2.27

Typesof Tolerance
Development
of Amphetamine Dispositional Tolerance The body speeds up the breakdown
Tolerance
OverTime (metabolism) of a drug to eliminate it, particularly alcohol
Desiredeffect and barbiturat es. The way alcohol is metabolized illustrates
this biological adaptation. Alcohol increases the amount of

I
200mg cytochrome and mitochondria in the liver, causing the pro-
duction of more enzymes available to break down and deac-
C tivate the drug and requiring greater quantities of alcohol
C.
0
150mg to be consumed to reach the same level of intoxication. This
g stresses the liver and can result in a disease that causes
'-..., healthy tissue to be replaced with scar tissue known as
g, 100 mg
cirrhosis.
E
-sl
..c: PharmacodynamicTolerance Nerve cells become less sensitive
C.

50mg
to the effects of a drug. The body can also produce an anti-
-0 dote or antagonist to it. The use of opioids causes the brain
to generate fewer opioid receptor sites and down-regulate
10mg them; it can even induce the intestines to produce cholecys-
1stday 25thday 50thday 75thday 100thday tokinin , a hormone antagonist to opioids.
BehavioralTolerance The brain learns to compensate for the
effects of a drug by using parts of the brain not affected. An
intoxicated person can, by strength of will, appear sober
This graphshowsthe graduallyincreasingamountsof amphetamine when confronted by police but might stagger again a few
needed to producethe samestimulationand/oreuphoriaovertime. minutes later.
© 2014 CNS Productions,Inc
ReverseTolerance Initially, a user becomes less sensitive to a
drug (regular tolerance ); but as the drug destroys certain
tissues and/or as the person grows older, the trend can
be reversed and the user becomes more sensitive and there-
fore less able to handle even moderate amounts. This is
'When I rrst started, I rememberhavin9a hu9e reaction to a particularly true of alcoholics; as the liver is destroyed , it
small amount of speed. Insideof a qear, I could shoot a spoon loses the ability to metabolize the drug. An alcoholic with
of it easilq, which is a pret¼ fair amount, and it rnallq9ot to a cirrhosis of the liver can stay drunk all day on a pint of wine
point where I couldn't even sleep unless I'd done some." because the raw alcohol is passing through the body repeat-
34-year-old recove ring meth user edly, unchanged.

Although some tolerance develops with the use of any drug,
a user must cross a certain level of use for the development
of tolerance to accelerate. If a user takes 5 or 10 mg of diaz-
epam, a sedative, every few days, the development of toler-
ance is minimal. But if the user starts taking two or three
times that amount every day; within two or three years he or
she may need to increase the dosage up to 100 mg or more
per day to achieve the same effect. Cases of people taking
1,000 mg per day-100 to 200 times the standard dose-
have been recorded. 67 •75
In experiments using rats, one hour of access to self-admin-
istered cocaine per session did not increase intake or toler-
ance . Six hours of access, however, escalated tolerance and
increased the hedonic set point , defined as "an individual's
preferred level of pharmacological effects from a drug ."57 ,76 •77
The development of tolerance varies widely and depends
primarily on the quality of the drug itself, along with the
amount , frequency; and duration of use ; the neurochemistry
of the user ; and the psychological state of mind. Tolerance
usuall y returns toward normal once the user stops taking
the drug but is reestablished quickly the next time excess
amounts are used. •
"At rrst I could drinka lot, for about ei9ht or nine qears.
Theq'd saq I rnished 10or more hi13hballs in the bar,
but I'd never9et fallin9-downdrunk. I'd be prettq hi9h
but neverpassed out. Now, especiallqsince mq liveris
onlq sli9htlqsmallerthan a Volkswaaenand not doin9
its job, if I drink overfour drinks, I can't walk one of
those white linesa cop makesqou walk if he thinks
qou'reDUI."
43 -year-old alco hol user
AcuteTolerance(tachyphylaxis)In these cases the brain and the
body begin to adapt almost instantly to the toxic effects of the
drug. Tolerance and adaptation to tobacco begins with the first
puff. Those who take barbiturates to commit suicide can
develop an acute tolerance and survive the attempt . They
could remain awake and alert with twice the lethal dose in
their systems even if they have never taken barbiturates before.
Seled Tolerance The body develops tolerance to mental and
physical effects at different rates . Tolerance to doses neces-
sary to reach an emotional high from sedatives occurs
more rapidly than the development of tolerance to their
depressant effects. With continued use, the dose amount
 2.28 CHAPTER 2
necessary to get high can come close to the lethal physical
dose of the drug (Figure 2-16). A barbiturate, for example,
induces sleep and causes a slight euphoria the first day it is
taken, but within a few months it no longer causes euphoria
though it still induces sleep. If the user is seeking the eupho-
I
ria, more of the drug must be taken to reach the same level
of "feel good." If the user has not developed tolerance to the
respiratory depressant effects of the barbiturate, the effect is
more severe and potentially lethal.
"Shewasdrinkin9 champa9ne andstrai9htvodkaandoccasional/~
poppin9a pill.. . I said. 'Maril~n.the combination of pillsand
alcohol willkill~ou.' And shesaid, 'It hasn'tkilledme ~et.'
Thenshe tookanotherdrinkand poppedanotherpill. I know
at ni9htshetookbarbiturates."
James Bacon on Marilyn Monroe's drug use
"Asman~pillsas I had, I wouldtake. I didn'treal/~care
about overdose,which I did man~ times."
Former barbiturate user
Inverse Tolerance (kindling) A person becomes more sensitive
to the effects of a drug as the brain chemistry and neuron
pathways adapt to the drug's effects. A marijuana or cocaine
user might experience minimal effects from the drug for
months and then sudden ly get an intense reaction. Once a
cocaine or meth addict becomes more sensitive to the toxic
effects after continued use, he or she develops a greater risk
of heart attack or stroke.
Cross-ToleranceAs a person develops tolerance to one drug,
h e or she develops tolerance to other drugs, as well . A
h eroin addict is also tolerant to doses of morph ine, Vicod in, ®
OxyContin, ® and methadone, even if th e addict has never
taken them before, because the same biological mechanisms
that establish tolerance to one opioid are in place to provide
tolerance to others as well. Someone tolerant to the effects of
alprazo lam (Xanax ®) is also tolerant to the effects of other
benzodiazepine sedatives and to alcohol. Cross-tolerance can
occur between drugs of different chemica l compos itions. A
person tolerant to the effects of barbiturates will also be toler-
ant to benzodiazepines.
Tissue Dependence
Tissue dependence results from the b iologica l adaptation of
the bo dy due to pro longed use of a drug. The body compen-
sates by resetting normal homeostatic levels and altering
homeostatic mechanisms to withstand chemical stressors.
This creates an allostatic state - an altered state of balance
that maintains the stability of bio logica l systems by the con-
tinued exposure to drugs. Sometimes the alteration is exten-
sive, particularly if downers are used. Certain drugs change
the body so much that tissues and organs b ecome depen -
dent on the drug sim ply to stay functional. One of the signs
that tissue dependence has developed is the appearance of
withdrawal symptoms when drug use is stopped. Tissue
dependence that occurs in the brain from psychoactive drugs
can greatly affect feelings and emotions.
DoseofSeconal'" Neededto ProduceSleep
Dose
or Euphoria vs.Overdose
1,000mg
Overdose
750 mg
Safetymargin
500mg atthe
beginning
250 mg
Omg-'-----------------~
I day 6months lyear
Time
WHh many drugs, tolerance t.o mental effects develops at a different
rare than tolerance ro physical effect.s. If a user increases the amount
of barbiturate ro continue the high, tolerance ro the respiratory
depressant effects doesn't increase as quickly as tolerance ro the
mental effect.s, so an overdose (potent ially fatal phys ical effects)
becomes more likely.
0 2014 CNS Productions, Inc.
"/ would start to feel ver~abnormala~er two or three hours,
and I was,like,trqin9to maintainuntilI couldbe9into feel
normal.And that wasthe on/~ kindof normalthat I knew,
Darvon®-induced normalit~."
Recovering Darvon ll>user
Cross-Dependence A tissue dependence on one drug creates
dependence on other drugs. If one is dependent on heroin,
he or she has also developed physical dependence on metha-
done, Vicodin, ®and all other opioids. This is the reason why
buprenorphine is used to treat heroin addict ion. Replacing a
dose of heroin with buprenorphine or methadone will pre-
vent the occurrence of withdrawal because cross-dependence
on all opioids develops along with the heroin addiction.
Psychological Dependence
Psyc h ological dependence is recogn ized as an important
facto r in the develop ment of addict ive behavio r. Users begin
to rely on psychoactive drugs emotiona lly as well as physi-
cally. Studies by Dr. Anna Rose Childress, research associate
professor in the Department of Psychiatry at the University
of Pennsylvania School of Medicine, showed that psycho-
logical dependence also produces many physica l effects,
concluding that defining drug dependence as strictly physi-
cal or strictly mental is not accurate.
 lhe Neurochemistryand the Physiologyof Addiction 2.29

• Positive and negative reinforcement. A desire for the

OpioidEffectsvs.Withdrawal
Symptoms positive effects of a psychoactive substance or a desire
effectsareoftentheoppositeof thedrug's
Withdrawal
directeffe<l5. to avoid the negative effects or emotions of abstinence
compels a user to continue. The desire for an OxyContin ®
EFFECTS WITHDRAWAL
SYMPTOMS
high or the fear of opiate withdrawal symptoms can drive

I
Euphoria becomes
dysphoria,
depressio
n, or craving opiate addicts to continue using the drug.
Numbness becomes
pain
Dryness
of mouth becomes sweatin&
runnynose,tearin&nausea, "/ had hundredsofVicodin® tabletssquirreled
awaqaround
vomitin& andincrease
d salivat
ion the house 'cause I was so afraid ofrunnin9out and 'Jonesin9'
Constipation becomes
diarrhea [ha,in9withdrawals]. I cou/d',eusedformonthsbeforerunnin9
Slow pulse becomes
rapidpulse
out, but I had crampedand ,omitedandspasmedbeforeand
woulddo anqthin9to aYOid it."
Lowbloodpressure becomes
highbloodpressure
48-year-old recovering opioid addict and pathological gambler
Shallowbreathing
and becomecoughingandexcessive
yawning
suppressedcough
• Social reinforcement. Peer pressure, the desire or need for
Pinpointpupils becomedilatedpupils social inclusion, and other social factors encourage the
Sluggishness becomessevere hyper-reflexesand muscle continued use of an addictive psychoactive substance.
cramps
Sedation
andtranquil
ity becomeanxiety,
restlessness,
andinsomnia "I'vemade some wisedecisionsin not 9oin9 hack tom~ old
stompin99rounals, not keepin9in touchwith the people
I used to keep in touch with, and I don't associatewith
peoplethat use,qouknow,and it'sworkedso far."
34-year-old male recovering meth addict
Drug use can alter one's state of consciousness, distort per-
ceptions, and change emotions. These changes can reinforce
continued use of the drug. Drugs also have the innate ability
to guide and virtually hypnotize the user into continual use Withdrawal
(called the "positive reward-reinforcing action of drugs"). When a user stops taking a drug that has created tolerance
This is seen in animal experiments where rats are trained to and tissue dependence, his or her body is left with an altered
press a lever that delivers heroin or other drugs intra- chemistry (allostasis). There might be an overabundance of
venously-they continue to press the lever long before enzymes, receptor sites, or neurotransmitters. Without the
physical dependence develops, showing that a psychoactive drug to support this altered chemistry, the body tries to return
drug, in and of itself, can reinforce the desire to continue use. to normal. Withdrawal is defined as the body's attempt to
rebalance itself after cessation of prolonged use of a psy-
'"M~palms9at sweatqri9htbeforeI wauldaet loaded;~ou choactive drug or compulsive behavior. Table 2-2 compares
9et the turnin9of the stomach,~auknaw,and the shakes the desired effects of heroin with the withdrawal symptoms
sometimes,and m~ mind was just, like, What am I doin9 here? that occur once a longtime user stops taking the drug.
Wh~did I put mqselfin thispositian?Youknow?I wasin a
Many compulsive users are unwilling to go through with-
room with m~ so-called friends."
drawal, which is one reason why they continue to use
34-year-old male recovering meth addict
(negative reinforcement).
There are other ways addictive drug taking is psychologically
'Your musclesare, like, wrenchin9;~ourentire di9est/vetract
reinforced.
is 9oin9 craZ!f.Stomach cramps. Not just stomach cramps,
• Drug automatism. Substances such as sedatives and diarrhea-ever~thin9 that can 90 wron9 with ~ourintestinal
opiates can induce an aimless, unconscious, repetitive tracthappens.Yourle9s,qoukickconstantlqat ni9ht;that's
drug-taking behavior characterized by continually tak- whq I thinktheqcall it kickin9the habit.Yourle9swilljerkand
ing a substance without being fully aware of the action. kick uncontrollabl~.You have insomnia.You vomit, sweat-
Even behavioral addictions like compulsive gambling what else?-and, oh ~eah, the crazinessand delirium."
can induce automatic behavior, which is often referred to
23-year-old female recovering heroin addict
as "zoning out."
Many treatment programs use medications to temper the
"It9ot so bad that I 9ot up at 11at ni9ht,wentto the nearest most severe symptoms of withdrawal. Withdrawal from
lotterqoutlet,and pla~edthe pokermachineuntiltheqclosed, opioids, alcohol, nicotine, and many sedatives is triggered by
and I didn'tremember I had doneit until / 9ot din9edforan an area of the brainstem known as the locus coeruleus. Drugs
overdra~in m~ checkin9account. It was a blackout likean like Catapres, ®Vasopressin, ® and Baclofen® act to quiet this
alcoholichas, but I hadn'tbeendrinkin9." part of the brain, partially blocking out the withdrawal symp-
43-year-old female recovering pathological gambler and compulsive sho pper toms of these drugs.
 2.30 CHAPTER 2

Many drug users who are physically

dependent keep using because they are
Cornered by Mike Baldwin
10-7 C2006 Mike Baldwin/ 0 1st Dy Universal Press Syndicate www.cornerecs.com
unwilling to go through withdrawal. cornered@com1c.com

I
Types of Withdrawal
There are four distinct types of withdrawal symptoms: non-
purposive , purposive, protracted, and post-acute.
Nonpurposive Withdrawal Nonpurposive withdrawal is char-
acterized by objective physical signs that are a direct result
of developing tissue dependence and are directly observable
once an addict ceases using a drug. These can include
seizures, sweating , goose bumps , vomiting , diarrhea , and
tremors , depending on the drug.

'When I ranout, it wassevere.I mean, bodqconvulsions, lon3

memo~ lapses,crampsthat werejust enou3hto - qou couldn't
stand them. And it lastedfor aboutfivedaqs-the actual
convulsions,the cramps,and thepain and stuff And then it took
anothercoupleof weeksbeforeI felt anqwherenearnormal."
18-year-old recovering heroin user

Purposive Withdrawal Purposive ("with purpose ") is a false

portrayal of severe withdrawal symptoms by an addic t to "Wow, all the way from the couch. Have
manipulate a physician or pharmacist into providing drugs
to manage the symptoms (e.g., "My nerves are in an uproar.
the endorphins kicked in?"
You've got to give me something, Doc!"). This type of with- CORNERED© 2006 Mike Baldwin. Universal Udick. All rights reserved.
drawal can also occur from a psychic conversion reaction
generated solely from the expectation of the withdrawal pro-
gers a heavy craving for the drug after an addict has been
cess. Psychic conversion is the physical manifestation of
detoxified. The cause of this reaction (similar to post-
symptoms resulting from an emotional expectation of phys-
traumatic stress phenomenon) often happens when some
ical effects. These originate in the mind or psyche rather
sensory input (odor, sight , or noise) stimulates the memories
than from any other physical adaptation . Because malinger-
of drug use or withdrawa l, which in tum evokes a desire for
ing or manipulation to secure more drugs, sympathy, or
the drug. The odor of burnt matches or burning metal (smells
money is a common behavior of most addicts, they may claim
that occur when cooking heroin) several months after detox-
to have withdrawal symptoms that are very obscure and dif-
ification may cause a heroin addict to suffer some withdrawal
ficult to verify.
symptoms. Symptoms can last up to six months after initia-
tion of abstinence. 78 Any white powder may cause craving in
"It takesa doctor30 minutesto saq no, but it onlq takeshim
a cocaine addict, a blue pill may do it for a Valium"' addict ,
fiveminutesto saq qes.We used to sharethe namesof doctors
the sight of burgers on a barbecue can cause a recovering
that we couldscam. We calledthem 'croakers .'"
alcoholic to crave a beer.
33-year-old recovering heroin user

"I had just3ot a disabilitqcheck,and that checkwasa triBBer

Over the years the dramatization of drug addiction and with-
for me. It just sent me into a state of nervousness
or anxietq,and
drawal in print and on the screen has resulted in another kind
I didn't knowwhat to do. Todaq I maq not evenwalkon the
of purposive withdrawal affecting naive drug users. These
sameblockthat I used to walk on becauseI knowif I'm feelin3
addicts expect to suffer withdrawal symptoms similar to
shakq,therecould be a possibilitqthat I'll run into somebodqI
those portrayed in the media, and that expectation results in
want to use with, so I haveto staq awaq fromthoseareas."
experiencing a wide range of reactions even though tissue
32-year-old recovering crack cocaine abuser
depend ence has not truly developed . Treatment personnel
must avoid overreacting to these symptoms , remembering
Protracted withdrawal often causes recovering addicts to
that psychological dependence can cause many physical
slip , or renew their drug use , ultimately leading to a full
symptoms not directly attributable to biological changes in
relapse. These slips present a greater risk of dru g overdose
the body.
because users often take the same dose they were injecting ,
Protracted Withdrawal (environmental triggers and cues) A major smoking, or snorting when they quit, forgetting that their last
danger to maintaining recovery and preventing a drug over- dose was probably very high because tolerance had devel-
dose during relapse is protracted withdrawal. This flashback oped. They don 't focus on the fact that abstinence returns the
or recurrence of the addiction withdrawal symptoms trig- body to a less-tolerant state .

"Wecleanedup becausewe didn't haveanqdrugconnections
whenwe moved.We had about15 clonidinepillsto helpus
through,and I wasdrinking.Then we sharedone bag,one $20
bagof 'cut,'and bothof us wereon the poor."
33-year-old husband -and -wife heroin us ers
Research on animals and interviews with addicts demon-
strate that once abstinence is interrupted with use, both tol-
erance and tissue dependence develop at an accelerated rate.
Post-Acute Withdrawal Symptoms PAWS is the recurrent per-
sistence of subtle yet significant emotional and psychologi-
cal problems that can last for three to six months or (rarely)
even longer into recovery and can trigger relapse. PAWS is
similar to protracted withdrawa l, but the symptoms occur
episodically; they can go days or weeks without occurring.
When PAWS recurs, it usually lasts for only a few hours to a
day. These are the major PAWS symptoms:
• unclear thinking and cognitive impairment
• memory prob lems
• emotional overreaction and mood swings
• sleep disturbances
• motor coordination and dizziness problems
• difficulty managing stress
Drug craving is also part of the PAWS syndrome , sometimes
inducing symptoms that are severe enough to cause relapse. 79 •80
People take psychoactive drugs for the mental, emotional, or
physical effects they induce . Most often it is the memory of
what a drug did in specific emotiona l situations that prompts
people to use and to increase use to the point of addiction .
DesiredEffectsvs. Side Effects
Curiosityand Availability
"Sheaskedme if I'deverdoneit, and I told herno, and she was
doingit rightin frontof me, and I just wantedto trqit just to
seewhatit waslike.I wasa cheerleader then, but whenI quit
cheerleading,I startedsmokingweedagain."
17-year -old marijuana smoker
To Get High
"It's kindof likelifewithouta coherentthought.It's kindof like
an escape.It'slikewhenqougo to sleep,qoukindof forget
aboutthingsin qoursleep.It'slikeeverqthing's
dreamlikeand
thereareno restraints on anqthing."
17-year -old heroin user
The Neurochemistryand the Physiologyof Addiction 2.l 1
Self- Medication
"/ wasverqhqperactive , qouknow.Just alwaqs0ettinginto
troubledoingthings, gettinghurt, fallingoff of things,gettingin
fights,gettingin arguments.And the moreI smokedas the qears
wenton, the mellowerI got. I stoppedgettingintotrouble."
I
23-year -old marijuana user
Confidence
"/ felt likeI wason top of the worldand I couldaccomplish
anqthing.Just the phqsicalpartof stafng up so longand being
ableto feelthe freedomof stafng up so longwasgreat."
22-year -old recovering meth addict
Energy
"/ felt reallqtinglq,excited,sexq.I felt that I had all thisenergq.
I felt likeI coulddo anqthing.I felt reallqpowerfuland I
enjoqedthat feeling.It mademe feelgood."
19-year -old male recovering meth addict
Psychological
Pain Relief
"/ had friendsalongthe waqthat passedawaq, familqmembers
that passedawaq,and I alwaqsgot highoverit. I alwaqsgot
loadedoverit becauseI didn't wantto feelpain. I didn'twant
to feelwhat I wasgoingthroughanqmore.Asa childgrowing
up in an abusivefamilq,no brothers,no sisters,no dad, I didn't
wantto feelthat painno more."
29-year-old recovering po lydrug abuser
To Cope with a Bad Relationship
"/ remember beingbeatup phqsicallq and beingemotionallq
abusedand drinkinga gallonof wineand feelinglikeI just
wantedto be out of it. And for me that wasthe waqto deal
withthe pain. I thinkwomentend to do thosethings; either
theq'lltakedrugswiththe perpetrator to havesomekindof
relationship,
or a~ertheq'vebeenbeatup usealcoholor drugs
as a waqnot to dealwiththe pain."
39-year-old ex-wife of abuser
BoredomRelief
'Theq tellqouqou'regoingto schoolto get an educationso qou
canget a good job,okaq?Theq told me howto get a job, so
that'seighthoursa daq. I knewhowto sleep;that's eighthours
a daq. I had anothereighthoursa daq that I didn't knowhow
to fill,
and I usedmarijuanato fillthoseeight-hourperiods."
35 -year -old recovering marijuana us er
Controlof Emotions(anxietyor depression)
"It relievedcertainanxieties.It alleviateddepression,whichI
had- lotsof depression. You tell the doctor, 'I'm depressed.'
'Okaq,takesomeValium. ®' Now theqtrqto giveqouanti-
depressantmedications prescribed bq the doctor./'[[take
the Valium.®"
44 -year -old Valium ®user
To Oblige F<ie nds (interna l ~nd externa l peer pr=ur e) they •I"" trigger mild , moderate, d•ngerou•, •nd oome-
time,fat21,ide,ff«n . Thi>ronflictbetwerntheprn:eh'<d

·!;;:tt,~~ll~~;~tt~ po<ith'<emotionoVphysic•l<ffect.sde,ir<dbyU><Croand1he

if'l"""""''ton,J
"
=-
~n=:,:~~-i
r:;'~
negativ,oide,fferuiothe catch -22ofpsychoactiv,drug=
PhyoicWl>pr<>erih<psychoactiv,drug<likecod<in,(m
opioiddowner ) torelievepain,to,upp=
trutS<Vered i.orrh<• . butthatdrug>l!iO
• cough,orto
>C1' U >5<dotiv,
giv<> • f«ling of well -being, •nd induc,s •n emotioil.l!
numb,,,.. _ P,oplewho • busehydrocodoneOTOxyContin "
lorthel«lingofv,.,ll -beingornumbne,,mu,t> l!iOda l with
the,id ee ffecaofslowubiologiclunctionsthatoftrnladto
ronstipation.V.'ithmodemeu5<,nou.sa,pinpointpupils
dry,kin,•ndslowedrespiration=•b.ooccur.Fn<jll<nlu5<
caU«S lethorgy • nd lou of sexu.al d<>ire. md oompul,h ., use
l~stoabus,•ndaddiction . lnadditiontoharmlu l physical
andp,ychologic • l•id< effeca.drugu5<>looca u ,e,nega tive
,;oci.ol,ideeffects,includinglegal.rebtionship . fiIUI>ci.al,
andwOTkdifficulti~yofwhichc anb<c•tas t rophic
AlteredConsciou sne "5
"lflp«up111ljd,,;,tij. jt"""'1Jl,,""lcliil<lit...,..l,J!,, ""I
"A<:.Jpot.., illa~""'"'otl,,,. ,,,tl".ldoOt ~ ;if,l.uJ
ro,,pL ., ,.,l,,,t ~""' !ik,_Of= . 11,,,,...,,, tl,,.,...,i,
"°""· jt """'IdI,, '"'I 01,. it wouldbe '"'I'""'"'I
·
it ...,..l,J be
""l',/,m,,,,!,ip.111ljf'<l""t,·'"'lb.,,;,,,,,t;l,,,ti1Wotto,tort .
...i,,,,,.,"ltl,"'l,.,,,,,,dro,;1l,,,l,,drip""18orlil:<<Wfljllti"!J f,eoWall1j.rJworl:do...nto ""l ..,..i"l:l"in. '""'ll,,'"'llif, . tli,
fi,,,lsacrifiu.tl,,0Ntl,at'l""doo·t8'tanotli,rcl,,,nc,at. ·
...,..l,Jt.,.nit>top,,tt,rruanJlcooldlool.attl,,carp,t""d
...,..._r-.,,...,,,.,..,._
~:=~::i::s:~'i;t bi.t,.,,.,"' I .,,J {<lfW,J
Sidedf,rucanbe cauoedo,:,ggr:a, .. <rob)·•numberolother
!actoB,indudingpolydrugabw<mdaccelecratingl<>d,ofus,

PolydrugAbuse

-~•t:, t::::;~::;"z":":~t,\f"'9'
~ ,ar,tofu,dad"'8ad.kt wl,,,abu«doo lijtl,,;,drotJof
choiu_5.i.,,,~<lic..,amtliattl,,""of""'/"'ICl,o,ocu,,
drotJioma>fttl,<pot<ntia!toabu,,ofhtrp,vc),oocm-<Jr,;g,
Oftl,,lw,,J,,J,oftJ.ou,,,nJsofp,opl,r,..,,,,,,,,o;,,

Competilivt!Edge
;:~":,"i::a t::~f.::
:,r~:'t"::
o>ccoWltoicotiti<oodrnff,i"'ad.o<Cho
"-·
~a=J

·s1~t~!~~~;~:;;~,
"'lint!M.,ah,,"9"11,qi-
·
.,.,,,, ,........... ., .D.,"""""""'""""'Yc,""'

Drugabu0<andth<pncticeofromput.iv<b<havi<>T<C2n
· """"°'-00

,;om<tim« be ronsid<r<d the •ymptoms of und<Tlying prob-

,...__
,......,""' ~':';,
~!:'!":..:~
h':::ii~••
•~~~~.•:~:~::.:1:e':;
int<nseh<ha,iorto>ttlinthed,sirrdchang<ofmood
SideEffects Virtn•llyev,ryclirntwho<nt=trutm<n l h2'proctic<d

;;::~If.
polydrug • bu., _u,ingon,ormor,o/thelollowing
~~a:;:i\,:i:
:.i::~tu,
d«t""M9alif,, .,lh<l/diJto..,Sojtr,j lij<kp<od,on
• R,pw:<ment. Some people us, •nothu drug when
th<ird,s ireddrugi,no l a\.,ibb l<<>Tifthey • relook -
ti,, ilktj..J.ial - ~•l,,,ta.,J OowI,,'"°""'and I,,,., wMlij ingfor!i0m<thingle55honnfu l thonth<irdrugofchoice
l,,..,,o,,i.oc..,,.,,rro.,,,,,.,Jabo,uaodd"'9' . (e.g.,drinking•lroholwhrnheroinisunovllilob le. u,.ing
,,,___...,,..""".....,,.
...,,,..,..,......., e-cigarett<<imteadol,mokingtobacco
• Mu ltipledrugn><.Someuse,evaaldrug,to>t
)
tli ndif -
lfdrugswrn, 12k<nonlyinoontroll<ddosolorth<irint<nd<d f,r,ntf«ling, (e .g.,tokingm<thomph <11minefOT51imu -
purpo><,theywouldnotb<muchof•problem.Butdrugs lotion•ndbecomingbor<dwithi1,th<nu,ingk<11mine
notonly generatedtoindemotion•l•ndphysic•leff«n for • differrnt effect)

• Cycling. This involves intense use of a drug over a period
of time, abstaining or using another drug to rest the body
or to lower tolerance , and then using the original drug
again (e.g., taking an anabolic steroid for two weeks,
then a different steroid for two weeks , then nothing for
two weeks, then back to the anabolic steroid).
• Stacking . This involves taking two or more similar drugs
at one time to enhance a specific desired effect (e.g., us-
ing alcohol and a benzodiazepine to fall asleep, or using
MDMA with meth to enhance the ecstasy high).
• Mixing. This is combining drugs to induce different ef-
fects (e.g., speedballs [cocaine with heroin] ; lacing a
marijuana joint with crack; X and L [ecstasy and LSD] to
prolong the effects of each; methadon e with Klonopin ®
to mimic the effect of heroin ; or an antihistamine and a
sedative to intensify the downer effects). Some of these
combinations are taken intentionally ; others are not-for
example , when a dealer spikes his drug with a cheaper
drug (e.g., PCP is used to spike a marijuana cigarette to
mimic a high THC content).
• Switching. This involves using one drug in an abusive or
addictive manner and then switching to another drug ad-
diction (e.g., a recovering heroin addict who starts using
alcohol compulsively, or a cocaine addict who switches
to methamphetamine). The sequence can also include
behavioral addictions (e.g., a recovering alcoholic who
becomes a compulsive gambler, or a compulsive mari-
juana smoker who switches to compulsive eating).
• Morphing. Morphing is using one drug to counteract the
unwanted effects of another drug (e.g., a cocaine user
becomes so wired that she has to drink alcohol to come
down; a drunk who drinks coffee in an effort to sober up;
a heroin addict who uses methamphetamine simply to
function).
Becausethe diseaseis "addiction,"and
not opioidismor cocainismor alcoholism,
most people who abuse one drug almost
alwaysuse othersas well.
Levels of Use
To determine the level at which a person uses drugs, it is
necessary to know the amount, frequency, and duration of
use as well as the impact the drug use has on the individu-
al's life . For example, Sam might drink a six-pack of lager
beer (amount) twice a week (frequency) for 12 years (dura-
tion) without developing any problems. Max might drink
only on Friday nights but doesn 't stop until he passes out
(bingeing). Max will probably have more relationship, health,
legal, and financial problems than Sam, who drinks more
frequently but functions well on the job and works at his
relationships.
The following categories are used to judge a person's level
of use:
• abstinence
• experimentation
The Neurochemistryand the Physiologyof Addiction 2.33
• social/recreational use
• habituation
• abuse
• addiction
Even though the levels of use are neatly presented as distinct
categories, the transition from experimentation to habitua-
tion or from habituation to addiction is not as neat. It is a
continuous process that can ebb and flow.With most psycho-
active drugs , there is a point where it becomes harder and
harder for the person to rationally choose the level of use
at which to remain-the hedonic set point. That point can
vary radically from person to person .
"Goin3 from bein3a social drinkerto an alcoholicis not
predictable, it is not an exact science. It's likea cucumber
turnin3into a pickle. You'rea cucumber,qou're a cucumber,
qou're a cucumber,and then qou're a pickle!No one is
reallqsure when that happened, but once qou're a pickle,
qou are not 3Din3to becomea cucumbera3ain."
Robert Harried, CADC I counse lor, Addictions Recovery Cen ter, Medford , OR
The 2013 Diagnostic and Statistical Manual of Mental
Disorders, DSM-5 , classifies an addiction on a scale, usually
mild, moderate, and severe.
Abstinence
Abstinence means a person does not use a psychoactive
substance except by accident (e.g., unintentionally drinking
alcohol-laced punch, taking prescribed medication that has
a psychoactive effect, or being in an unventilated room with
smokers). Even if a person has a very strong hereditary and
environmental susceptibility to use drugs compulsively, he
will never have a problem if he never begins to use. If he
never uses, there is no possibility of developing drug craving.
He might, however, have a problem with compulsive behav-
iors, such as gambling, excessive Internet use, or compulsive
sexual behavior if he has an addiction vulnerability and
participates in such activities.
Those who experiment with alcohol , nicotine, and mari-
juana between the ages of 10 and 12 are more likely to
abuse alcohol, nicotine , or other drugs than those who wait
until they are at least 18. A person who does not use nicotine
before the age of21 almost never becomes addicted to tobacco
later in life.84 The same applies to people who avoid trying
any drug until their mid twenties; significantly fewer of them
become addicted. 85 -86
Researchers once believed that a spurt of overproduction of
gray matter-the working tissue of the brain 's cortex-dur-
ing the first 18 months oflife was followed by a steady decline
as unused brain circuitry was discarded. In the late 1990s, the
National Institute of Mental Health's Dr. Jay Giedd and his
colleagues discovered a second wave of overproduction of
gray matter just prior to puberty, followed by a second bout
of "use it or lose it" pruning during the teen years. The part
of the brain that blocks risk-taking behavior is not fully
developed until the age of 25 or so. On the positi ve side, the
risk-taking and novelty-seeking behavior in adolescence
 2.34 CHAPTER 2

helps provide maximum brain development with appropriate

'The friendsI startedhan9in9out within schoolwereprettq
feedback. 93 More-advanced functions, such as integrating
muchthe onesthat werereallqrebellin9and alreadqknew
information from the senses, reasoning, and other execu-
tive functions, mature last. 87 ,88 ,89 ,90 ,91 Gray matter abnor-
aboutci9arettesand pot, and so wejust startedsneakin9off
and someonewouldhavea jointor somethin9that theirdad
malities are not limited to those with a drug addiction; they
le~ around."

I
are also found in those with Internet addiction (a behavioral
addiction). 92 24-year-old marijuana smoker

"Mqbrotherdiedof alcoholism,so I haveneverhad a drink
of alcoholor, for that matter,a puff on a ci9arette."
Donald Trump, 1999
Experimentation
When people become curious about the effects of a drug or
are influenced by peers, friends, relatives, advertising, TV, or
the Internet, they experiment and take the drug if the situa-
tion presents itself. The distinction between experimentation
and abstinence is a person's curiosity about drug use and the
willingness to act on that curiosity. Experimentation is usu-
ally limited to a few exposures to a drug. No pattern of use
develops, and there are only limited negative consequences
in the person's life unless:
• large amounts are used at one time, leading to accident,
injury, or illness
• the person has an exaggerated reaction (e .g., cocaine
allergy)
• a pre-existing physical or mental condition is aggra-
vated (e.g., schizophrenia)
• the user is pregnant (e.g., fetal damage)
• legal troubles arise (e.g., failed drug test or arrest for
possession)
• there is a high genetic and/or environmental suscepti-
bility that can lead to compulsive use and addiction
• there is a prior history of addictive behavior with other
psychoactive drugs that can lead to a relapse
These are all factors that could rapidly elevate experimenta-
tion to a more intense level of drug use.
Habituation
Habituation is characterized by a definite pattern of use
(e.g., the TGIF high, five cups of coffee every day, or a half
gram of cocaine most weekends). Regardless of what hap-
pens that day or that week, the person will use that drug; and
so long as it does not affect the person's life in a really nega-
tive way, it could be called habituation.
"Youwouldsaq that I wasa habitualuser,but I don't reallq
thinkthat's the case.So it is a habit. I likea drink,And the
question,qouknow,the questionis, could I S° a daq without
havin9a drink?I thinkso, but I'veneverhad a reasonto trq."
42-year-old habitual drinker
Habituation is an early sign that one is losing control over use
of a drug. Once a specific pattern is established of how and
when a drug is used or an addictive behavior is practiced, the
pattern starts to supersede all other aspects or needs in a
person's life. Some college students begin habitual alcohol
use on weekends-TGIF (Thank God it's Friday [I can drink
now ]-but then continue the pattern after leaving college,
which can result in future alcohol problems.
1-\oWTo ri;;LLYoU'\/1;
G,oNt;FRoM<:%UM.
To~ t..OOICTloN
...

"A lot of mq friendsdid heroin.I just wantedto trq it. It wasan

experiment.I just wantedto seewhat it waslike.It feltaood for
a littlewhile;qou nod off
and qouare half-dreamin9."
22-year-old polydrug user

Social/RecreationalUse
Whether it is a six-pack at a party, a bowl of "bud" with a
friend, or a couple of lines of cocaine at home, someone
engaging in sociaVrecreational use is seeking a known drug
to experience a known effect, but no pattern has been estab-
lished. Drug use at this level is irregular and infrequent and
has a relatively small impact on the person's life unless it
triggers exaggerated reactions, pre-existing mental and phys- 2-6 'Vll§Y
ical conditions, an existing addiction, a genetic/environmen-
©1997 Wiley Miller/ di!!, by E-1t1all:wllevtoo""'aol.eo1t1
Washl11gto11
Post Writers http://www.washi11gto11post.co'"/wiley
tal susceptibility, or legal troubles. SociaVrecreational use is
NON SEQUITUR©1997 Wiley Ink, Inc. Dist By UNIVERSAL
UCLICK.Reprintedwith
distinguished from experimental use due to the establish- permission. All rights reserved.
ment of drug-seeking behavior.
 >
Abuse
lhedefinins5Yfflplomofab!Jseand
Thedefinitionofdrug•bu«istherontinueduseoF•drug
add~is•continuedused es pite
deop'tenegat'econ""'lnceo . lt'u<ngcoco.'n<','·f
nesa!M!con""<!u ences.·
highbloodpr<Mur<.takingl.SDthoughth<r<is > familyhi<-
toryolmmta li n,ubility,•typeldi•beticdrinking<xcnoive
•mounl5•lcoho l. ••mok< rwith asthma goingthroughtwo
Classification(DSM-IV-TR,DSM-5, and ICO)
pocks•da)·,or a u=with•><rie,ol•rre,'5/orpo«ession
Regordl,.,ofthefm:iuencyofu,, .i f negativeoorncquenc,s
d<>'<lopin a penon'sr<btiomhip,,,ociallife . financ:es.l egol
,utu,, h<lllth. work . <ehool, or emotionol well-being •nd In \9~l the lint edition of th< American P,ychi•tric
drngu,,continue>on>r<gubrba,is . thatb<h"'-iorcouldl>e Association's Diagnostic .,i,J Stali<tirnl Man""/ of Mrn<al
cbssifiedasdrug abuse Di<onlm (DS.'J) was published. In •ddition to mental
illne..,,, rnch••schimphreni• . depression, •nd manic
"/hodanEEC[electrotnc,pl,,,loya,.].aCI\T[compotmud
mialrot!IO/fapl,ijJ=•.an.11...,toUlhatlhodk-red""I ::.=:rc:ut:~•: .:::) ·~;:;;-.,:u•~::u~:!.~:=~o:
"""" thrd.ol/Olj.h"8 "'""'"'I'~'"""'"~·
b.ttliat', oot
ha,.,c!angedo,.,rth<)"Ur>tore0ectnew=an:hmdid<.a5.
lnthema,trecentedition,r<le:L<roin),laylOU,•Substanc<
~,;:::,: ~'r0::'1.'!:a!71/ik;'.;~/:t:rd
p,o&.bLj..,,,contuu<J"~'/'<,d"',nwilhtl,,,,W<m" ~"-!'.::!:~i::~~ i;,:r:;::g:ri:~~

~~~h=,..t~::!:,~:n:i.!~.:•:~ ::i!i::.~~
Specific ,ub<Unc<5 or cW, ol sub<unc<5 are d<>ign,.ted
Addiction
mdd<>eribedwithdi>gno,ticcriterialor a rangeofsev<rity
:!:.-:•~~':~
:.~:..;~d"!~~~.:t;'~;e:,:;pul- ~:;'.!;.'od<rol< . «v<re)lorach,ubstanc<•nd for gambling

• :i'::i::,t~!":!~:i~r •mounts or lor kmger p<ri- Theu«ofthet<rmaJdicti,·edi,orderv.':l5gre.:ttlydebat<d . ln

• · unsucc,s'l'n atl<mpl5tocutd,rcontrolu«
• c,b
""'.'1'th<· u:,l ·::•:;~::of.\::~:
• gi=uporreduc<>participotionin,ocial,occu?1,tioruol
orm:rutionalacti,-iti<>bec>u«ofthedrugu«
• rontinu<>usingd<>pit<theknowledgethatitiscausing
physicalorp,ychologicalproblrm,
• ntt<h•hitofthedrugto,urtth<da)·
• g<ts•ngryorenr.tgedwh<ndefendingthedrugu,,
• aperi<nc,swithdraw. l whenunobletoobtainthedrug
• :;;~=~::!ncr<>«th<•mountof•drugtoobuinthe
Suchu«"havelostcontrolofthrirdrugu"' . •r.dthosesul,.
,wx:nhaveh<com,themo,;timporuntthingintheirlfr<>
Theauth<>T>b<li<>"<t hataddictio ni,romposedofthe,ix
Cs,orcom<Bton,so/oddicti,.,b,ha,ior
• c""'l'ul,l,,edrugu«
• craving,fordrug,
theD5.'J-ll"TR,thewordaJdictionw .. notu.,.edbecau«of
thegrea1md,.,r,·iruoppropria1<stigmousociatedwiththe
· 'foto t<rm . lnt<n<i>'<r<.,.rchoverth<pa>tdecadeha,oonfirmed
that addiction i, • medic•I disorder, which l<>oen, that
stigmo . Theeditor,ofth,DS.'J- , rompromisedtheirpo,ition
byusing"Subsunce -R<Ut<dmdAddicti,.,Disord<n ."
Specific diagnostic d<>eriptions "" provided lor ach
cbssofdisord,n : "Alrohol-R<lated,""C.ff<ine-R<la t<d,"
"Cannabis-Re lated ." "Hallucinog<n-R<bt ed," "lnlwant-
R<bted," "Opioid-Related," "Sedatiw-Hypnotic- or
Anxiolytic-R<laltd." "St imnl •n t-Rebted " (with ,ome
uniqut criteria for amphetamine vs. rocaint), "Tobacco
Relat<d ."and"Non-S ubstonce -Rd•t<d"(go mbling)
Each ind ividual drugclassificationdesign,.t<• • clu,terof
CO:'i:iti~e. be~vi:r.t l. ~nd _ pdh~!ol~ica~ •ymp;oms al':~
the,ubswiced<5pit<signific•nt•ub.tanc<-r< laledproblems
•r<Olthe levdof•buse a ndoddiction.Pauermofrepnted
«lf-administrationthotca n=ul tintolermc:< . withdr:aw:al,

~=
..o::;,~t:;;;
mdcompu l,ivedrug-wdngb<ha, iorandtha toccu r ov<r a
• cmuinuedusedtspit<incre .. ingc.ata<lrophi<:
longp<riodoftimeoomtitut<thedi>gno,ticcrit<ri>forthe
""'''"fl''"'"'"""". ted 'thu.,.e
:~~~::~~•=~~?h:~~f}:~;h
"/nlh,"'9mn"'!Jl""'abl,tocontrol"lljoddicoo,,_/...,.aJ.e

__
to Joit ""llj otl,,,d,~ , ..,~!,,or.:, Q w,,j, "ntil ii ,tart,Jto pr<litnt<d
!,,,.,llj>ine/<tialj... tolllhm/,n.1,d"('lm"!Jindowntow• Alon g with withdrawal criteria . other ,ub.wice -induced
~f=~~a:,;w:.t
~::~:~71'?i
:!t;":!'~"'~ disord<r>>r<presentedwithwhat<verun,pecified related

...,..,..,..
H,....,IP"8to8't~.- , __
_
an!jfhi"8totl,,dop,..,•to8'tah.jt"""8"'litaliopp,n
,ymptomscau,,clinical ly, ignificantdistr<Mor!m?1,irm<nt
·nsoc' l. occup;ti,ruo l. oroth<r'mporu.nt•re.,offunct'on
ingbu t donotm«tthefulldiagn0>ticcriteri>,pecifiedfor
that,ub.tanceorg:,mblingl>ehav:ior ...
-
 2.36 CHAPTER2
Criticismand ControversyBefore it was released in 2013 , the
DSM-5 generated a great deal of criticism. Many believed that
its heavy reliance on subjective self-reports of those being
assessed for diagnosis, disregarding more-objective recogniz-
able signs, was inappropriate. These critics argue that recent
I
discoveries and analytical tools like genetics, brain imag-
ing, and various other biological anomalies of addiction
and mental health disorders could have greatly strength-
ened the current version of the manual. Another major
controversy involved broadening the diagnostic criteria for
disorders to a wider spectrum of severity from mild to severe.
Many complained that including diagnostic descriptions
for diagnosis of a mild disorder (e.g., mild alcohol use
disorder) could be used to justify a diagnosis as a disorder
for almost anyone who drinks, even those who have an
occasional drink or two. The controversy surrounding the
2013 edition of the manual is so strong that some have advo-
cated using the World Health Organization (WHO)
International Classification of Diseases (ICD) as the diag-
nostic standard for addiction and mental health disorders
instead of the DSM-5.
WHO InternationalClassificationof Diseases
In 1948 the World Health Organization adopted an
International Classification of Diseases, representing the
basis for a nationally and internationally comparable and up-
to-date consistent collection, classification, processing , and
presentation of disease-related data. The last major revision
of the !CD was in 1990. It is periodically updated , with the
next major release, ICD-11, scheduled for 2014 .
The majority of the content is directed toward physical dis-
eases and conditions. One section covered Mental and
Behavioral Disorders (F00-F99), and part of that section
(Fl0-Fl9) covered Mental and Behavioral Disorders Due to
Psychoactive Substance Use:
• FlO: Mental and Behavioural Disorders Due to
Use of Alcohol
• Fll: Mental and Behavioural Disorders Due to
Use of Opioids
• Fl2-Fl9: Cannabinoids, Sedatives, or Hypnotics
Under each category, subdivisions include: Acute Intoxica-
tion; Harmful Use; Dependence Syndrome ; Withdrawal
State; Withdrawal State with Delirium; Psychotic Disorder;
Amnesic Syndrome; Residual and Late-Onset Psychotic
Disorder; Other Mental and Behavioural Disorders; and
Unspecified Mental and Behavioural Disorder.
Theoriesof Addiction
"It's not just a phqsicaladdiction;it's a spiritualand emotional
problem,too. It doesn'tencompassjust qourbodq;qourmindis
totallqoff-keq. You'rejust so involvedin whateverthe addiction
is, qou're not livin9qourlife-qou 're livin9for the addiction
."
43-year-old recovering addict
'The developmentof addictionpro9resses fromrrst the spiritual,
to then the emotional , and rnallqto the phqsicalaspectsof
an addict's existence
. Treatmentworksbestwhenit pro9res ses
bqrrst addressin9the phqsical, then the emotional,and
rnallqthe spiritualaspectsof the addict."
David E. Smith , MD, found er, Haight Ashbury Free Clinics, and past
president of the American and th e California Society of Addiction Medicin e
In addition to a number of psychodynamic concepts of com-
pulsive behaviors , including "regressive behavior caused by
unconscious conflicts " and "ego conflicts regarding the envi-
ronment and inner drives ,"95 •96 there are three major schools
of thought regarding addiction; some are influenced by the
DSM-5 and ICD-10 categories. One school emphasizes the
influence of heredity (addictive disease model) , another
focuses on the influence of environment and behavior
(behavioral/environmental model), and the third centers on
the influence of the physiological effects of psychoactive
drugs (academic model).
AddictiveDiseaseModel
"Druaaddictionis withoutdoubta braindisease- a disease that
disruptsthe mechanismsresponsible
for9eneratin9,modulatin9 ,
and controllil1£j
coanitive
, emotional,and socialbehavior
."
Alan Leshner , Ph .D.
The addictive disease model , sometimes called the "medical
model, " maintains that the disease of addiction is a chronic,
progressive , recurring, incurable, and potentially fatal con-
dition that is generally a consequence of genetic irregulari-
ties in brain chemistry and anatomy that may be activated
by the particular drugs that are abused. This model main-
tains that addiction is set into motion by experimentation
with the agent (drug) by a susceptible host (individual) in an
environment that is conducive to drug misuse. The suscep-
tible individual quickly experiences a compulsion to use , a
loss of control, and a determination to continue the use
despite negative physical , emotional , or life consequences .97
'The rrst timeI triedit and I 9ot hi9h, I said, 'I thinkI'd use
someof thisfor the restof mq lifeif I couldaffordit. ' If I could
affordthis, I woulddo thiseverqdaq for the restof mq life."
43-year-old recovering heroin addic t
Studies of twins in many countries throughout the world,
along with other human and animal studies, strongly support
the view that heredity is a powerful influence on uncon-
trolled compulsive drug use and behavioral addictions.
Some studies place the influence of genetics at anywhere
from 40% to 60%.98 Researchers have found about 89 genes
that exert an influenc e on whether a social user will progress
to addiction. 22 •99 Another 900 or so genes are also suspected
to influence the development of addiction.
Under the addictive disease model , addiction (dependence)
is characterized by the following:
 • rompul>iv,drug•buS<mHkedbyu..,orintoxication tion work tog<th<r t o re,ult in •n irulividu.:tS unique
throughoutthtdayandanov,rwh<l m ingnttdtoron- vulnaabili tytoaddiction. "'
Theb<ho,ionl.lrnv!ronmrnta l mod, l delin<at<stheoixlev,I,
• 10.. ofcon t rolo,,er1heuS<of a drug,with a nirability10 of drug u .,._. bstinrne<, ap,rim<ntation. <OCUVr«r<-
ruluce'ntak<or,topuS< Olion.alu5<. habitu.otion, >buS<, md addiction - nd <mpho-
• rontinuationofa lms,ed,op it<th<progr<>•iv<dnd o p- •iu• th< progru,iv, notur< ofthe di"""'
mrnt of S<ri<m• physiczl. mental , or social di!i<>ni<n
aggmr.u<dbyu,.e AcademicModel
• r<pnt<do tt<mpt>torontrolu.,withp<riodsolt<mpo- lnthi,mod< l •ddictionoccunwh<nlh<body adaptototh<
"''Y ..i,,~n<ne<inturupt<dbyr<la~intocompul>iv< to xic,ffectoofdrugsatthtbioch<micilandcelluiorl<wt.
inth<proc< .. c• llcdallostHis ."' ·"'·m Fintpropo,<dby
• proll:'•.•iv~ ~oc~lation ~nakt and problem• ~<>'<n C.K Himmd.b•chinl9-41,iti,iba<edonth,thro rythot
p,ychooctiv, drug, dl>rupt th< homrosaoi, (naturol bal-
b<fatalduetoovml= . ph)"icaldet<rionotion,inf«tion anC"<C)o/1h,l>ody. p•rticulariybrainch<mistry.lf•p,non
fromdrug,orn«dl,s , orrora,qurnc<>from•high - l>gi,.,n,uffidrntqwontitie,ofdrug,for•n•ppropriat<
ri,klibtyl<);thisinclude,both='<r<ph)"icaVm,dical dur.ttionoltime,1h<body•rulthebrainchang<•ndadopt
probl,m,andcat>.<trophic«><UlconS<qurn= """P'°" tionmecha ·,m . lt'•th',att<m pttor<bal:mc<
• incurobleonceth<11>acro=lh<lin< intoaddictiv< t~t,\ndu~~ng-~ clung,• t hat will l,ad to H wd l.,
uS<(r<m',Son · ·' •~«toftrtttm<nt , notcur<)
• potho logic • lrttctiontoi n itiildrug11«c,•nchHin- Fourphyoiologic•lchange,chor.tct<ri,ethi,proc,,.
""'""'dtol<I2It«,bWCko ut>orbrownout>,andlo r d,.._ • Tol<nn«.R<si,itanc,toth<drug'sdT«:to in=,nec e,-
m>ticp<B<>n•liry•rullif<,ryl,chang,. .. ·"(blac kouts ,i tatinglatj!<rmdl•'l!<rdo,;,s
ar< los,ofm,mory, not ur.comdou<n<Mwhil< under th< • Ti••u<d<prnd<n«. Actualchang,sinl>odyce ll>occur
infiu,nc,of•drug;brownoul5>r<P"ni> l m<moryloo, h<cou><of,xce .. iv<uS< . r<quiringmor<ofth<drug to
whileundertheinfiu,nceof•drug) ront'nu< funct' nin~
• Withdrowal,yndrom<. Ph)-.ic • l •ignsrnd,ymptoms
Behavioral/EnvironmentalModel app,or whrn~guS<i.s>1opp<d . .. th,bodytri<S to
Thi,throry<mpruo5izestheov<rriding,ignificmceof,mi - 1
• Psychologicald<p<ndrnc,c.Th<df«tsolthedrug•r<
:~:~:: 1:.~!:';1::i;,•::~n=;~;:~-::~i;:::: d<Sir«lbytheusatoob tain<mot ional,tability,which
thotemironm<nt>.lfactoBcanchang<brainch<mistry u r<infon:esthedeoir<tok«puoing
,ur<ly.,druguS<orh<r<dity . Environm<nl.l!lyinduced
<motion • lm,morie,hov, a lifdonginfiu,nceonpropl< ."°'"' Diathesis-StressTheoryof Addiction
Many,tudies,rnpport«lby!iC>nsthot,howb rainfunction,
Allth<< xl>tingthroriesofaddiction•r<validinth<irown
,ugg,stthotphy,icaV,motiono l st==ultingfrom•bus <,
right.hi.sh<neficiol,hov.nu,toint<gr.,t<th<""throri<s
mg<r,p<<rp=ure,•ndoth<rrnv!ronmrntalfacton,<Sp< •
do lly ifth, ,ttt..!ul situation OCCUBduringchildhood,
cau=propl< to><<k,uS<,and,us tain a oontinu«ld<p<n ·
::~'7~:.tr~!~::;;:;,~;:-;:~:::r:;.:
dlath<sis-slf<Mlhroryofpsychologi caldisorders,uch••
d,nc,ondrug,. ""·"' Chronic•tr< .. cand<crns<broin
!iChizophr<ni•bntlm'5form«l ittooddiction.Adiothesi,i,i
l<V<l,ofm<t-<nktpha lin(anrnrotran,m itta)inmice,m.ok-
"aco nstitutionolpr<di,po,itionorrnlnenbilitytode>..elop •
ingnonruil mi« thot avoid alcohol more,usc<p tibl< to gi,.,ndisorderund<rcertainconditions .•
•lroholu,.e. '°" Many>1udiesfocu,onth,critic alinfiurnceol
<mi ronm<ntoombir.«lwithher<dity "'·''" Apr<dis!""ition(dioth<Si•ltooddictioni,thtre,ultof
grn<tic and emironm<nt a l infiumc,o (e.g., childhood
Rd igious • ffiliotionor a lackth<r<ofha,h«n,howntohov<
•bus,,adrug-u,inghou.,hold,orn,nbodnu t rltion)
minfiu,nc,on,uoc<ptibility•ndr<l•~ ·"' Nulrition•lddi -
which.whrnfurthtr,tr<>..,dbyth<n..,oFp,ychoactiv<
cirnd,scm•b.o•l t<r>p,non~brainch<mistry•ndfnnc -
drugs OT th< practice of cm.in rompul,iv< h<havioB
tion . mokingon<vu lnaab letodev,lopingmaddiction .1"'-'"'
•lt<rsn<nroch<mistry,brainfunc tion . and,vrnnew
R«rnt•d=«•intheunderstandingolepigrnctic•lt<r> • <, in<t'cg<n<<Xpn,Snotor ' p<' tt l •r<tumto
tion of gm< <,q>r<Won, d<momtnt< how rnv!ronm<ntal normalb<hoviori,,xtnmdydifficult.
troum.o,, u-... ,to'm.ande.,.,nh<ha ' ,r,canr,,;u· ·n •
For mor< informa tion"' wwwcnsproduction,.rnm/pdjl
grttt<rvulner:,bilitytooddiction . ThoughDNAl>immuta -
rpigrnn;,.,
bl,,g,n,scanb<,xpr<55<ddiff<r<ntly•ndtum«lonoroll
due IO<mironm<nta l <xpo,ur,,; . Epigrn<ticg<n< <xpuo- Thestrong<rthedioth<>i,,th,fewudrugoor l<M•ctingout
•ions promote th< J>O"ition tha t a ll thr« modd• of addic- l>ne«l«ltopu,hth<p,nonin to•ddic tion;conv,rsely,th<
W<•k<rthedi.othe>.is,themoredrugoorb<ha,iors•ren«ded the"tip<)'g<n<" actuall)'prot<ctan!ndividualfromb<com -
tof:1.•p,r,on'nto•c'"ri ,n ing an addict or ~lcoholic
1
7.:" ~cynu"' _th, pe=m to

Susceptibilitytodrugab!J..,andaddiction TheS<g<n<>c•naff<e tI<Cc:<ptor,,g<n<tr:m .criptio nfacto B

isformedbythecombinartionofheredity, ,nzymes,n<nrop<ptid<> . Gprot<im,andtr.tnsponu,;
environment,andth e useof?SYCl,oaclM! amongoth,rs _lf • personh.asjust•fewofth<g<nesth.ot
dr"ll•orpractic.eofcompulsivebehaviors promot<addiction . heo rshemightha>., • lowpropensity
todrugd<p<ndence: • Fewdounm>yindicote • highpro-
pensityto•ddiction.Dr . MarcSchu cki1. a majorre«.:uch<r
Heredity,Environment,Psychoactive inthisfield . sugg<><>lha1about'50%ofd,pend<nceand
Drugs,and CompulsiveBehaviors add ictionto :,lcoholisduetogen<t ic:,_LL•Genesthataffect•
procnocall<dcdl•dh<>ion•reolparticu lorint<re'1
Todaymore•ndmo r,r,c .,._rchu,;in th<fi< ldofaddictionol -
"C,1/adl,,,ionmoltculn:cootroltl,, fo,maOOfl , ,toOiliultion
ogyb<li<v<lhotth<rnsonswhydrug•ddictionoocuro•r< , nh.,.,w.,nt. o.d ,~mina!ioo of cootm:t, l,,t,.,,,n l,,oin «JI,
• rombin>tion0Fheredity . <nvironm<nt, • ndth<u.,ofpsy-
d10=ive drugo ."' "" ·"' &c•ns, !ndividn • l p<rsonoliti<>
ph)'Siology.andlifr,iyl<>v.ry,<.achp,r,on's=istanc<or
su<e<ptibilityto exc<>0ivedrugn«•OOvari<>.histh<refon
neces<arytoex:omineth<d<t<rmininglactonv,rydos<lyto
i-::;r~i~;;:::¾1:
..,/dicoo,,.,,,l~;IJl,,lpu,:wd,r,t.,,,,/~h ~ odd,::t,cm,r,/,,p><
d.cod,,aft,r tlwla,;t""o{onoddictiwd'"8-.
under,tand why on< p,=m might mn.ain •hst inent, •noth<r
might n><e drug, sparing ly,• third will us< Ion lif<tim< and ~ u"'.• ·,.· ·'""'"' '"'..,_"'""°l:r
:::,~v::~ 1:7::.":n::•on< <I><will u« •nd become

>
Heredity Eighty-ninegen.,.hav e beenidentifiedas
Heredityhllapowafulinflurnc:,oncompul,iv<drugu.se
havinganinfluenu,onadd~on . lhe.• • •
For)'<.Or><eien1is1>ha,., knownlhotmonyu· ai t u r<passci
hundredsmore , yettobed,scovered
fromgrnaationtog<n<ntionthroughg<nes : ,yeandh.oir
rolOT,facialf<.atur<>. bone>tructuI<C. >nd . mo51sign ificm~y. TwinandRetrmpectiveStud i""
lheini1ialotructureandchemistryofth<n<TVous,y,1<m . ln Ones,1o/indic:ator,that•1<ndenc)'looddictionhllan
recrntyanscirntis1>h.ove,xpanded1helis1olgenetically
infiu,nc<d tni1>toinclude more -complexph)'Sic • l"'action,
andd~a«,,,uch .. typeldi.ob<t<>(fonnerlyknown.,
~~ctci !~ mu.ic-Ountrie, !a..v:! ~<~<> o: ·Don.aid
W.GoodwinoftheW.ashingtonVniv<r<itySchoolofM,dicine
juvenile di • b<tes), !iOm<fonm of Alzhcimu\ di"'"" · <ehim - inS1 . Loui,did•studyolid<nticaltwinswhow,readopted
phreni.o, !i0m<forms of depre..ion, •nd • 1<ndenc)' to Cffl>in bydiffer,n t f:omili<S,hortl)'aft<rbinh.Regardl<»olthe
cancer,_ Many bdu1vi<>B •lso rulv< Et inheriWlle rompo- adopt<dfamil)'\<n,ironm<nt,odoptedchildrenwer<v<ry
n<nt (e.g. , a basicbr.tinchemistrythat<ncouragesrisktaking likdytodevdop•lcohol•bu,eor•bstin<ne<pall<m,simibr
toreln,,admi.aiin<oranimpul<ivepuson.aiit)'lh>t<nrour - tothOS<ofth<irbio logic:alparen<>-"' "" One,twlydemon -
,0, crim<r ti 1)_1",lLll,JIO •tratedthatiloneid<ntic:altwinis•n•lcoholic,th<oth<Tha,

Otherevidenc:,ofgeneticpredi,po,itionto:,lcoholi,mcome,
lrom a r<Viewofthebiologicalfamilyreoordsof:,lroholic:,
'nv. 'ou,tratmrntprograms acros, ·' ''n'ted' ,_,,.
Th<data,howedtha tifone biologic:alpar<n twasan:,lro -
holic . hisorherm.ai<childw:n:J..1%monlikely1obean
:,lcoholicthanthemalechildof•nonalcoholicparenLlf
bothhiologic:,Jpurn1>were•lroholics,th<childwu•bout
400'£morel ikdyto bean• lroholic . UbothpaI<Cn<>and•
gr:ar.dfathu W<r<• loo holies . the child wu a bou t 900'I, more
M>Il)'grn<S•ffect•ddiction-mor<than89h.ovebttnasso- likdytodevdop•koholism . AboutlllmillionAm<Tican,
ci•t<dwithdrug•bus,,andanother900are,u,p,cl«ltob< havea1 l,as1on e • lcoholicparent ."'
involvedwi th thernlner.tbilityofd <>1'lopingan addiction
lhough!i0m<•remor,c,ignificantthanoth,rs .. ,1., CUIT<Tlt
_<0, "IM 't!il,,lh<""!""jfatl,,,fou&!,twitOmimotl,,,
..i,,,,1,,dn, ... ,ol.,...,,d,on(adrop.l>O!admp.""til
;;;:.;',:~': ~~w1~:::•:d~,:::: a :;:1:"i.1;::1c::~ l"",lJ_Th,nit,,,,.H,aligl,ttpWm<d""andlm,d
tinueto iden tif)'ge ne,tha tmak< a perwnmoreOT l<55likely 1o ... 1:tupfo,IO<t6.,,
·
to de,;elop addiction . Grn<> like th< "Mian flush gm< " and
lnh<Tiubility• l"' ul<nds to b<ha,iora l •ddictiom . Twin
studi<, inAu,tr:ali>found•grnrticconnectionthat<hows •
high li>bilitylorcompul<h,eg:,mblingifor.<ofth, twin,i< •
Blum•ndf,llowre,urchef'.5b<li<>'<lhatt heDRD,A 1 a ll<le
oompul<h-eg:,mbler;•<imii>rli•bility<lri<tsifor.<ofth<
grntindicat<s a t<ndencytowardanydrugaddictionor
t ·,,.ruo, , 'lmticn :; ,ruorn. 1'"""'
probltTru1ticbehavior.includ ingg:,mbling,>11<ntion-d<ficit
di<order. •be rrmtsvru.olbehavior,o, ., ra ting . anti<oci>lpu-
"""'litydi<ord<T . •ndTo urett< ~• yndrom e. Theyref<rtoit
Oneolthefirstbr<2kthrough,!nthi,lir.<olinquiryc•m<in
.. a" compul , ivitygene"andcalltheproctss "thereward
1990, wh<n • •p,cific gen< >soociat<d with >leoholi<m wu
deliciencysyndrome. "'" ·' '"
idrn tifi,dbyDrs.Emrn Nobl,mdK<nnrthB lum.r<« • rch-
u,;at UCLA•nd theUniv<nityolTa.a,atS.nAn tonio, People with one or mor< genrtic fflli~f'.5 >t< moT< , uscepti -
=p,cth'<lJt ' "'Thcy •ndmanyotherr<«.archef'.5b<lie\'<that ble to dev,loping • lcoholi<m or <ng,.g!ng in othu compu l-

1:.~:~~~1~~~:;::7;
thi, gm< indi cat« • r<=~ su<eeptibility to compul<iv<

~:::i,•~":"or
~;~:';:~!
,ivedrugu«thanarepeoplewithou11ho«marl«f'.S
wh<nthrybeg!ndinkingoru,ingotherdrugs
; >nd
, th<y•remor<
li~ly toprogKM rapidly toaddictiv< ust . Though man)"
tr<>tm<ntbutinl, .. than30%olprop lewhow=cwoifi«l su<eeptibl<proplerec<ive•n int<M<r<actionfromth<i r fiut
..,50ci,, J drin~Bor>bstoinu,; .1" Thi<grneindicates•=r - dinkingexpeience,th<ymustconsum<mor<alcoholthan
cityofdopamin<r«<ptor>in1h,br.tin . pa rticu i>rlyinth< non ~ u<eeptibi<prop ledotog<tdrunk. Wh<nthcybttome
nuclru, accumb<m .A,hort2g<ofdop•mineD , K«J>torsin intoxicat<d ,t heint<n<i tyisgru terthanalmostany th ing
th< "go"s witchofth,brnn,,umnl.lrrinfore,men t cin:u it they'veFdtbefore,anditquicklylead,togrttt<rdy,;func--
ca=•pn,onto n «dm~ 'nt<n«e«nsoryor<mot"nal tion(andcravin&J .' "·"'·1"
:~r,u,:;;}«l,. 1i,fac tion .'>0." 1Exc<><•mou ntsol• lcoholfill The fiutfewtim es theyu« . manyexp<rienceblackouts,
wh<r< the)'don\mnemb<r •nything , or thry<xp<ri<ne<
!oom<0n<with•nadequa1<numb<rofdopamin<D,rec:q,tor, bro"'10Ut, , wh<r< they can rememb<ron lyparuofth<ir
raches • pointof,.ti,factionthrough•l<M int<M<>c ti,-ity drunUnaperi<n«. '" lnitialto lerar.ct,ear!y-on«tbbck -
or<implybytheu«of • mildlyp,ychoacti,.,,ub,unc ,,uch outsorbrownou<>,•nddramo t icp<""""litychang«when
: ooff« rath ~ <Xe':. amounts ~f mrtham!'hru.m in< intoxicated•repa t homimrtic<ign,ol•g<nrticpredi<posi -
tion 10 addiction . Pathomim«i, i< mimicry of th< symptoms
oFD , m:eptoBacts .. o prot<ctivefactoragoinstaloohol- o,d!ectsof a ,pecificdi<orderorpathology .
ismevenilth,lamilyoloiginhas a historyof a lcoholi,m. '"
Grn•••l<ohdpprev<ntdep,nden«fromdevdoping . Th<
Th<pns<nc eofth ,D RD, A 1a ll<l<g<n<mdthas<y<ttob< DRD, grne,which<ignifi<S an uc«<ofdopamir.e . ~b«n
di<cov<r<dind icat<s tha1ilindividwo l,withthes<h<T«liury ,howntoplay•roleinth<p<""nolit)'tr>itol,piitu.ol accep-
fflli~f'.5=•lcohol(or•nyp,ychoactivedru&) . th,yhav<
=~.:~::::::t:~:c~~::_' ,~ p<T<Ondevelop • lif«tyle
• higher risk of becoming •lcoholic, (or drug addicts)
thanthes<withou1,uchgen«
ever. prob l,mswith•koholwi
." ll1heynevudrink . how -
ll nenroccur . Re,urch Anywhere horn 40'!b to 60'lb susceptibility
comesfromheredity . Titeother40'!bto60'lb
comesfromenvironmentandtheuseofth e
I
add,ctivesubstanceort>ehavior.

Akohol!oom<g<n« (CREB,CHR.\12, Ltu7Pro allei<,GABRAl,

md NQD2) • long with theDRD , A1 •ll•l< grn<>area<ooci -
a1ed with incrused predi<position to alcoholi,m . whera,
other atypical gen <>-ADHi . K).IALDHl , and COMT
).\<1(1~)).1 <1-areusoci>t«lwi thdecrasedalcoholu,,
mdmayprol<et>p<T<Onfromde\,elop ing•koho li<m. Other
•re GABRGJ, TA51R l 6, S~CA . OPRKI, •nd

Opiold1 TheEp,t<innovdty -seeki nggrne . CYP206,i<liSO-

ciat<dwithincras«lpot<ntialfo,opioidaddiction
C<><alnoThe DRD 1 A, >11< 1< i< a,,,odaled with inc.....d
oddictionpot<ntiallorbothalcoholandooc•ine.Al<o
a<o<>ciat<dwith rocain< dependrne< >T< the Home,-\ •nd
HomeTlgrn<>
N-. oT heCYP2A6 "3m dCHRNAigen« a r<>«oci>t<d
with inc.....d nirotir.e u«, wh<r<>< CYP2A6• 2 •nd
 2.40 CHAPTER 2
CYP2A6*4 are associated with decreased use. One study found
that nicotinic receptor genes, such as CHRNA5 and CHRND,
modify the risk of nicotine dependence and can have as much
of an influence as peer pressure . 144 The 3p26-3p25 gene has
been linked to both major depression and nicotine addiction,
I
suggesting a link between these two conditions. 145A
Increased Sensitivity to All Drug Addictions or Polydrug Use
DeltaFosB, DRD2A1 TaqlA, and polymorphism in the fatty
acid amide hydrolase gene are associated with increased
susceptibility to compulsion for a wide variety of drugs. 145
Genetic approaches to diagnosis and treatment of addiction
are rapidly evolving. Some diagnostic clinical labs already
offer genetic testing to not only aid in the appropriate iden-
tification of addiction but also to guide medical treatments
that can enhance positive outcomes. Genetic targeted treat-
ment is known as pharmacogenomics. Dr. Kenneth Blum at
the University of Texas at Austin developed such a genetic
analysis named the Genetic Addiction Risk Score (GARS)
that identifies nine addiction-linked genes and their 18 alleles
in a subject's saliva. The nine genes consist of MAOA,
5HTTLP, SLC6A3 (and its SLC6A4 aide), DRD4 , DRD2 ,
COMT, GABRG2, GARBA2, and the GABRA6 genes_l46
Another marker for a propensity to alcohol addiction is the
P300 ERP (event-related potential) wave that relates to a
person's cognition, decision-making, and processing of
short-term memory. In alcoholics and in their male children,
the voltage of this wave is reduced, suggesting yet another
genetic connection. 136 •147 •148 This may explain why early-
onset blackout or brownout syndromes are associated with
the rapid development of addiction.
Environment
The environmental influences that determine the level at
which a person uses drugs can be positive or negative and are
as varied as sexual/physical/emotional abuse, stress, love,
nutrition, living conditions, family relationships, nutritional
balance, healthcare, neighborhood safety, school quality,
peer pressure, the Internet, and television. Interactions that
occur, particularly in the home environment, actually make
new nerve cell connections, create memories, and alter a
person's neurochemistry. These determine if and how a per-
son will use psychoactive drugs. Many studies demonstrate a
definite link between major behavioral health problems like
addiction and serious mental illness with traumatic life experi-
ences, especially adverse childhood experiences. Dr. Kim T.
Mueser at Dartmouth found that 90% of all behavioral health
patients had experienced at least one traumatic event in their
life, most more than one. 149 Neuroplasticity (changes in brain
chemistry, receptor sites, and neural pathways) along with
the new science of epigenetic adaptations helps explain how
environmental experiences can have a dramatic impact on a
person's future behaviors.
Environment,BrainDevelopment,
and Memory Networks
We are born with most of the nerve cells we will ever have-
about 100 billion neurons in the brain alone; but over time
our environment influences the 100 trillion connections
(dendritic spines and synapses) that develop among nerve
cells. In this way our environment molds the brain's architec-
ture and neurochemistry, altering the way the brain reacts to
outside influences. Current evidence indicates that it takes
at least 20 to 25 years for the brain to become "hardwired,"
forming major and vital connections, including the decision-
making part of the brain, which is the heart of the control
circuit. Adolescents who disrupt this process with drug use
become vulnerable to making poor decisions and damaging
impulse-control behaviors like substance abuse. The frontal
lobe volume continues to increase until age 44 and the
temporal lobe until age 47. 15° Changes that occur in the first
10 years of life are the most influential, especially if they
were caused by traumatic events .
"M~ mother was addicted to speed and heroin, and I srew up
with it. Then I was taken awa~ from her. I'd !JOand visit her,
seein9her hi9h, seein9her not hi9h, seein9her hi9h a9ain,
comin9 down the next time, back and forth. And then when
I was 11 ~ears old, she was shot and killedon Valentine'sDa~.
After that I didn't have an~thin9to look forwardto, so I
didn't care an~more."
24-year-old heroin addict
Because the brain keeps making and losing connections
throughout a person's life, however, the ability to change is
always possible, but the older a person is, the more difficult
it is to change.
"Ever~experience~ou have matters to ~our brain. And if
~ou are bein9bathed with repetitivestresshormonesand
stresschemicalsin ~our brain, it chan9es ~our brain in a
ne9ativewa~ and can actuall~cause ~our brain to become
more at riskfor these disorders."
Daniel Amen, M.D.
"/ brokedown after about six months in combat. I was in char9e
of a 9un crew. I didn't respondto m~ dut~ of openin9 up an
M-60, and some people's liveswerelost in m~ outfit and I'm
responsible.The~ new me out to the States, and I immediate/~
jumped into alcohol and heroin."
Veteran with post -traumatic stress syndrome and a heroin and
alcohol addiction
Children who grow up in a chaotic household and are sub-
jected to excessive emotional pain remember that pain and
deal with it in different ways. 151 They either try to find people
to help them understand why it happened, learn they must
face and accept what happened, or run away, become hyper-
active, make jokes, use drugs, gamble, overeat, or do things
to temper the pain or discomfort. If the stress continues long
enough, the counter-behavior that the child adopted becomes
ingrained in the brain. 152 The brain remembers the counter-
behavior with as much clarity as it remembers the stress
and the pain, so when any unwanted emotion arises, the
brain is often drawn to the quickest, most familiar solution.

"Mq9randfatherwasa drunk and mqfatherwasa drunk.That
is whobasicallq
beatme up. I ~9uredthe morepainhe caused
me, the morepot I couldsmoke.Bein9abusedas a kidreallq
scars~ouforlife.So the morepot I couldsmoke,the morerelief
I 9ot from the pressureof bein9abused."
3S-year-old male in recovery
Emotional events that become imprinted on the brain can
be pleasurable or painful, and this usually involves the
amygdala, the emotional center of the CNS.
"I had $600, put down$240, and did nothin9but win.
At f1veminutesa~er 8 o'clock I walked awa~ with over
$12,000. Gee,thisis it. This is what I'vebeenwaitin9for.
This is mqluckqdaf That wasthe bi9winthat tri9.9ered
me. I can do this. I don't have to workan~more."
4S-year-old recovering compulsive gambler
James L. McGaugh, in his excellent book Memory and
Emotion, writes about how memories were recorded in medi-
eval times. When an important event such as a wedding, a
treaty, or a large transaction had to be recorded, adults took
a child about seven years old, had him carefully witness the
event, and then quickly threw him in a cold river to shock
his body so that the memory would be imprinted for a life-
time. 153 The cold water probably released excess adrena-
line, cortisol, and other neurochemicals, which in turn
deeply imprinted the emotional memory on the child's
brain. 154
"Asa childI usedto laqin mq bedroom,mqmotherbrin9in9
menin off the streetto do thin9sto trqto helpsuprortUS. That
wouldki me.That wouldkillme.AllI couldthin aboutwas,
I 9ot to 9et a job. I 9ot to helpmq mother.So I wa~ea9erto
useanqthin9I coulddo to freemqselfof that pain.'
SS-year-old male recovering heroin addict
In summary, environment can make a person more liable to
abuse psychoactive substances when the following is true:
• Stress is the norm rather than the exception.
• Physical, emotional, or sexual abuse or trauma occurs.
• Drinking or other drug use is common in the home.
• Healthy ways of dealing with stress or anger are not
learned, and self-medication becomes the solution.
• Society illustrates in word and deed that drinking,
smoking, and using drugs to solve all problems are a
normal part of life.
• There is easy access to legal and illegal drugs.
• There are pre-existing mental health problems aggra-
vated by the home environment.
• There are nutrition deficits during brain development,
such as insufficient vitamins and proteins in one's diet
to synthesize neurotransmitters and maintain a healthy
brain chemistry (e.g., being underweight reduces dopa-
mine levels, possibly leading to amphetamine use to arti-
ficially rebalance brain chemistry).
lhe Neurochemis
try and the Physiologyof Addiction 2.41
• The media portray tobacco and alcohol in a positive light.
• Social, business, or peer groups normalize excessive
drinking or drug use.
"M~ parentshave a 9/ass of wine a~er the~ come home
I
from workto relaxand unwind. I'm the same wa~, just with
marijuana.It'sjust kindof a re9ularthin9that I do instead
of alcoholor anqthin9else."
23-year-old marijuana smoker
PsychoactiveDrugs
Hereditary and environmental influences are factors in
drug addiction only if a person actually uses psychoactive
substances. Drugs affect susceptible individuals as well as
those with no predisposing factors. This occurs because, by
definition, psychoactive drugs are substances that affect the
functioning of the central nervous system. Excessive, fre-
quent, or prolonged use of alcohol or other drugs inevitably
modifies many of the same nerve cells and neurochemistry
that are affected by heredity and environment. This influ-
ences not only the person's reaction to those substances when
they are used but also the level at which they are used.
"I wasdrinkin9frommaltliquorbottles,40 ounces,to pints
of vodka.I wouldn'thavea limit.I couldjustdrinkuntilI
dropped.I wasa functionaldrinker.I helda job. But I just
wanted m~ own free time to 9et drunk and escape."
44-year-old male recovering alcoholic
Regardlessof how susceptibleone
is to addiction,if he or she never uses
or never practicesaddictivebehaviors,
addictionwill never occur.
Another mechanism contributing to increased vulnerability is
a process called apoptosis, where damaged cells are pro-
grammed to kill themse lves; several drugs, particularly meth-
amphetamine, set this process in motion. 156 Nico tine produces
immediate and long-term changes in neurotransmitter levels,
particularly dopamine and norepinephrine, which lead to a
faster development of tolerance and dependence. 157 Nicotine
also causes immediate degeneration of neurons in brain fibers
(fascicu lus retroflexus) that communicate the "stop " message
from the "stop" switch to the "go" switch, which ultimately
causes loss of control over its use. 158
Anima l studies confirm that some drugs compel more addic-
tive use than others (positive reinforcement). Cocaine and
heroin have a tremendous hypnotizing effect prompting con-
tinued use, whereas the psychiatric medications Thorazine ®
or Tofranil ®have no positive reinforcing effects. 158
Modern imaging techniques now confirm that psychoactive
drugs cause both temporary and permanent changes in
various parts of the brain. In the past simple X-rays and
EEGs were the only way to examine the brain, but over the
past 30 years a wide variety of technologies and imaging
 2.42 CHAPTER2

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1-2 3-4 5-6

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6-7 7-8 8-9

Multiple brain-imagingtechniqueshave been developedto view the

anatomy, neurochemistry,functioning, and activity of the brain and
eventhe communicationbetween brain cells. The images shown here
are MRI,fMRI, PET,SPECT,DTI, BOLD (blood oxy-genation level
dependentimaging), 5PM (scanningprobe micros-copy), GUI
(graphical user interface), and other scans createdby the Laboratory
of Neuro Imaging at the University of California, Los Angeles.
© Arthur Toga/UCLA,Photo Researchers, Inc.
techniques have been developed. A SPECT scan is a sophis-
ticated nuclear medicine imaging technique that looks at
blood flow and metabolic activity in the brain as a behavior-
like taking a psychoactive drug-is occurring.
PET scans show brain function by imaging radioactively
labeled chemicals that have been injected into the brain . A
CAT scan uses X-rays, and an MRI uses magnetic fields and
radio waves, to produce anatomical studies of the brain , but
they do not show brain function. There is also the fMRI,
which traces blood flow to different regions of the brain,
yielding information about motor , sensory, visual , and audi-
tory functions.
DTI, a variation of MRI technology, images the brain 's wiring ,
examining the network of nerve fibers connecting different
areas of the brain. This technology can be used to study a
number of brain conditions, including epilepsy, traumatic
brain injury, and addiction .
CompulsiveBehaviors
Certain behaviors, such as gambling, eating, shopping,
sexual activity , video games, TV, and the Internet , can
become compulsive, mimicking compulsive drug use and
affecting the neuroanatomy and the neurochemistry of brain
cells in the same way addictive drugs do. Parental gambling
(heredity) affects a son's or daughter 's vulnerability to gam-
bling as does the availability of gambling outlets (environ-
ment) and the addictive draw of a slot machine (the drug/
•.
9-10 10-20 20-30
These are PET scans of a personsbrain on cocaine.The yellow areas
are wherecocaineis attachingitself (binding)to the brain. After 3 or
4 minutes, the cocaineis bindingto the striatum;at 6 to 8 minutes, there
is maximum involvementin all areas, and then it starts to diminish.
At 20 to 30 minutes, it has spent its major effect,particularlythe high.
This rapid up/downcycle is the reasonfor the bingepattern of use and
the inevitabledepletionof dopamineand norepinephrine.
Courtesyof NoraVolkow
behavior itse!D.159 Many believe that gambling, like drug
addiction, causes the brain to be rewired, particularly the
addiction pathway 's survival/reinforcement and control
circuits. People experience a loss of control and increased
craving and will continue to gamble despite catastrophic
adverse consequences. 160
"/ had 9ambfedmost of the moneqawaq,and the onlqmoneq
I reallqdid haveat that point wasour dau9hter's moneq;
and I rememberone ni9ht- ninemonthsto the ni9htthat mq
husbanddied- saqin9,'Screwit, I'm outta here,'and I sat
downin front of a $25 videopokermachineand in 24 hours
I wentthrou9h$10,000. /t just happenedto be hercolle9e
moneq,but, uh, I wasalwaqs9oin9to 9et it back."
43 -year-old compul sive gambler
Research has demonstrated that an equivalent amount of
dopamine is released in the survival/reinforcement cir-
cuitry of the brain of a compulsive video game player as is
released by an injection of methamphetamine or Ritalin .®161
PET scans of the brains of compulsive overeaters have shown
a lack of dopamine (D 2) receptor sites in the nucleus accum-
bens, which is part of the survival/reinforcement circuit. This
 TheNeurochemistry
andthe Physiology
of Addiction 2.43

is the same area first activated and then deactivated by psy-

choactive drug use.162 Researchers at Japan 's Kyoto University ..a....Hereditaryhater ..a....Hereditarylover ..a....Alcoholic
also discovered decreased norepinephrine transporter activ- of alcohol of alcohol mouse
ity in the brain 's survival/reinforcement circuit of pathologic
gamblers, which made them dismiss losses a normal gambler
would consider major. 163 These and many other studies led
to the inclusion of pathologic gambling in the new DSM-5 as
an addictive disorder like alcoholism or methamphetamine
addiction.
0 Alcohol-hating mouseis force-fedlargequantitiesof alcohol.

Regardless of whether a person's compulsive sexual behavior,

eating disorder, or other behavioral addiction is the result of
heredity, environment , or the intense practice of the compul-
~ +~ +Y= ~
sion , the reward system reacts in a similar way to a drug or @ Alcohol-
hatingmouseissubjecte
d to stress, and alcohol is madeavailable.
alcohol addiction.

"If qou have a decreasein dopaminereceptorsthat transmit

pleasurablefeelin9s,qou becomeless responsiveto the stimuli,
such as food or sex, that normallqactivatethem. When qou 8 Alcohol-hating
mouseisnutritionally deprived,
and alcoho
l ismadeavailable.
don't rewardqourselfenou9h, qour brainsi9nalsqou to do
somethin9that will stimulatethe circuitssufficientlqto createa
senseof well-bein9.Thus an individualwho has low sensitivitq
to normalstimuli learnsbehaviors,such as abusin9dru9sor
overeatin9,that will activatethem." @ Alcohol is madeavailab
le to alcohol-lovingmouse..

Dr. No ra Volkow, Director , NIDA

Behavioral compulsions often accompany or follow drug

addictions. Studies show that 25% to 63% of all compulsive © 2014 CNS Productions,Inc.
gamblers have been alcohol or drug depend ent. 164 Many recov-
ering addicts began to gamble to pass time, believing it to be a
harmless activity. Gambling and other compulsive behaviors
tion , a closer look at a series of classic animal studies done
are now recognized as actual dysfunctions of the same brain
over the past 40 years is useful. Conducted by Gerald
chemistry disrupted by psychoactive drug use. 161-165-166
McLaren, T. K. Li, Horace Lo, D. S. Cannon , and other
Psychological and social treatments for these compulsive
researchers ,167 these animal experiments, particularly those
behaviors have evolved along the same lines and use the same
using mice, are often used to determine likely effects of a
interventions as the treatment of drug addiction .159
drug on humans. 168 Animals were first used scientifically in
Compulsive behaviors are different from obsessive-compul- the 1600s by Johann Jakob Wepfer, a German physician, and
sive disorder (OCD) (e.g., repetitive hand washing, repeat- in the 1800s by Claude Bernard, a French physiologist.
edly checking/rechecking to ensure that the door is locked or
Years ago researchers developed two genetic strains of mice
the stove is off, and compulsively arranging objects and expe-
(Figure 2-17) that are still used today in experiments to
riencing distress if the objects are out of place). OCD occurs
understand alcoholism. One strain of mice , identified as
along a different brain and neurotransmitter pathway from
C57BU6J, loved alcohol. When given the choice between
the one associated with drug and behavioral addictions.
water or 70% concentrations of alcohol , these mice went for
Addiction is often associated with experiencing a state of
the alcohol every time, but they would drink water if that was
consciousness described as positive reinforcement. The
the only choice. The other strain of mice, identified as
repetitive behaviors of OCD patients are not described as a
DBA/2], hated alcohol. Given the same choice and with con-
positive experience even though they have been observed to
centrations as low as 2% alcohol, the mice always chose
reduce the patient's stress level. OCD is also different from
water. 169-170 Research forcing the alcohol-hating mice to be
obsessive-compulsive personality disorder , in which a per-
exposed to alcohol for a sufficient period of time changed
son is preoccupied with details, rules , lists, order, organiza-
them to become alcohol-loving mice like the genetic alcohol-
tion , control, and doing things "just right " to the point where
loving mice, even when alcohol was no longer forced on
very little is accomplished .
them (Figure 2-17 A). This demonstrates that just toxic
effects of addictive drugs can alter brain functioning , causing
AlcoholicMice and SoberMice an allostasis that results in addiction regardless of genetic or
environmental influences. m
To better understand the close connections among heredity, In another experiment a group of the alcohol-hating "sober "
environment , psychoactive drugs , and compulsive behaviors mice were subjected to stress by putting them into very small
and to further visualize the diathesis-stress theory of addic- constrictive tub es for intermittent periods. Within a few
 2.44 CHAPTER 2
NO EXIT © Andy Singer
ANIMAL TESTING
I
© 2008 Andy Singer. Reprinted by permission of Universal Uclick.
weeks, this group of sober mice also came to prefer higher
and higher concentrations of alcohol over pure water because
alcohol relieved the stress. In essence sober mice had been
turned into alcoholic mice by applying stress (environ-
ment) and providing access to alcohol (exposure to psycho-
active drugs) (Figure 2-l 7B).
Researcher Dr. Jorge Mardones, a nutritionist, eliminated
vitamin B and some proteins that are essential to the brain 's
production of neurotransmitters like dopamine from the diet
of another group of alcohol-hating mice. This limited nutri-
tion resulted in increased alcohol use after several months 108
(Figure 2-l 7C).
When the mice whose genetics made them prefer alcohol
were given access to it , they drank themselves to death.
They continued to drink while subjected to aversion therapy
in the form of electric shocks (some close to being fatal)
aimed at preventing them from drinking the alcohol (Figure
2-l 7D). None of the mice would have become alcoholic had
they not been given alcohol, even those with the highest sus-
ceptibility to compulsive drinking.
When the forced drinking, stress induction, and nutritional
restrictions were stopped, the once genetically sober alco-
hol-hating mice did not return to their former nondrinking
habits . They had been transformed into alcohol-loving mice
and, if given the chance to drink, would be alcoholic mice .
When the brains of the four groups of mice (the hereditary
alcoholic mice , the stress-induced alcoholic mice, the
alcohol-induced alcoholic mice , and the nutritionally
restricted alcoholic mice) were examined, all had similar
brain cell changes and neurotransmitter imbalances that
made them prefer alcohol, although they all started with
different neurochemical balances . This research suggests that
neurochemical disruption caused by heredity, environment,
psychoactive drugs, nutritional deficiency, or a combination
of several factors can lead to serious addiction. 167 -170 -171 -172
This validates the diathesis-stress theory of addiction .
In addition to a preference for alcohol , mice can be bred to
prefer or not prefer other drugs such as methamphetamine .173
A SimplifiedView of the
AddictiveProcess
The research on psychoactive drugs , the addictive process,
neurochemistry, and medications that promote recovery gen-
erates several thousand research papers every year. Most
people, however , have no need or desire to dig that deep.
What is helpful is an overall view of the process that can be
passed on to clients , their friends , and family to help them
plan their recovery . It is also valuable to expose the general
public to the information to help them plan their commu-
nity 's response .
Compulsive drug use is a combination of an overactive go
switch in the old brain, a damaged stop switch in the new
brain, and a lack of communication between these two
circuits.
To avoid moving from social or habitual use into abuse and
addiction , three actions must be taken:
• avoid activating the go switch;
• repair the stop switch;
• improve communication between those two parts of
the brain.
Determining how to accomplish these actions depends on a
person 's level of use . Humans are obviously different from
mice . We are more complex , our brains are more intricate,
and our social patterns are extremely diverse. We have the
power of reason, we have more control over our environ-
ment, and we have self-awareness. Yet research, especially
over the past 25 years, shows that the basic drug-craving
mechanisms in humans , which reside mostly in the old
survival/reinforcement circuit of the old brain are similar
to those of most other mammals- including mice.
The major difference is that the compulsion to use and the
ability to recover exist because of our new brain which
enables us to learn ways to override the automatic old
brain-relapses (akin to allergic reactions) when faced with
physical and emotional triggers .
Conclusions
The advances in our understanding of the neurochemistry
of addiction (much of it through animal studies) suggest
more-precise methods of treatment and identifying targets
fortha•py•ndmedicatioru;. R<S<>rchexploringmemory ~~\,":;thi:~:tuil)sothatn.oturalbalance(homeo-
bumps . •llasw.is . ,yruopticpl.,.ticity.the•ddict ionpathw•y,
the "go" •nd "stop " ,witche> . andthe, a y-stoppedcircuit • AnunderstandingoF.ynapticpl .. ticiryand,pigenetic,
,howstbataddictionisdiffer=tforeveryone . hdepend,on h<IJ>' • therapist acceptthatcrav!ngandoth<rneuro-
anindividual'>uniquephy,iology .. moldedbyhen,dity, chemicalandphysiologicalchange•aremotedeep ly
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cal • nd • ruitomical ch• nges tba t compel tbat pen.on to
rontinuetherompul,ivebehavior • T•iloring a recovery plan to each individual~ •n=p-
tibility •••ugg<>t<d by hi, or her drug hi>tory•nd the
• Thelunctiomolthe,ur.-i,,.Vt'<inlon:ementcircuitofthe ,trength,of1h e indiv!du.ol"scontrolcircuit and ",1ay-
br>in'>•ddiction pathw a y,withitscontrol, ·,top ." •nd stopped " br>inare ... offa,;gn,athopeformor<e -dfective
·go " cirruits,ohow tbat cr:avingi• involunary . ,end - tr<.atmen·,·,col,
ing"do!tagain,doitagain " m...,.geslromthenudeu,
accumbens ·go • ,witch. To avoid telap,e, recovering
that
lt is cuTT<ntly projected 30% to -t0% oF t- born in
the Unit<d Stat<s will meet diagnostic crit<ri.o for <><p<ri-
addictsmuot11VOidtriggerslikeexce,,moneyinon
pocket,bar,; ... eingoldu,ingbuddi
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.. ,,u-..,ful<itu•
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- ad:::;~!:
;:;~f:t:i:i;;::~::..:,:.nd«>•
herediarypr<edi,position.rn vi romnrntiltnum.oorotre ..
• Continuedabstin<nceisvitilinr«l:oimingthehijacked (induding n utritionalimbalanc,c),andthetoxic<ffectsof
addictionpathwayand, .. toringhomeostnisto a ltered addictivep,ychoacti~e drugs . Thiscombiruot ionoffactors
brain chemistry. ladingto addictionisknown ... thediathesi ... tr<Htheory
• Theknowledgethatstrongmemori«>r<emb<ddedfor oFaddiction . Unda,;andingandacc:epanctofthismoddis
a lif<timeemph2siz«reco,uy u alif,timeproc<55b< - ,italforh <althy,m<>ningful.positive,lifelong!iObri<ty . also
causetho,ememo· ,canca u ,ear<elap,eatanyfme referredto._.rero,,.f}.
giwnenough'1imuli Anystudyofaddic6onortreatmrntt<chnique,mustfocus
• R«ognitionthatb<cau,echrnnicdruguseputsthebody onthetotalityof-1,Slive.:th<irp<BOn.ality,thinking
inadiffer=tbalance(•llooa<i, ),recov,ryc•llslorr<ad - pattem,, r<eiationshiJ>', li/,style, what the)"e at, •nd their
justmrntinillpartsoFu,ero'live•(phy•ical.J>'Ycho- f.omilyhi,tory ""

How Psychoactive
Drugs • Drug, •re metaboli,ed by • numb<Tofti,su«but
prindpallybytheliWT . Thryar<eeliminat<dthrough
AffectPeople thekidn9~,swatglands . •ndlungo

Addictionrohs a penonofthe abilitytorontroltheu...of The NervousSystem

:oicoholand/ordrug,•ndto1ru1nageorstoprompulsive
beha,ior,_ Dr . WillWll D. Silkworth, in the Alcoholics
An<ll>)'fflOUSBigBook,,ugg<>tedthataddictionis•combi -
nationolanall<Ij()'illln<Mollh<body•nd•no~nol
themind . Theinabilitytostopistheessenctofaddiction.
How DrugsGet to the Brain
• AJ>'ycho>ctivedrugi••bsorbedintothebody
latory,yst<m•nddistributedvi>thebloodtooth<T
ti .. u.. a ndorgans,«peciallythebrain
Drug,canbe•hsrn-bedthroughinhalation.inj«tion,
mucou, membn.•bso-r,Jon,ora l 'ng,.f
conUCt>bsorptin
• P>ychoactfre drug,travd through the bloodstI<Cam,
cros,;theblood -brainbarria, a ndinlu,eth e crntr•I
IlffVOU>system (CNS). The drug, C>U« an dfect,
areignor<d. a ncabsorbed . a nd/or ar<ebiotran,fonned
Thry can alsocrossth e blood-cerebral,p inalfluid
•ndplacentalbarrius
• Thetwoiru,inparuofthenervous,yst<In>rethe
periphe ra l n<rvou,;syst<mand the ctnt ra l n<rvou,;
,yst<m(bnin a nd,piruolcord)
• Thetwoparuoftheperiphaaln<r.'Ou,,ystem - th<
autooom'c a ndsomat' ,yst<Tm-Control'm 'mwy
bod)"functiom,relay,eru;of}· lnformation . • ndsend
information to and from muscl,sandorgam . <>pe·
'>c!Tcu- ciall)"thebrain
• BothparuoltheCNS-thebr>inandthe,pinal
rord-tte<i,,.inlormationfromth<p<ripheraln<rv0u,;
system . ana ly:«it,andth<n .. nd•ppropriat<action
n.•nd -backthroughthep<riph<ralnervou.s,)"st<m
• Theevolutioruoryperspectiveofhumandevelopmenl
looks at physiologicalchang,sinthebrain.particu -
larlytheoldbrain . u ,urv!,,.l adap tatioru;.lndrug
u.,.er,thecra,-ing,causedbyJ>'ychoactiv<drug,
hij• cknormal,urv!valmechanismsinth e oldbrain
and . asare,ult , wi ll o, .. ,ridethecommon=and
therea!iOningolthenewbrain
 2.46 CHAPTER 2
• The old brain and the new brain carry out their func-
tions by creating, storing, and utilizing memories.
Memories actually exist as dendritic spines, which can
I
trigger euphoric recall of drug use and false survival
impulses caused by addictive drug activities, causing
a person to keep using.
The AddictionPathwayand Its Survival/
Reinforcementand ControlCircuits
• This pathway contains a survival/reinforcement cir-
cuit with a "go" switch and a control circuit with a
"stop" switch. Normally, before drugs are ever used,
these areas of the brain, particularly the nucleus ac-
cumbens ("go" switch), gives a surge of satisfaction
when a physical or emotional survival need is met or
when pain is relieved. Activation of the "go" switch
results in a survival message to continue the activity;
then the control circuit, particularly the left orbital
prefrontal cortex ("stop" switch), sends a message
back to the "go" switch to shut it down.
• When psychoactive drugs or addictive behaviors
hijack the survival/reinforcement circuit, the "go"
switch turns on and continually sends a distorted
message that the action is necessary for survival, so
we must remember what we did so we can do it again
and again. These messages are so powerful that they
override common sense and drown out the need to
engage in most other activities.
• The left orbital prefrontal cortex ("stop" switch) can
become damaged, taking away the choice to stop. With
excess drug use, even if the thinking brain knows that
it should send a "stop" message, the communication
to the "go" switch is so damaged that the message is
never received.
• Drugs affect natural body functions such as breathing
and circulation, so overuse for the mental effect can
impair heart function and respiration.
• The stay-stopped areas are a collection of distinct
locations in the conical brain that can help decide if
someone has a strong tendency to relapse when trying
to recover from an addiction.
• The historical conflict between doing what an indi-
vidual wants to do rather than what one should do is
similar to the conflict that arises between the old brain
and the new brain when addictive drugs and behav-
iors are involved.
Neuroanatomy
• Psychoactive drugs affect the nerve cells and the neu-
rochemistry of the brain and the spinal cord, altering
the way messages are received, processed, and trans-
mitted .
• Nerve cells consist of dendrites, cell bodies, axons,
and terminals.
• Messages travel from nerve cell to nerve cell (neu-
ron), alternating electrical and chemical signals. At
the junctions between nerve cells, called synapses,
neurotransmitters jump the gap to carry the message .
• Neurochemicals called neurotransmitters relay mes-
sages across the tiny space (synaptic gap or cleft) be-
tween nerve cells and slot into receptor sites on the
receiving nerve cell. When psychoactive drugs modify
or mimic the way these neurotransmitters function,
they cause physical, mental, and emotional effects.
• Neurotransmitters include dopamine, endorphins,
norepinephrine, epinephrine, GABA, serotonin,
met-enkephalin, glutamate, anandamide, and acetyl-
choline.
• Down regulation is a process whereby excess drug use
can cause a person to produce fewer neurotransmit-
ters or decrease the number of receptors for drugs to
activate.
SynapticPlasticity,Allostasis,and Epigenetics
• The use of drugs causes changes in the way genes
direct the body's functions. This occurs because of
synaptic plasticity, which is the ability of the synapse
(connection between two nerve cells) to change in
strength and sometimes function when a particular
pathway is overused or avoided.
• The changes lead to a new balance in the body called
allostasis, as opposed to the natural balance, which is
called homeostasis.
• These mechanisms are the focus of a new field of
research called epigenetics. The genes in one's DNA
can be turned on or off or expressed in different ways
when exposed to different environmental stressors,
drugs, and behaviors. This is known as epigenetic
adaptation and explains why some identical twins can
have totally different physical features or behaviors
even though they have identical DNA.
PhysiologicalResponsesto Drugs
• In addition to direct effects, phenomena such as toler-
ance, tissue dependence, psychological dependence,
withdrawal, and drug metabolism determine a user's
reaction to psychoactive drugs.
• Excess use of a drug (or compulsive behavior) causes
the body to change so it can handle excess amounts of
the drug. This process is known as tolerance.
• With excessive use, tissues change and adapt, causing
the body to better handle the toxic effects of a drug.
• Excessive drug use and practice of addictive behaviors
also cause a person to depend on the mental effects to
handle anxiety, boredom, depression, and mental pain .
• When a person stops using, the body tries to return to
normal, causing mild to extremely severe withdrawal
symptoms, some of which can be life threatening.

From Experimentationto Addiction
DesiredEffectsvs. Side Effects
• People use psychoactive drugs to change their mood,
to get high, to self-medicate , to socialize, and for many
other reasons.
• Drugs also cause undesired physical and social effects
(adverse reactions, toxic effects, dependency; isola-
tion, and crime), particularly with prolonged or high-
dose use.
• Most people use more than one psychoactive drug or
behavior. Techniques such as mixing, stacking, re-
placement , and cycling can have unexpected effects.
• The amount, frequency, and duration of drug use and
the effects on the user's behavior indicate levels of use:
abstinence, experimentation, social/recreational use,
habituation, abuse, and addiction.
Classification(DSM-IV-TR,DSM-5, and ICD)
• The Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) now classifies addictions under the
overall heading of "Substance-Related and Addictive
Disorders " and distinguishes between substance-use
disorders and substance-induced disorders.
• Individual addictive substances like marijuana are de-
scribed individually (e.g., Cannabis use disorder) with
diagnostic criteria for range of severity: mild, moder-
ate, and severe.
• Some critics think that the changes do not take into
account scientific advances that make more-precise
definitions possible.
• Internationally; the World Health Organization's Inter-
national Classification of Diseases (!CD) is widely
used .
Theoriesof Addiction
• Theories of the roots of addiction emphasize a com-
bination of genetic factors , environmental influences,
and excessive use of psychoactive drugs or compul-
sive behaviors.
• Prominent theories are the addictive disease model,
the behavioral/environmental model, the academic
model (allostasis theory), and the diathesis-stress
theory of addiction.
Heredity,Environment,PsychoactiveDrugs,
and CompulsiveBehaviors
• Heredity, environment, psychoactive drugs, and com-
pulsive behaviors determine at what level a person
might use psychoactive drugs or engage in compul-
sive behaviors.
The Neurochemistryand the Physiologyof Addiction 2.47
• Family history can indicate a genetic susceptibility to
compulsive drug use. More than 89 genes have been
correlated to a greater or lesser vulnerability to addic-
tive behavior. Some 900 genes are also believed to
contribute to this vulnerability.
• The pressures and the stress of growing up, particu-
larly if there is abuse or trauma, can make peop le
more susceptible to addiction, especially if there is a
strong hereditary component. Environmental stress
and trauma and even poor nutrition can alter the
brain 's chemistry and function, making one more vul-
nerable to compulsive drug use and behaviors . Peer
pressure and availability of the drug are also strong
environmental factors.
• Drugs can activate a genetic/environmental suscep-
tibility to drug abuse and addiction. They cause al-
terations in brain chemistry, structure, and function ,
which can intensify drug-using behavior and create a
functional imbalance of brain chemistry known as an
allostasis.
• Compulsive gambling or shopping (buying), eating
disorders, hypersexuality, excess Internet use, game
playing, cell phone use, and other uncontrolled
behaviors can cause changes in brain function and
neurochemistry .
AlcoholicMice and SoberMice
• Classic experiments with mice confirm the interrela-
tionship among heredity, environment , psychoactive
drugs, and levels of use .
• Researchers were able to change mice that hated al-
cohol to mice that drank until they died , through en-
vironmental stress, by forcing them to drink alcohol,
and even through nutrition.
Conclusions
• Studies of the neurochemistry of addiction can sug-
gest more-precise methods of treatment and identify
targets for therapy and medications. Neurochemical
changes in the brain literally compel the person to
continue use of psychoactive drugs and behaviors .
• The totality of people's lives must be factored into
any treatment protocol. Understanding and accepting
how addiction results from a combination of hered-
ity; environment, and psychoac tive drug use or prac-
tice of compu lsive behaviors is vital to encourage an
addict to engage in and maintain the recovery process.
Young girls addicted to "ya ba"
(methamphetamine) at a
treatment center in Mae Rim,
Thailand, take a break during
their treatment. Stimulant use
in a number of Asian countries
has been growing at an
alarming rate in recent years.
© 2001 Thierry False/Getty Images
 Uppers

Thi,clu.pt<rexamines1h,wider.mgeofst imulantsthatauanilab lew0Tld-

wide.Thedrugsinclude,trongstimulan1>•uch••rocain,/crack.111tth2mphtt-
amine,dittpill,,andmedications furatt<ntion-ddicit.lh)'pffactivitydisorder
• (ADHD).Thew,zkerone, indudeplan t otimul•n"•uch .. khat . b<ttl n uts,
q,h<drint . caff<ine,andnkotin<.Todaythef=iurncyofn,w,ynthrtic,timu -
lant>beingcr< • t<dto•~on<>1q,ahadofdet«tion, l<golp<na lti<>. • ndjailtim<
iscauoingdrugrnfo=mentagmci<>to a mpupth<iractiv!ties.Synthetic,, include
drugs d=ptive ly sold•• bath .. 1,. that ar< actu.olly • fonn of designer metlu.m -
phw.mine, derh'ro mostly from methcathinone
Anin-depthlookattheooci>.l,linancial,phy,ical,and<motion.alimpactofall
stimulantsexp lor,showthedrugsinfiuenceth<w;ayoursoci<tyfonction,
Th<a<1panoltheclu.pterlocu«•ontobo.cco,history . df«ts . andtob.oocorom-
p•nies'kno wlcdg< • nduS<oFtheadd ictinprop<rtinofnirotin<loaddictl0%
ofAmerie2m a nd'IO'l.ofth<world'ssoci<ti<> . lta!so,nmine,th<JlndR<ponol
theSurgronG<n<r.tl.r<l<a5edinl0li,on1h,d,va,;,.. tingha l1hcon,cqu<nce,o/
,mokingand,eoondhand,moke

Stimnl•ni, u <e the most widely us,ed p•ychoactP,'e drugs in the world. In the pa, t frw
)'Ur>.themediofocu,on,timubnt>ctnluedonbath>ala . <lectronicdg:urtl<>.•tron •
ger<n<rgydrinks,1h<,xpandedtnffickingofm,t!amph<t>min<>fromM,xiro,mor<
oon,..miruot«lform,o/roc•inepast<,and a rnurgenceof«:>,...y.ThemOT<common -
pa<C<stimubna---aff<ine•ndtobaoco-took•l>Hk,,..,tolh<mor<=tionaldrug,
evrnthough,,.tist ic,proveth.ttheyar<mor<wide lyused.E>·enbet<lnuaandkhat
•remorewid<lyusedthancocain,andmrthamph<t>min<
l.asty,carinth e UnitedS,.t,s
• Almo>t i .6millionA-· - U>Cdcocain< (indudingc rock) . while LIS million
,hot, ,non«l . at<, or smoked methamph,wn'ne,' r nonmed 'cal r<a<on> '
Compar<thi,with
• 67.8 million Americans who ,mok<d cigaret"" '
• Iii million ( 18 • nd up) who d=k coff« on• daily b.,i, '>
• O.S gallons of soft drinks per person (most of thrn, c•ff<iruot<d) that w<r< con -
•umed (young people •vaage • lmost thru tim,s th.t •mount) '
 3.2 CHAPTER3
In the past year worldwide, the use of stimulants was even
more preva lent:
• 400 to 600 million people used betel nut, often in com-
bination with tobacco (gutka) the way others use coffee. 6
• More than 1 billion people smoked cigarettes.
• In Ethiopia, Somalia, and Yemen, the majority of the
male population and much of the female population used
khat, a stimulant leaf, during many socia l occasions.
• Thailand and a number of Southeast Asian countries
I
have a severe problem with "ya ba," a popu lar form of
methamphetamine.
Some stimulants are found in plants: the coca shrub (co-
caine), the tobacco plant (nicotine), the khat bush (cathi-
none), the ephedra bush (ephedrine), the betel nut (areco-
line), and the coffee plant (caffeine). Other stimulants are
synthesized in legal or street laboratories; methamphet-
amines, diet pills, methylphenidate (Ritalin ®), methcathi-
none, bath salts, and look-alike stimulants are the most
common.
There is also a class of synthetic designer drugs that are
variations of the amphetamine molecule (amphetamine
analogues or phenethylamines). Drugs such as MOMA
(ecstasy). MDA, MMDA. and MDE are classified as psycho-
stimu lants and are covered extensively in Chapter 6. In addi-
tion to their psychedelic effects, the drugs also cause meth-
amphetamine-like stimu latory physical and mental effects.
General Effects
Although there is a great difference in strength, all stimu-
lants increase the chemical and electrical activity in the
central and peripheral nervous systems. In low doses stim-
ulants boost energy, raise the heart rate an d blood p res-
sure, increase respiration, reduce appetite, and subdue
thirst and hunger. They also make the user more alert,
active, confident, anxious, restless, and aggressive.
A l','ll;GP.-\<.\\AOS·
Fll\L 11\l?oillS-
Rs:, 'al\L- M~-1<13.0/>.P-
c:Rl>KK-01t.sa- \/,t:.l.ll.T-S\l!Ga
~~\1-lK\!\
i I
,; ..
CITYO 2006 ScottSantis.Reprinted by permission of Universal Uclick. All rights reserved.
PRICKLY
• Stimulants are used clinically to treat narco lepsy, obesity,
andADHD.
• The stronger ones are used nonmedically to induce eu-
phoria and to keep the user awake ( on a run), energized,
and skinny.
Stimu lants produce their effects by manipulating the brain 's
natura l energy chemicals and stimu lating the brain 's surviva l
pathway (reward/control pathway).
Borrowed Energy
Normal Energy Process (internal stimu lants)
The b ioch emical process that increases energy primarily
involves two adrenaline neurotransmitters:
• Epinep h rine (E) has a greater effect on ph ysical energy.
• Nore pinephrine (NE) has a greater effect on confi dence,
motivation, and feelings of well-bei ng.
Other neurotransmitters, serotonin (5-HT) and dopamine
(DA), also affect energy but to a lesser extent.
More of these energy chemicals are released while we are
awake than wh en we are asleep, but the average 24-hour out-
put is fairly constant. When the body needs extra energy or a
shot of confidence (e.g., during exercise, while making love,
or in a fight-or-flight situation), the nervous system auto-
matically and naturally releases extra epine phrine, norepi-
nephrine, and other chemicals. Eventually, the extra energy
chemicals are reabsorbed or metabo lized, allowing the body
to calm down and return to normal.
'The closestthin9/',e had ta a naturalhi9hwasthe rockclimb,
and I wasterri~ed. The adrenalineisjustpumpin9throu9h
of
~our s~stem, and ~ou're just so hi9h off that ~our heart is
pumpin9 and ~ou sit down . We sat up there about f1veminutes
a~erthe climb,and I neverfeltso900d and alonewith
m~selfotherthan whenI wasusin9dn195."
18~year--oldmale recovering cocaine abuser
Drug-InducedEnergyProcess(external stimulants)
In contrast to the natura l release of the body 's own energy
chemicals (epinephrine, norep inephrine, and dopamine),
 Uppers 3.3

rs(stimulants)
==============
DRUGNAME SOMETRADE
NAMES STREET
ORSLANGNAMES
(fromcocaleaQ
COCAINE
Cocaine
HCL(Schedule
II) None,but it isextracted
andsold legally for Coke,blow,toot snow,flake,lady,nosecandy,
medica
l purposes(topicalanesthetic) big C,la damablanca
Cocaine
freebase
(ScheduleII) None Crack,base, rock, boulya,hubba,primo, basuco,
pestillos
Cocaine paste(interme
diateextractionprocess
containing None Pasta,
paste,basay,basuco,oxidado,
oxi,rust
other alkaloids
andcontam inants)

AMPHETAMINES

Benzphetam
(synthetic
d,l amphetam
)
ine (Schedule

ine (Schedule
Dextroamphetamine
II)

Ill)
sulfateOisdexamfetamine)
Dextromethamphetamine
(Sche
dule II)
(dextro isomermethamphetam
ine) None
Adderall,® Biphetami

Didrex
®
Dexedrine
,®Vyvanse
®
ne·~ Cross
tops,whites,speed,blackbeauties,bennies,
cartwhee
ls,pep pills

Dexies,Christmas
Crysta
trees,beans
l meth,ice,yaba,glass,batu,shabu,yellowrock,
I
Nazispeed,smurfdope,peanu t butter meth
Freebase
metham
phetamine
(Schedule
II) None Snot
Levoamphetamine
(no schedule) VicksVapor Inhale
~
Methamphetamine
HCL(SdieduleII) (overseas) Desoxy
n~ Crank, meth,crysta
l, peanutbutter speed,pervitin
Methylene
dioxymethamphetamine
(MDMA)andother None(seeChap
ter 6) Ec.stasy
amphetamine
analogues
(MDA,MMDA,andMOE)
Phenethylline(fenethylline)(a prodrugthat converts
to Captagon®
amphetamine andtheophyllinein thebody)

AMPHETAMINE
CONGENERS
Dexfenfluram
ine(Schedule IV) Redux®(no longersoldin the UnitedStates) Dexfen
fluramineandfenfluraminewith phentermine
HCLor phentermineresinwascalledfen-phen
Dieth~propion (Schedule
IV) Tenua
te®
Fenfluramine(Schedule
IV) Pondimin® Fen-phen(in combina
tion)
Methylphenida
te (Schedule
II) Ritali
n-SR, ®Concerta,® MetadateER® or CD,® Pellets,
kibblesandbits,pineapple,vitaminR,West
Methy lin ER,
® Daytrana
® Patch Coastkiddycoke,skittles,
poor man'scocaine,rids,
studybuddies
Dexmethylp
henidate Focalin
®
Phendimetrazine
(ScheduleIll) Bontril,® Prelu-2~ Pinkhearts
Pemoline
(Sched
ule II) (and streetmethylpemoline) Cyler!® Popco
rn coke,U4EUH,euphoria
Phentermine HCL(Schedule
[V) Adipex
-P,® Obenix,
®Zantryl,
® Fasti
n~ Robin'seggs,black-and-whites,
fen-phen
(in combination)
Phentermine resincomplex(Schedule
IV) lonamin
® Partoffen-phen

ITTHER
DIETPILLS
ANDATYPICAL
STIMULANTS
Modafinil Provigil®
Sibutramine (Schedule
IV) Meridia
®
Atomoxetine Strattera®

LOOK-ALIKE
ANDOVER-THE-COUNTER
STIMULANTS
Cancontaincaffeine,ephedrine, phenylephrine, Look
-alikes:SuperToo~ Lega
l speed,robin'seggs,blackbeauties
phenylpropanolamine (takenoff the market), OTCs: Dexatrim,
®Acutrim,
®Sudafed®
and/orpseudoephe drine
Herbalcaffein
e, herba
l ephedra Misce
llaneousbrand names
continu ed
 l.4 CHAPTER3

Up~ rs(stimulants)
DRUGNAME SOMETRADE
NAMES STREET
ORSLANG
NAMES
MISCELLANEOUS
PLANT
STIMULANTS
Arecoline
(arecaor betelnut) Bidi Areca,supari(Hindi),binlang(Taiwan),
mahk(Thai),
bidi,gutka(withtobacco)
Cathinone,
cathine(khatbush)(Cathaedulus) None Cat,qat chat miraa,Arabian tea,catha,goob,ikwa,
(methcathinone
isthesynthetic
version) ischott.khatkaad,kafta,lasalade,liss,bathtub speed,
wildcat
Ephedrine
(ephedra bush) Manycommercial
products Mahuan&marwath

I
Yohimbine
(yohimbe
tree) Yohimbi
8,®Manpowe
r®

NEWDESIGNE
RSTIMULANTS
Methcathinone
(Schedule
I) Variousmisrepresented
products(e.g. insect Bathsalts
repellants)
4-methy
lmethcath
inone(Schedule
I) Mephedrone Bathsalts
Methylenedioxypyrovalerone
(MDPV)(Schedule
I) Various
misrepresented
products Bathsalts,M-KAT,
drone,plant food,meow,Ivory
Wave,®supercoke,peevee
Methylene
(Schedule
I) Various
misrepresented
products Bath salts
6-(2-aminopropyl)bensofuran
(6APB) Various
misrepresented
products Benzofury
Dozensofvariations
ofthemethamphetamine-like
molecule Various
misrepresented
products Bathsalts
areonthemarket;moreareaddedeverymonth

CAFFE
INE(xanthines)
Chocolate
(cocoabeans) Hershey,
®Nestle,
®Ghirardelli,
®Snickers,
®
Mars,
®Cadbury,
®Lindt®
Coffee Colombian, French,
espresso,latte,mocha, Java,joe,mud,roast,batteryacid,leaded,unleaded,
decaf,drip mojo,rocketfuel
Colas(fromcolanut) Coca-Cola,
®Pepsi®
Caffeinated
softdrinks(no-cola
-nutsynthetics) Dr.Pepper,®Mountain
Dew®
Caffeinated
snacks Cracker
Jack'D
®
Energy
drinks RedBull,®Blast,
®Energy,®Monster,
®
NoFear,®Rockstar®
Guarana,
mate,yoco Various
Over-the-counter
stimulants NoDoz,
®Alert.
®Vivarin
®
Tea Lipton,
®Stash,
®Tetle
y® Cha,chai

NICOTINE
Chewing
tobacco Day'sWork,
®Beechnu
t" Chew,chaw
Othersmokelesstobacco(pouches,
sticks,pills,strips, CamelStrips,®Orbs,®Sticks,
®Snus,
®Nicotrol
®
inhalers,
electronic
cigarettes)
Dissolvable
tobacco RJ.Reynolds
Tobacco
Candy
Cigarettes Marlboro,
®Newport,
®PallMall,
®Kent,® Smoke,butt,toke,coffinnail,cancerstick
AmericanSpirit,
®Capri
®
Cigars DutchMasters,
®Garciay Vega,
®Montecristo,
® Stogie
Muriel,
®WhiteOwl®
Electronic
cigarettes
(e-cigarettes) V2cigs,
®BullSmoke,
®Green,
®Smoke,
®Halo,
® Vape,e-cigs
Panda,®Blu®
Pipetobacco SirWalterRaleigh
®
Snuff Copenhagen,
®Skoal® Dip
Bidi(groundtobaccoandbetelnut ina cigarette-gutka) Various,
mostlyin India Beedi
stimuWndrug>for<:<th<i r r<lt..,andinfu..,thtbody When stimul:m t drugs •r< nKd . they confuK the l>Tainby
withlarge•mounts0Fextr.1energy!,efor,cthebodynero, triggeringfedingoabout,urvlvalactivltinbeforethtylup-
it . Theextr•energy i,uprndcdthroughph)-.icalactiv!ty, p<n(< .g.,thathungerisbeingsatisfied althoughnofoodi,
talking . md hypervigil.mce . Cocaintand amphttaminn b<ingeatenandlm1thirstisb<ing,atisficd•lthoughnoliq-
multiplyth<eff«tsbecau,,th eykeq,t heen,rgyneurotrm s- uidisbeingronsumed) ; hencetheus,rd0<>no1e:,t0Tdrink
mittencirru l.otingbyb locking t h<irrub.mption•ndlOTby
Dopam'ne ',theneurotI2mm'ttamos t 'rn'nvolved 'n
blockingtheirmetaboli,m''
triggeringthes,cf«ling,. Strongerstimul:mtu .. rde...,
twoto!Ot' e,umuchdop;a 'nea, ,' nornu.lad 't 'e•
"/did jt~tl,,..d,,...Jin<.ldiJitto<to~.-.k<.ldiJit"c=
,!J~t•:,i«:;f
'.::,); j~7:_--ootofli~. I <tllj<d
This stimubtion i,interpntcd.,•nover:allhigh(f«ling,of
pla,ure •nd well-being) . Stronger ,timul.onl5, <>p«i•lly
.....
.....
,..,..,..,...,,..,.....
_,, when,mokedor inj«tcd,deli,u•nint<m<ru,h,<>p«i•lly
::::~ ~:::~ :'m:~::gd::~:~rase,, the intensity of

CrashandW~hdrawal
lf,trong,timul.on,. • retakenonlyoc=ionally,thebodyha,
"Th,d"'IJ,tam ""'™"1:i""
'I""'!,,.,;._ P,,tt~"""' 'I""' !,,au,
timetorecovufromthedfec,.olexcnoen<tjff,bulifthey
;,1,ll"'l1'f"'. Yoo"""ttl.:it~, 'I"" lil,,tl.:it~, 'r"' lil:,
•re'2k<nin!.orgequantiti<>overap<riodoftime,theen-
~""1t'l""a" Joine· /)oj/"9"ill. a.,,l'l'i"'°· oiiJ"9"""-
"
<rgyoupplinb«omedepltt<dandthebodyi•leftwithout
r,..,,.,.e,.llis,qu«=ldry---ochau,;ted . Withstrongu,tim -
Re:..an:h<B from th e Natio nal Institute on Drug Abu«
ulrn,.thiscr:oshandits,uboequentwithdrawal•ymptom,,
(NIDA) i~«lthelimbic(emotionol),ystemofthebnrin
particu larly >nen depn,.ion . can l.ost fo,- days . wttks , OT
du ' ngcoc:lnecn 'ng . u 'ng•F itronem·, 'ontomogn -
ocasion•llymonth•
phy(P ET)san ; th<yloundthatcoc:a inecravi ngoctivate ,
thi,circuitrytornexctptioruollyh igh leve~peciallyth<

--~
•mygdab,thebnin~emotiona!,witchboo.rd .' ~ TheKeffects
onth<brainare,,ery,imil.ortolh<>Kolm<thamphetamin<

Weightloss
Normolly , th<h)'J'Otha lamu,;mediate,hunger;butbtt:a u ,e
stimul.ontoFoolthebodyintothinkingthatitsbu icnu tri-
tlonandhydntionnttd,h.avebernuti•fi ed . aus<rcan
beoome malnourished and dehydrated. Many long -tenn

>
Stimula . "' "". ce t~e. rele•"'.· .o! th.e oody', usersofstimubntsdeve lop, itaminandm iner •ldefi cirncies
own energy chermcal, (epmephnne,
thatre,u lt indamagetothete<thandc.useotherha lth
norepmephnne,anddopi!mme).O...Mi<!of
tl,.,..,ne11rotransmrtteBwrlldepletethem prob lems. ' Thenirot inei ntobaccocand ecraS<•pp<ti te
becau«ofthiseffect.The fa r ofgain ingweightc•use,

Even•mildot imnl•nt likecoffttor•nenergydrinkcan :::• ,:oc:l·n:;,.~/~ • ,,b'te, n 'cot' ne. •nd !iOm< c,"ei
loweren<rgyotor<, u th<use r b«om<>toler:1nttothe,ub-
,1ance.O,.utime,10,tay•w•k<rnd•l<rtitwilltakemor<
thantheoi x oreightrup,OTcans •day a usah"5grown
occu,;tomcdtoconsuming. Thtenergyandtheronlidence
reac'ved'<m •fmul.ontsarenot 'thou t ro,t:theyar<a
loanfromther<stoFthebody andmustberepaidbygivlng
thtbodytimetorerover .

SurvivalPathway
Cocaine,•mphewnin<>, a ndoth<rSlrnng,timul.onl5,inad -
ditio ntor< leasingenergychemic•ls.c•nhijackthe•urvival
pathway , a lso called th< rew:1rd/trinlorcemen1 pathway.
Eventhemilder,timul.onl5have!i0meeffectonthls,ystem
Normally , theourvivalpathw.yis•rou..d when a physN>-
l"!licalorp•ychologic:aln«dmustbeut i•fied(e.g .. hun -
ger,thirst,OTsexu.alde,ire ). Whentheneedlsfullpatisficd, CardiovascularSide Effects
the "•top " ,witchintheprefront.1.lcortexoigna l,the "go" Mrny<ou lmt,, 'nclud'ngn ·rot'ne•ndcaff'-,,con,t'ct
switchtostopdrhingth<pe=inin toaction bloodve,; .. ls • ndc:minduc,c,pa,ms,thu,decr<Hingblood
 l.6 CHAPTER3

flow to tissues and organs, including the skin. (Heavy smok- Toleranceand AddictionLiability
ers and meth addicts often have pale, pasty complexions.)
The continued use of strong stimulants causes a decrease in
Because blood flow is decreased , tissue repair and healing
the number of serotonin and dopamine receptor sites in the
are slowed, heart rate is increased , and , with the stronger
nucleus accumbens and other areas of the primitive brain.
stimulants , various heart arrhythmias , including tachycar-
This is known as down regulation, and it causes the brain
dia, can occur. At the same time, blood pressure increases ,
to crave even more of the drug to continue to overstimulate
so a ruptured vessel (stroke if it is in the brain) is possible
the small number of remaining receptors.n This tolerance
though unusual during early use . The chronic use of these
can grow to very high levels; and although the physical
drugs continues to weaken blood vessels, increasing the risk
dependence of extended cocaine and methamphetamine use
of stroke .10
is not quite as severe as that of heroin, the psychological

I
Polydrug use of a stimulant with a depressant can cause
additional, unexpected, and possibly life-threatening cardio-
vascular effects. Alcohol and cocaine metabolize to coca-
ethylene, a potent metabolite that can have more-serious
cardiovascular effects (higher rate of heart attacks the day
after a cocaine/alcohol binge) than either of the drugs alone.
Emotional/Mental Side Effects
The initial release of extra neurotransmitters by stronger
stimulants tends to increase confidence, focus attention
(especially in those with ADHD), and induce euphoria.
'You9et excited.Youdon't just sit down and relax. Youcan't-
qou9otta be movin9.Youcannotstaq still, qou know,qour
handsand qourfeet noran~thin9-And qou see somethin9,
qou like, start trippin9offof it."
43-ye ar-old recovering meth abuser
People over the years have used cocaine to block out un-
wanted feelings; but as use continues , the imbalance of
dopamine , epinephrine, norepinephrine , and other neuro-
transmitters often promotes the feelings into talkativeness,
restlessness, irritability, and insomnia. Excess use of even
the milder stimulants, like caffeine, khat, and ephedra, can
cause some of these symptoms.
With excess or continued use of the stronger stimulants,
paranoia, aggression, and violence are more likely.
"It'salmostlikethere's a veneerovermq nerves,and it takesoff
that veneer,that coatin9,and I wasjust likea livewire. I'd be
on a crowdedbusand mi9htaointo a ra9eve~ spontaneouslq,
withoutanq realcause."
25-year-old meth abuser
High-dose or prolonged methamphetamine/cocaine use can
cause stimulant-induced paranoia and psychosis due to un-
balanced levels of dopamine in the central nervous system
(CNS). Even high-dose Ritalin® use can sometimes induce
a psychosis. Stimulant-induced psychosis is often hard to
distinguish from a real psychosis, such as schizophrenia .
dependence is just as powerful and causes intense craving
during a crash and the subsequent withdrawal. The increase
in physical dependence leads to developing an addiction .
Tolerance and dependence can also develop with metham-
phetamine congeners, caffeine, nicotine, and other milder
stimulants. The strongest dependence, both physical and
mental , develops with tobacco use.
Cocaine
"I snortsome. I easebackon the couchand considerthe
R.,biconI'vejust crossed.There is a momentof rearet,
followedbq vastsadness.Then comesa tidal waveof
euphoriathat sweepsawaqeverqne9ativethou9ht.. . .
I'veneverfelt such ener9q.. .. I 90 tearin9aroundmq house,
cleanin9it fromtop to bottom."
Tennis superstar Andre Agassi in his 2009 autobiograph y, Open, writing
about his cocaine use (New Yo rk: Alfred A. KnopO
"Durin9the periodwhen I wasdoin9cocaine,it waslikethe
dru9was mq friend. I neverdid it with otherpeople.It's such a
terriblewaq to fillthat void,becauseit just adds to that void,
becauseit's not real."
Lady Gaga
Aside from the celebrity tell-all biography or the occasional
headline announcing the latest film or sports star busted for
cocaine use or enrolled in rehab, publicity and notoriety sur-
rounding cocaine has diminished drastically since the free-
base epidemic of the 1970s and the crack epidemic of the
1980s and 1990s. Today the media is more interested in bath
salts, synthetic and medical marijuana , and prescription
painkillers.
There is a cyclical nature to stimulant and depressant drug
epidemics .
"Mostof the crimein our citq is causedbq cocaine."
Police chief of Atlanta, GA, 1911

"I used to drivearoundand hearmq motorcqcletalkin9to me,
and I wouldsee facescomeout of the treesand I'd see all
kindsof crazqstuff A~er 10 daqsof no sleep, it's likelivin9in a
dream'causeI couldn't distin13uish
realitqfromwhat the dru9
wasdoin9to me. I was that far9one."
22-year-old meth addict living in a therapeuticcommunity
Cocaine epidemics recur every few generations.
• The first was at the end of the nineteenth century soon
after the coca leaf was refined into cocaine. The writ-
ings of Sigmund Freud and other physicians , aided by
the spread of patent medicines and cocaine-laced wines,
were at the heart of the initial explosion of use .

• During the Roaring Twenties, a cocaine epidemic coin-
cided with the euphoria that came with the Allies' vic-
tory in World War I and a free-for-all economy and stock
market.
• In the 1970s and 1980s, use exploded again with the
popularization of smokable cocaine (freebase and
crack) .
Experimentation and casual use have declined since the latter
part of the twentieth century, but hardcore use has remained
strong into the 2000s in the United States and especially
Europe. The average age of those entering treatment for
cocaine, especially crack coca ine, has gone up, while the
younger generation has turned to methamphetamine, ecstasy,
and bath salts as the stimulant drugs of choice.
Botany,Crop Yields,and Refinement
The coca shrub dates back millions of years. One writer half-
jokingly specu lated that dinosaurs became extinct because
of the toxicity in the coca shrubs they dined on. 12 The coca
bush, which contains cocaine, grows main ly on the slopes
of the Andes Mountains in South America (Bolivia, Ecuador,
Peru, and especially Colombia). Lesser amounts are grown
The Erythroxylum coca plant grows almost exclusively on the slopes
of the Andes Mountains in Colombia , Bolivia, Ecuador, and Peru.
It takes 200 pounds of leaves to make 1 pound of cocaine.
Courtesy of the FitzHugh Ludlow Memorial Library
Uppers 3 .7
in certain parts of the Amazon j ungle and on the island of
Java in Indonesia. The South American cultivation of the
Erythroxylum coca and Erythroxylum novogranatense plants
accounts for 97% of the world's crop. The green-yellow
shrubs, which grow best at altitudes between 1,500 and
5,000 feet, can grow to be 15 feet tall, but those that are actu-
ally cultivated are usually 6 to 8 feet tall. The leaves of the
coca bush contain 0.5% to 1.5% by weight of the alka loid
cocaine . One acre of coca bushes will yield 1.5 to 2 kilo-
grams (kg) of cocaine. D
I
The cocaine refinement technique is a four- or five-step
process, depending on the chemicals used:
1. Soak the leaves in an alkali and water.
2. Add gasoline, kerosene, or acetone.
3. Discard the waste leaves and add acid.
4. Mix in lime and ammonia.
5. Separate the cocaine hydrochloride from the paste . 14
The refinement of cocaine from coca leaves typifies the im-
pact of refining and concentrating the active ingredients of a
psychoactive drug (e.g., opium to heroin, or 1% tetrahydro-
cannabino l [THC ] marijuana to 12% THC in sinsemilla-
grown plants).
Smugglingand the StreetTrade
In 20 13 the United Nations Office on Drugs and Crime est i-
mated the number of hectares under coca leaf cultivation in
three South American countries (see Table 3-2).
Colombia was once the primary producer of coca leaf, but
the coca-growing and cocaine refinement activ ities of a rebel
group in Peru, the re-election ofEvo Morales as president of
Bolivia in 2009, and a vigorous coca eradication program in
Colombia (supported by the United States) has changed the
balance of coca-growing acreage . 15
Cocaine-smuggling operations have shifted to drug gangs
and cartels based in Mexico; and even though cocaine use
has declined somewhat in the United States, there are still
almost 4.6 million annual users. The United Nations esti-
mates an equal number of annua l users in Europe .
Caribbean groups also share a piece of the smugg ling pie,
preferring sea routes due to increased surveillance of air-
space and greater scrutiny of the southern U.S. border since
September 11, 2001. Although the federa l government seized
more than 80 tons of cocaine in 201 1, an estimated 100 to
200 tons still got through to U.S. markets. It was estimated
that about 700 to 800 metric tons of cocaine were produced
in the Andean region in 2011. 15
Cocaine smuggling operations
have shifted to drug gangs and cartels
based in Mexico.
The revenue generated by the cocaine trade is staggering . In
1884, when the drug first became popular , the price of a
gram (gm) was about four times what it is today (factoring
 3.8 CHAPTER 3

the juice, adding some lime or ash (from ground shells) to

Estimated
Numberof Hectares
increase absorption by the mucosal tissue in their cheeks
underCultivation and gums (it takes three to five minutes for the drug to af-
COUt-llRY 2002 2011 fect the brain). A habitual user might chew 12 to 15 gm of
Bolivia 21,600 27,000 leaves three or four times a day. The maximum amount of
Colombia 102,000 64,000
cocaine available for absorption would be well under 1 gm.

Peru 46,700 64,000 The Incas in Peru integrated the coca leaf into every part of
their lives much as modern-day Americans integrate coffee
and tea into everyday life. Use by the Inca civilization was
inflation). Cocaine production increased from 0. 75 lb. in originally confined to priests and the nobility, but when the

I
1883 to 158,352 lbs. in 1886. 16 Current prices have risen, conquistadors subjugated the Inca Empire in the sixteenth
making the money involved in the trade just as remarkable century, they mandated a large increase in cultivation of the
and difficult to calculate with accuracy. leaf. They grew it for personal profit, to generate govern-
ment taxes, and to enable the subjugated Incas to work for
• In recent years Americans spent an estimated $40 billion
them more efficiently at high altitudes, particularly in the
annually (retail) on cocaine.
Spanish silver mines. 16,n
• At the wholesale level, cocaine prices vary from $12,000
to $35,000 per kilogram ($23,000 average) of refined Even today 90% of the Indians living in coca-growing re-
cocaine, with an average purity of 84%. gions chew the leaf. In many native homes in Bolivia, visi-
tors are ceremoniously offered pieces of leaves to chew be-
• At the street level, prices vary from $50 to $200 per
fore refreshments are served. The cocaine blood levels for a
gram ($95-per-gram average) in the United States, with
coca leaf chewer are about one-fourth those of cocaine smok-
an average purity of 56.5%.
ers and one-seventh those of intravenous (IV) users. 14 In ad-
• "Rocks" of crack cocaine, varying in size from 0.1 to
0.5 gm, sell for $10 to $20 each.
• The average hardcore cocaine user spends about $186
per week. 1s,11,1s
,2s6

Estimates of the number of casual and hardcore cocaine us-

ers vary widely, depending on the survey and the definition
of hardcore user. ls someone who binges once a month a
hardcore user? For example, in 2012 the National Household
Survey on Drug Abuse estimated that there were 1.65 mil-
lion monthly cocaine users in the United States. The Drug
Use Forecasting program, charged with questioning arrest-
ees in city jails about their drug use and then confirming the
findings with urinalysis, however, estimated twice as many
hardcore users. The consistency of survey methods from
year to year is more valuable in judging trends in use rather
than absolute numbers. 19,20,21

History of Use
Many landmarks in the history of coca and cocaine are as-
sociated with the purity of the substance and methods of
use, which include:
• chewing the leaf or chopping it with ash and placing it
on the gums
• drinking the refined cocaine alkaloid in wine or tea
• injecting a solution of the drug into a vein
• snorting cocaine hydrochloride
• smoking freebase or crack crystals

Chewing the Leaf

Remnants of coca leaves dating back to the Huaca Prieta
settlement on the northern coast of Peru show that native
cultures of South America have used coca leaves since 2,500
B.C. to lessen hunger, fight off fatigue, increase endurance,
and enhance social occasions. Natives chewed the leaf for
A shaman holds up coca leaves during a ritual for good luck in 2012
in Lima, Peru. Historically, chewing coca leaves is common in many
ceremonies and celebrations and is the stimulatory substance for
many social interactions.
0 2012 Karel Navarro.AssociatedPress.
 Uppers l.9

dition to serving as a stimulant and controlling hunger,
about 4 oz. of chewed leaves provide the recommended daily
dose of all vitamins and minerals_23 The cultivation, trade,
and chewing or brewing of coca leaves is legal in Bolivia,
Peru, and northwestern Argentina . Cocay bica (coca leaves
and bicarbonate of soda or other alkaline substance) are sold
at markets, newsstands, and other small shops .
Recently, the United Nations Office on Drugs and Crime
agreed to accept the traditional chewing of coca leaves as a
permissible use of the drug. This single exception to the
The overly optimistic judgments of Freud and others were
made early in the experimental process before cocaine
dependence and addiction were recognized problems . As the
drug became more widely available, some people became
chronic users, making the true nature and liabilities of
refined cocaine obvious even to Freud and his colleagues.
DrinkingCocaine
The fact that cocaine hydrochloride can be dissolved in wa-
ter or alcohol made other routes of use possible, namely

I
drinking, injecting, and contact absorption. It takes 15 to 30
1961 Single Convention on Narcotic Drugs of the United
minutes for the metabolites of cocaine to reach the brain
Nations was a victory for Bolivian president Morales, who
after oral ingestion .
felt a cultural tradition of his country was being destroyed.
Beginning in the late 1860s, cocaine wines became popular
Cocato Cocaine in France and Italy; but it was not until a clever chemist,
Back in 1859 Albert Niemann, a graduate student in manufacturer, and salesman, Angelo Mariani, concocted
Gottingen, Germany, isolated cocaine from the other chemi- Vin Mariani and promoted its use through the first celebrity
cals in the coca leaf. This powerful refined alkaloid, cocaine
hydrochloride, was 200 times more powerful by weight Coca-Cola"' was
than the coca leaf, thus setting the stage for the widespread
use and abuse of the drug. The refined cocaine could be in-
gested, injected, or smoked. Twenty years later word of the
lttElde~1~r:}~!~~!C
,., • .ii......~.
introducedto the public as
a patent medicine in 1886.
It containedcocainefrom
the coca bush and caffeine
drug spread, due in part to the physician Karl Koller, who from the kola nut, hence
discovered its anesthetic properties, and to Sigmund Freud, its name. Each 8 oz. glass
who promoted the medical and psychiatric uses of refined contained9 milligrams
cocaine hydrochloride in his book UberCoca. The drug was (mg) of cocainevs. 50 to
recommended to treat a variety of ailments, including de- 100 mg for a line of
pression, tuberculosis, gastric disorders, asthma, and mor- snortable cocaine. The
drink was advertised as a
phine or alcohol addiction .24 It was the drug's stimulating
brain tonic until 1903,
and mood-enhancing qualities that most interested Freud; when the cocainewas
but because cocaine was a new drug that had not been stud- removedand the beverage
ied over time, he made a number of errors in judgment. was touted simply as
delicious and refreshing.
"Coca is a far morepotentand far lessharmfulstimulantthan
alcoholand its widespreadutilizationis hinderedat presentonl~
b~ its highcost. ... I havea/read~stressedthe fact that thereis
no state ofdepressionwhenthe effectsofcoca havewornoff"
Sigmund Freud (Freud, 1884)

This 1897 postcard by Alphonse Mucha is an advertisementfor a cocaine-lacedwine, Wine of the Incas. There were dozens of cocainewines at
the end of the nineteenth century.
<ndors<mrnt<(< .g.,Tho=EdOOn,Ro b<nloui>SW.1'mon rocain< from ,noning "" much lower thE1 th0>< from IV

::•:;•=~~
andPop,LroXlll)thatth<fiBlcoca in<<pid<micb<gan u ... A,th,romlricting<ff«tolcocain<wunoff . th<msal
Although th< win< contain«! on!)·• mod«t amount of
rocain<(twogWO<Shadth,equiva lrntofon,lin<of ::':.i:;-::.
c;;:;';!~i,,c;::;~
•;~m!:~
was mOT< than mod«t b, c,.ux of th< ::;:; ;_!,<W~p<rfor:at<thena,al"!'tumthatdi>id<>th<
1
Suddrnly . inth,1880sandl890o.patrntm«licin<slattd ll<Sid« •b.orption through mucau in the """'• gum,, rnd
with rocain< . opium, mOTphin<, haoin, C.U.na.t,u. •nd ch<ek>. oocain<canb<aboorb<dthroughmuros.1.ltissutin
• lroholb<cam<th<ni;<. Thcyw<r<tout«l>5cUr<•> llslor the r«tumandth<vaginaandact .. a topical anesthetic
>ilmrnl< =ging from "' thma • nd hay f..,.,, to f.otigu< Rrctal•w licationisu>«lby,omemale,inth<?)'Commu -
d<pr<ssion.•nxi<ty,rnddozensofothuilln,..., nity 1' Cocainecaniliob<•bsorb«lthroughth<out<r<kin
(<pid<rmi, )-- not>tle-.1'1'highrnoughtocau.,,ff,ruinth<
ll<aU>< th= patent m«li c,.tionscon troll«lpain •nd in -
br.tinbuthighenoughtob<d<t<cubl<inth<bloodsuam
duc:cd<nphoria,th<prn:<ptionthatth,ycuredilln< .. ,..thu
whichrould,k<wth,,..ult<of•drugt<>t
thrnju<toontrolledthe,ymptom>wup<rp,tu.ot«l . lnth<
lot< l SOO., theprolong«lu.,ofrocain< • ndoth<rpr< · Smoking Cocaine
«riptionm«lication,cre•t<d•lorg,groupoFd<prndrnt
Although th<r< i, 50m< <Vid<nc< t hat coca luve, w<r<
u.,,.andadd'cts,mostoFwhom w<r<womrn ."
~':'«!rnd ~• ,m~k< icla~d i:,:,ru,-ian ,laman, _~~l:r
Injecting Cocaine
god.>. itv.':l5notuntilcocain<wur<finedthatap<rim<nt<r:s
Theinven tionofth<hypod<rmicnttdleinl8 S3h.J•
look«lforw:ay,toinh•l<th<mOT<conc:<cntm«l,mok<.ln
mor< imm«liat< ,ffect on th< u., ol morphin< than on
19H th<phmnactntic•lcom panyPork< -Da>i,introduc«l
rocain,fortwor<>50M. FiBt.ther<fin<m<ntofmorphin<
cigorrtt<>thatcontai...«Jr<fin«lrocoin<;bu t th<hight<m -
lrom opium occurr«l 50 yensarliu than th< r,cfin<mrnt of
p<r>ture(l95"C,or.3830F)n<e...arytoconv<Ttooc•in<hy -
rocain< . >nd , Kcond,th<u.,of•nopi>t<>uch><morphin<
drochlorld<to>mok<r<sult<dinth<de,tructionofmanyof
wo,commonlyus«lduringth<Criman'.'.'ll•ndth,U.S
iap,ychoacti,,eproputi<> . Con.<qu<ntly , ch<Wing, drink -
CivilWor .. •poW<Tful painkilluforwound«l50ldi<T>
M,dica lly.the,ubcu12nrousinj«tionor • pplic,.tionolco- ~!j:f~i~:1,~:::i~n~~:•m7~9;~ .~h:::::
cain<onmoisttis<u<>canS«!topic,.lan<>th<>ia.,usdullor ch<mi>l5conv,n,drocain<hydrochlorid<tofr<,b•0<eco-
minor,urgery Whrnphy,icians/ir,;tb<gonn>ingcoc>in< caint . Thi,prott .. low<r<dth<,ublimll tionpoin t to98"C
m«licinally,manyw<r<unow:,r,o/th<ovudo,epot<ntial and~ethtdrug,mobhle.Unlik<theorlgin•lcoca in<
,vrnfromtopic•l=.•nd•numb<rold,a1hsoccurr«l h)'Clrochloridecig•r<tt<,,fr<ehas<cocain<co11ldb<,mok«l
Somephy,icia.n,,includingWilliaml-u lst<od. on,ofth,"fa . withou t d«troyingmosto li1<p,ychoa ctiveprop<rti<>
thu,ofmod<m,nl)!uy,"b<c,.meaddict«ltoth<•uhstanc<
In th< arly•nd mid - 1980, . rna,lum<thodolmaking fr<,.
lnj<Ctingoocaineintr2V<nou>lyrnultsin•nin trns..ruoh bas<rocain,(ca ll<d"dinybasing")wo,d,v, lop<d.><tting
within300<rondo • ndproduc«th<high<.,bloodcocaine
L,v,J.Th<ru<hismo reint<n><thanwh<nch<Wingth<laf. ~o=~: :c:i:~t~ ~~~~c:i';"ic Thi, n<W form of
drinkingcocain<wi,.,. , ocmoningcocai n<hydrochlorid<
Whrnahoofb<dthroughth<lung,,rocain<r<ach,.th<
If cocaine i, injected ,uhcutmeOU>!y or in t r=u.cularly .
br:aininonly 5 to8s«ond,compam:!withthe l3toJ0
tb<highisddoy«lthr<<to/iv,minnt< ••ndisnotq ult<>5
><eondoittok<>wh<ninject«linto•,.,in.Smokoblecocain<
r<och<>thebr.tinsoquicklythatitca=mor<-dmruot icd -
SnortingCoc.Jin e andMuco..-.lAbsorption r,cts b<fOT<it i, ,wiltly metoboli,«l . Thi, r:apid up-2Ild -
down roller-coast<, ,!Feet of,moking u,ults in int<nse
Thearlyl900sgo,·•ri><to•populnn,wlormofcoc>in<
cravingandanv ctr<n1<bing,pattemofu.,
u .. :,noningth<powd<Tintotheno>lril,.Call«l "tooting,"

:~;::r::~::g;:.~i~~:!::
i!·~::.~~::u!i:
p;p,up
ut,._P a kdfect<l2k< • f<WmOT<minut<,tooccur .
Tu ~"! ti"" I -i,J aad cocain<. ..,l,,n I putti,, ,g/=
lo111lj~/"-itmad<111ljlip>!x.m.itmad,tl,,111 .,.,,,1,
,,,.,/11,,,.,,,U<?f~rodcocai..,o,cr..d;i>B:""';j!i,tl,,
.,.,l/toal1•o•ia,,,,.,,
"°'/'<J,,,.,1/rooldjust
,,__.,,.,
,..,.,,...,,...
,...,.
-.. .lf,ltjudo,mandlf,/tlil;,I
1·

Smoking uad cocain e and injecting

cocainehydrochlorid e u e themO<tpopuLor
Snoningroc •inei ,aKlf- limitingm,thodofu., : thedrug methodsofusingthedrug.lheyueal,o
ronslric1<th<c•pill •rle,tha1•bsorbth<drug , soth<mOT< th,, fastestandmostpowerful.
tha1i , mon«l, the,low<rth<aboorption c blood l,v,l,of

This tum-of-the-century product, Cocarettes, combin ed a Brazilian
coca leaf and Virginia tobacco and was touted as, "Stimulating and
invigorating; the greatest boon ever offered to smokers. Cocarettes can
be used for people with delicate health. "
Courtesyof the Library of Congress
Physicaland Mental Effects
As with any newly discovered drug , cocaine spawned many
myths and gained many advocates when it first became popu-
lar. In 1886 Robert Louis Stevenson wrote The Strange Case
of Dr. Jekyll and Mr. Hyde in just six days under the influ-
ence of cocaine, which he was taking to treat tuberculosis.
"/ have more than once observedthat in m~ second character,
m~ facultiesseemedsharpenedto a point and m~ spirits more
tense/~elastic;thus it came about that, whereJek~ll perhaps
mi9ht have succumbed, H~de rose to the importanceof the
moment. M~ dru9s werein one of the pressesof m~ cabinet;
how was I to reach them?"
Robert Louis Stevenson , D,jek y ll and M, Hyde, 1886
The novel's theme concerns the dramatic transformation of
Dr. Jekyll after he takes a new chemical compound he devel-
oped . The mania of his alter ego, Mr. Hyde, can be likened to
the effects of intense cocaine use , particularly drug-induced
psychosis, paranoia, and anger. This idea of opposites, of ups
and downs, of dramatic personality transformations is
always present when the effects of cocaine are examined.
Metabolism
Because cocaine is metabolized very quickly, effects dissi-
pate faster than those from amphetamines and amphet-
amine congeners. Cocaine is metabolized to ecgonine
methyl ester, benzoylecgonine , and , if alcohol is present ,
cocaethylene. The half-life of cocaine is 30 to 90 minutes.
This means that half the drug is metaboliz ed to pharmaco-
logically inactive metabolites over that period of time. Even
after the drug has almost disappear ed from the blood , effects
Uppers 3.11
I
Many film versions of Dr. J ekyll and Mr. Hyde have been made over
the y ears: 1908, 1910, 1912 , 1913, 1919 , 1920, 1931 , 1941, 1951 ,
1968, 1973, 1995, and 2002.
Courtesyof the Libraryof Congress
continue . Cocaine use is usually detectable in the urine for
up to 36 hours.
Medical Use
As the only naturally occurring topical anesthetic with
powerful vasoconstriction effects, cocaine is used in aerosol
form to numb the nasal passages when inserting breathing
tubes in a patient , to numb the eye or throat during surgery,
and to deaden the pain of chronic sores. This topical anes-
thetic effect numbs the nasal passages when the drug is
snorted. Cocaine receptors are also found on the bronchi
and the smooth muscles of the lungs , so use causes dilation
of the bronchi. Because of this effect, cocaine was once used
to treat asthma . Synthetic topical anesthetics, particularly
procaine and lidocaine that mimic the effects of cocaine, are
used today for eye surgery, dental procedures , and other
minor surgeries.
Neurochemistryand the CentralNervousSystem
Most of cocaine's effects are the result of its influence on
serotonin and three catecholamine neurotransmitters-
norepinephrine, epinephrine , and dopamine . Cocaine pre-
vents the reabsorption of these neurotransmitters, thus
increasing their concentration in the synapse and intensi-
fying the effects .27 ,28 In an experiment with cocaine users at
NIDAs Regional Neuro-Imaging Center, Dr. Nora Volkow,
director of NIDA, used PET scans to show that cocaine
 3.12 CHAPTER3

blocked 60% to 77% of the dopamine reuptake sites. At

least 4 7% of the sites had to be blocked for a user to feel a
drug-induced high. 293° ,31 When the neurotransmitters are
prevented from being reabsorbed and retransmitted, the neu-
rochemicals that metabolize them have more time to work ,
thus destroying more and more dopamine, norepineph-
rine, and epinephrine and accelerating the depletion.
Tbe Crash By blocking the reuptake ports, cocaine leaves
those neurotransmitters vulnerable to metabolism by en-
zymes that circulate among the brain cells, resulting in their

I
rapid depletion. 26 Because cocaine is metabolized so quickly,
the initial euphoria, feeling of confidence, sense of omnipo-
tence, surge of energy, and sense of satisfaction disappear as
suddenly as they appeared, resulting in a crash after use that
can be intensely depressing; this depression can last a few
hours, severa l days, or even weeks.
Even at the end of the nineteenth century, when every apothecary had
The biologica l mechanisms of cocaine are quite comp lex.
a supply of cocaine, it was expensive. Today, however, 1 oz. of cocaine
For example, in an experiment at Massachusetts Genera l when sold legally in the United States for medicinal purposes , mainly
Hospital, brain scans of 10 cocaine addicts taken immedi- topical anesthesia, costs about $150 to $250. When sold illegally,
ately after injecting the drug showed 90 distinct areas of 1 oz. can cost up to $2,000.
brain activation, especially the amygdala and nucleus ac- 0 2014 CNS Productions,Inc.
cumbens. 32 This stimulation has a price. It is like delivering
230 volts to a 115-volt light bulb. The bulb bums more
brightly, but the strain ultimately burns out the filament.
Cocai ne and amphetamines have similar sexual effects.
Cocaine affects a number of neurotransmitters. Cocai ne at low doses enhances sexual desire, delays ejacu-
• Dopamine coordinates fine motor skills, stimulates the lation, and is considered an aphrodisiac by many users. In
survival (reward) pathway, and regulates thoughts, some cases it causes spontaneous ejacu lation. With higher
but it can also overstimulate the brain's fright center, doses and chronic use, sexual dysfunction becomes more
causing paranoia. A shadow, sudden movement, or loud common.
voice may seem unbearably threatening.
"A~era whilewhenqoukeepdoin9it, it's just likeqou're
'Th ere were these little nail holes in the door, and he swore up impotent and ~ou can't . . it doesn't have no effect.
and down that someone was lookin9 at us throu9h them. The oppositesexcando anqthin9theqwantto qouand
I put mqfeetdownon the bed, and he wouldslaptheshit ~ou won't react. Your bod~ doesn't react to it, to an~
out of me, 'Bitch,whoqousi9nalin9?'
He would9et on his kind of touch or emotion, ~ou know."
kneesand lookunderthe bed." 36-year--0ld recovering cocaine addict

34-year--0ld recovering crack abuser

• Other catecholamines (epinephrine and norepineph-
rine) increase confidence and energy and cause a eu-
phoric rush, but eventua l depletion causes exhaustion,
lethargy (anergia), anhedonia (the inability to feel plea-
sure), and low blood pressure.
• Serotonin and acetylcholine are also released and then
rapid ly depleted by cocaine.
Sexual Effects
"It makesqoufeellike,~ou(now, qou'rereallqsexqand.
qou(now, makesqou/eellikeqou'rethe bestmanin the
wholeworld."
3&-year--0ld male recovering cocaine addict
'The firsttimeI did it. I feltall bubblqand likeor9asmicand
touch was ver~ sensual, but that went awa~ ver~ quick/~."
2S-year--0ld female recovering cocaine addict
The need to raise money to fund a habit coupled with the
disinhibiting effects of cocaine often leads to high-risk
sexual behavior and unusual sexual practices. 33
Aggression
, Violence, and Cocaethylene
Cocaine use is associated with increased aggression and
violence, especially in those prone to violence.
• Inhibitory functions are suppressed in the anterior cin-
gulate gyrus and the temporal lobes.
• Emotional triggers are overstimulated in the amygda la.
• The fight center is hyperactivated in the limbic system,
so aggress ion and occas ionally violence are often just a
hair trigger away.
"/ found that usin9 cocaine, mainlinin9 it strai9ht to the nervous
sqstem,it's likeI wantto (ill people.It is a verqunhealthqstate
of mind. It is likespin~in9out of control. and all the,,thou9hts
are centered around, Where should I hit them f1rst?
32-year--0ld recovering cocaine abuser
 Uppers

In a small study of domestic violence, researchers found that

67% of the perpetrators used cocaine the day of the incident
Calcification
in the CoronaryArtery
and all had consumed alcohol. Interviews and research indi-
cate that cocaethylene (an active metabolite of cocaine and
alcohol) induces greater agitation, euphoria, and violence
than cocaine alone. 31.35

"Mqmatehallucinated fromsmok;n9too much, thinkin9I was

trqin9to do hisbrothers,and I 9ot mqfacedama9edbadlqbe-
causeof hishallucinations.He slammedmq face into concrete."

I
28-year-old femalerecoveringcrack abuser

The paranoia and the dysfunctional lifestyle involved with

cocaine use engender excess violence. A study of auLOpsy
reports from the New York coroner's office showed that 31%
of all homicide victims had cocaine in their bodies (1,332
out of 4,298 victims). Two-thirds of those who tested posi-
tive were 15 to 34 years old, and 86% were male. 39
Cardiovascular
Effects
'Therewasa heavqbeatin9,tachqcardia,a senseof not bein9
ableto 9et mqbreath,the sensationof everqthin9
movin9verq
quicklqand ""1 inte115elq
.•
34-year-old female recovering cocaine abuser
Physiologically, the cardiovascular system is the most af-
fected by long-term cocaine use. Cocaine affects the circula-
tory system because it activates the receptors on the heart
and the blood vessels and by its effect on the sympathetic
part of the autonomic nervous system in the brain. When
injected, cocaine raises the heart rate and constricts blood
vessels, causing a 20- to 30-unit rise in blood pressure,
sometimes more. 40 This means that while more blood is
available for central blood vessels to energize muscles and
increase blood flow to the heart, less is available for the
smaller vessels to heal damaged tissues, aid digestion, and
infuse other peripheral systems with sufficient oxygen. This
leads to cellular changes that could damage heart muscles,
coronary arteries, and other blood vessels. Raised blood
pressure can also weaken the walls of the blood vessels and
cause a stroke, usually within three hours of use. The hearts
of chronic abusers are often slightly enlarged, and coronary
arterial blood flow is sluggish. Chronic cocaine use also
causes heart muscle scarring known as constriction bands.
This makes chronic users more likely to suffer a cocaine-
induced heart attack. 14•4 1
Dr. Shenghan Lai and his colleagues at Johns Hopkins
University found that cocaine abuse builds up calcium and
fat deposits on the inner walls of blood vessels (Figure 3-1).
They detected this problem in relatively young cocaine users
at a much higher rate than in nonusing young adults. 42
Cocaine constricts blood vessels and can
damage coronary arteries and cause heart
problems or a stroke.
Cocaine abuse can cause calcium deposits (in white) in coronary
arteries. The buildup of fat. and calcium along the inner walls of the
vessels narrows and eventually can obstruct the vessels, often causing
strokes and heart attacks. Cocaine:also constricts vessels, increasing
the likelihood of a totally obstructed coronary artery.
C 2014 CNS Prod uctions, Inc.
The active cocaine metabolite, cocaethylene, is more likely
to induce cardiac conduction abnormalities than cocaine
alone and therefore is more likely to induce a heart attack.
Because the average half-life of cocaethylene is more than
three times that of cocaine by itself (two hours vs. 38 min-
utes), its effects, including high blood pressure, last lon-
ger. 14·36 Many cocaine abusers are aware of this extended half-
life effect, so they "front load " with alcohol to prolong the
effects of the more expensive cocaine. 37.38
Neonatal Effects
'Threeof mqchildrenhavebeenwkendirectlqfrom me in the
hospital,likedirectlqout of mqarmsto the nurserq,found
out the~werepositivefor cocaineand, ~ou know, backto the
nurserq,and I wasn't allowedto see them."
30-year-old recovering crack user
When a pregnant woman uses cocaine, her baby is exposed
to the drug within seconds. Because of the stimulatory ef-
fects on the cardiovascu lar system, the chances of miscar-
riage, stroke, placental separation, and sudden infant death
syndrome (SIDS) due to raised blood pressure and blood
vessel malformations are increased. 41
In one study of 717 cocaine-exposed infants, the babies were
born about 1.2 weeks early, weighed 536 gm less, measured
2.6 centimeters (cm) shorter, and had a head circumference
1.5 cm smaller than nonexposed infants. 43 An analysis of 36
studies of physical growth, cognition, language skills, motor
skills, and behavior in cocaine-exposed children up to the
age of six, however, showed minimal effects, suggesting
that many children outgrow some of the effects or develop
alternative methods of leaming. +1
 3.14 CHAPTER 3
'The prst two or threeweek,out of the hospital.the babiesare
prett~normaland thenall of a suddenthe chemicalthat the~
werebornwith isout of the s~stem.The~90 throu9ha couple
ofweeksofseverewithdrawal,wherethe~ haveseizures,tremors,
vomitin9,and diarrhea, screamin916 to 20 hours a daq. A~er
about two weeksofthat, the brain releasessome ofthat cocaine
[actual/~
. a metaboliteof cocaine]backinto the s~stem;then
we have a couple of weeksofreprieve,and then that whole
processstarts overa9ain."
Foster mother who cares for drug-affected babies
I
Many of the abnormalities found in the newborns of drug
users have more to do with the mother's lifestyle than the
drug she used. Amphetamine and cocaine abusers are
generally malnourished, smoke tobacco, and have a venereal
or IV drug-induced disease, such as hepatitis or HIV/AIDS,
which also infects the fetus. A drug-dependent mother is
more likely to be indifferent to the daily demands of an
infant, so neglect, emotional deprivation, and a lack of
bonding are more likely to occur. 45 In a study of 218 cocaine-
exposed babies of high-risk, low-socioeconomic-status
mothers, the menta l retardation rate was five times that of
the general population but only twice the rate for non-
cocaine-exposed children of the same socioeconomic group.
The rate of mild or greater mental delays was also double
that of the nonexposed children. 46
Despite the severe prob lems of cocaine toxicity and with-
drawal in cocaine-exposed fetuses and babies, there is hope.
When treatment centers provide good prenatal and postna-
tal care, along with continued, first-rate pediatric and par-
enting resources, toddlers' emotional and physical develop-
ment can catch up to non-cocaine-exposed children by
their eighth to tenth birthdays. 44
Tolerance
Tolerance to the euphoric effects can develop after the first
injection or smoking session. Binge or chronic users have
escalated their use from 0.05 gm to 2 gm in a 24-hour period
within only a few days or weeks as they chase the rush of the
initial high. Tolerance is related to the brain's adaption to
excess dopamine, norepinephrine, and epinephrine that is
released by cocaine. These neurotransmitters gradually be-
come depleted, and the number of receptor sites is also
depleted. Fewer receptors means less dopamine activation,
which diminishes the drug's rewarding effects. Less nor-
epinephrine and epinephrine means fewer energy chemi-
cals, which in turn depresses the brain and the body and
increases the amount of the drug necessary to gain the de-
sired effects. 47,48·48A Tolerance does not occur evenly across
the board; paranoia continues to increase, and cardiovascu-
lar tolerance develops more slowly, putting the user at higher
risk. 36
Withdrawal , Craving, and Relapse
Contrary to notions held by many researchers until the
198Os, there are true withdrawal symptoms when cocaine
use ceases. Although similar to the crash, withdrawal ef-
fects can last much longer: weeks, months, and occasionally
years, depending on dosage, frequency, length of use, and
any pre-existing mental problems. The major symptoms are:
• anhedonia (lack of ability to feel pleasure)
• anergia (total lack of energy)
• emotional depression
• loss of motivation or initiative
• anxiety
• vivid and unpleasant dreams
• insomnia
• increased appetite
• psychomotor agitation
• an intense craving for the drug49 ,50,51
"/ 9ot shot in the le9.I ha,e a bulletin m~le9now. I wasbleed-
in9to death,and the onlqthin9I wantedto do wassmoke
[cocaine].I told mqbudd~,'Comeon. 9iveme a hit. 9iveme a
hit.' I am smokin9the pipe;the pipeis fullof blood. I am smok-
in9,trfn9 to aet hi9h,and hereI am aboutto bleedto death."
6S-year-old recovering crack addict
Half-a -million visits to
emergency rooms in the U.S.
each year are due to cocaine.
These same symptoms are also common in amphetamine
withdrawa l, particularly craving, which often causes the re-
covering abuser to relapse again and again. This is the time
frame for a typical cycle of compulsive cocaine (or amphet-
amine) use:
• Immediately after a binge, usually lasting several days,
the user crashes and sleeps all day, trying to regain
energy.
• A few days later, the user feels much better and, if in
treatment, often drops out. This temporary return to
normal feelings is called euthymia.
• A week or 10 days after quitting, the craving starts to
build, the energy level drops, and the user feels very
little pleasure from surroundings, activities, or friends.
Emotional depression increases.
• Two to four weeks after a user vows to abstain, the crav-
ing and the depression build to a fever pitch and, unless
the user is in intensive treatment, relapse often occurs.
Animal studies revealed that one reason for the powerful
tendency to relapse is the increased sensitivity of dopamine
D2 receptors in the prefrontal cortex, which makes the user
more susceptible to cognitive disruption and craving. This
means that it is not only the number of dopamine receptors
that can affect craving but also the proportion of sensitized
receptors available. It can take several months for the sensi-
tized receptors to return to normal. 52,53
"Findin9ssu39estthat extendedcocaineself-administration
chan9esthe brainin a wa~ that impairsthe abilit~to beattentiYe,
a capacit~that is importantin mak,in9decisionsin reallife."
Dr. Terry Robinson, NIDA researcher , Un iversity of Michigan , Ann Arbor , Ml

Overdose
Of 1.6 million emergency room (ER) visits per year in the
United States associated with drug misuse or abuse, 32% or
about 505,000 involve cocaine and most of those are
crack. 54 A cocaine overdose can be caused by as little as one-
fiftieth of a gram or as much as 1.2 gm. The "caine reaction "
is very intense and is generall y short in duration. Most often
an overdose is not fatal-it onl y feels like impending death.
In 2008 the American Heart Association urged ER doctors to
check more carefull y for cocaine use when patients , particu-
larly younger ones, present with chest pain, shortness of
breath, and other symptoms of a heart attack. Only 1% to 6%
of ER patients with cocaine-associated chest pain actually
have a heart attack , so the most efficient initial treatment is
to monitor them thoroughly in the ER before deciding on
full hospital admittance.
'"/a/mast did taa muchand I felt a~erI did it, I felt m~knees
buckleand I fell on the toiletstool. ~ouknow. And I wasjust
shakin9,likein a convulsion, ~ouknow.And if m~budd~wasn't
thereto 9rabme and put me in the shower,I don't knowwhat
would'vehappened."
36-year-old cocaine addict
In 2 ,000 to 3,000 U.S. cases every year, however, death oc-
curs within 40 minutes to five hours after using (occasion-
ally the next morning). Death usually results from either the
initial stimulatory phase of toxicity (seizures, hypertension,
hyperthermia, stroke, interruption of the normal electrical
control of the heartbeat, and tachycardia) or the later depres-
sion phase, terminating in extreme respiratory depression
andcoma. 16
Heart seizures and death occasionally occur the morning
after heavy use due to cocaethylene that lasts in the blood
and the brain after the cocaine and the alcohol have been
metabolized .35
"/ have seen a friend90 throu9h overdose. His skin was9raq-
areen. His e~esrolledback his heartstopped. and therewasa
9ur9lin9soundthat is ri9htat death;and I had to brin9him
backand that's enou9hto put the fearof God in an~bod~. "
Intravenous cocaine user
First-time users and even those who have used cocaine be-
fore can get an exaggerated reaction far beyond what might
normally occur or beyond what they might expect. This is
partially due to the phenomenon known as inverse toler-
ance, or "kindling. " This means that as people use a drug,
particularly cocaine, they get more sensitive to its toxic
effects rather than less sensitive.
Miscellaneous Effects
Formication This is an imbalance in sensory neurons caused
by long-term or high-dose cocaine and amphetamine use,
which creates the sensation of hundreds of tiny bugs ("coke
bugs," "meth bugs, " or "snow bugs") crawling under one's
skin. Users on coke or "speed runs" have been known to
scratch themselves bloody trying to get at the imagined bugs.
Uppers l.15
Dental Erosions These frequently occur as a result of mal-
nutrition, poor dental hygiene, oral dehydration, and the
erosive effects of acidic cocaine that trickles down from the
sinuses to the upper front teeth. Repetitive and compulsive
overbrushing of the teeth while intoxicated also leads to
erosions. 55 •56
Seizure Caused by overdose, stroke, or hemorrhage , seizures
occur in 2% to 10% of regular cocaine users. 14 Three times
as many women as men have seizures from cocaine .
I
Gastrointestinal Complications Though more unusual than car-
diovascular effects, gastric ulcerations, retroperitoneal fibro-
sis , visceral infarction, intestinal ischemia , gastrointestinal
tract perforation , and colonic ischemia have been observed
in heavy cocaine users .57
"Crack or Meth Dancing" (choreoathetoid movements) Involun-
tary writhing , flailing, and jerky and sinuous movement
mostly of the hands and the arms but also of the legs is be-
lieved to be a result of dopamine changes in the cerebellum
that result from cocaine or amphetamine toxicit y.5859
Cocaine Psychosis and Other Mental Problems
Because cocaine increases dopamine , repeated use can trig-
ger stimulant-induced paranoid psychosis/schizophrenia .60
In the 1970s the progression from euphoria to dysphoria and
ultimately to psychosis was observed to be mostl y dos e
related , but the setting in which the drug is taken can also
affect the intensity of the symptoms. Excessive use of meth-
amphetamine is more likely than cocaine to cause a stimu-
lant psychosis because meth has a much longer duration of
action.
Symptoms of cocaine psychosis include prominent auditory,
visual , or tactile hallucinations and paranoid delusions. 49 It
is difficult for clinicians to tell the difference between a
pre-existing psychosis and cocaine/methamphetamine-
induced psychosis. A thorough psychological and drug
history and a drug test are necessary to determine the cause .
One of the sure signs of any drug-caused psychosis is that
the symptoms disappear after a period of abstinence from
the stimulant, which may range from a few hours to a few
days or occasionally months. Repeated use of cocaine can
sensitize the user, so smaller and sma ller doses induce the
psychotic symptoms. Milder symptoms of transient paranoia
appear in 33% to 50% of chronic cocaine users. 61
Other Problems with Cocaine Use
Polydrug Use
The stimulating effects of cocaine can be so intense that
users sometimes need a downer to take the edge off or to
fall asleep. The most common drugs used for this purpose
are alcohol , heroin, and a sedative-hypnotic, although any
downer will do in a pinch. The combination of cocaine or
methamphetamine with heroin or another downer is known
as a "speedball. " Nicotine is also frequently combined with
cocaine. For reasons yet to be understood , a person who
smokes cigarettes is 22 times more likely to use cocaine than
a nonsmoker. 62
Adu~e,ationandContamination
Fteqoerqol(oc;ainetlseinlhe
In =cent yan the US Drug Enforcement Admin istf>tion
llnitedStates - 1012
(DEA),eporuthatabout80%ofcocainesrirn:lon itsway
intothe l' nitedSUtescon 1>.inedleva mi50le,adang erou,v et -
eriruuy medicin e used lor de-wonning that has been bl.omed
lor a1le.ostonedeath ." Regardl<>0ofthea\,.il.obili1y,purity.
orprice ,, tre<trocalneis•lmostalway,;•dulte.-.ted . The
streetdealerwilloddan:odulterant<ucha,;babyl.oxative
lxta,.e , viwninB,aspirin . mannitol,<uga, . Procaine • (to pi-
cal•n .. the tic), andevrntaicumpowdertolowuthepurity
lrom 80% o, 9()'1;down toappro J<imatdy 60% ...

Fr,quent

lfaoon1>.miruot<ddrugi,injectedintr:m,nou,ly . diluent5
bact<'• , and ·ru .. ,ne put 'ntothebloodotream·,·ruse,
indud eHIV . hepa titi,B,•ndes peciallyh q,a titi,C Theu,e OfWt1tlo •aUdJTmUI'°" Mit ri<..., .. ~o r.....ena eq,e.-,mrnud
of other ronwninated par:tph ema lia, ,uch., ,noning wl,A,..,,;,,,,5 .Jmilll "" ""dl, loWp,lilJ<"',! .9mill1"" ""dl1 1o
straws,c•n•isotr:1mmitinfection. Thehepatiti,C info:- <A,p,u,..,. <lcand,U,0,,1J.Jm,l/'°""'l""""d""al"'dtpt,l,l<,o<'"'
.i,..,,,, .,, "' 1""'1<"'0f'""-fig,,m""°"'""'·fw-~k"""O<dt1i,
tionnt<fo,IVdrugu..,,.isSO'l,to90% inmoo lOlud ie,; d.-.g(rn1<o)
The useo lcoca ne ,,eem,; to:,ggravat<va ' u,cond't'om
especia llyAIDS,byincre .. ing v!nl lo:uis•ndloweringthe
~::::,f, : hit< blood c,lis tha tfightinfection,, known••

Compulsion
Comidering•llthenegati,,.,ronn<etedtoroc•ineu,e-the
expense,the • dn ltaa tio n ,the illegality. th<po<Sibilityof
overd ose . •ndthephy,; ica landpsychologic•l danger,-
whydopeopleu .. cocaine"°rompul , ivelyl

Smokable Cocaine
(crack,freebase,oxidado)

"l coolJ,ttbeartobewber .loud,Jto,mol:, aadrocain,

t":.~1"t1,~;~•"y'.:,(,,"°""'7~u1:.:.:~
Ole ll.r« topaljtli~1omo1row·Yoodo.'1 rlli,,(o°"" t

0-
---~<rrl.-
...
_,,-
Thueare •numberofn, •>omfortheoompulsh'ea><olco- 'l"""'lf Yoodon'ttlii,,(ai,.,.,t nobod~"' .,, tl,'lj arou,,J
caine be<id<> heredi wy •nd rn,ironm ent>l vu lnaa bility 'l""b.tmdcocain,·
Proplea><it
• toT<capturetheextremeint<MityoFtheiniti.olru,h
Although,mokableoocainehad been a round,incelh<mid -
• becaa><cocainechangeothebnln'sneurochemkalbal-
1970.. in thefonnoffreeba,,rocai ne , itwa, eulyinthe
ance(allo,1><i•l . whichm.oke,onemorevulnenbleto
l980,befo,ethe,mobble-a,calneepidemicbegan.Aglut
inten«craving,
ofthepowderfromth<llahuruo,,them.ojo,tr,n,<hipmrnt
• 10avoidthecra,ha/t<rthein1rnsehigh-<hootingupor po int from Colombia al the time, caU><d the price to drop by
,mokingeverylOminut<,during•binge;mo.,cocain< 80%.Dealenmodea,hrewdmarketingdecisiontoconven
i,usedinabingepattem . evenoocale.ofchewing thepowdatoc.-.ck, allowingthem to,ell,ma llchunh . or
• torontrolthe>ymptom,ofamentalilln<><,«peci.olly · ,ocks ."lo rpricn as low ••S l. 3oOperhiLAft<rthatinn ova -
depr=ion tion ,>OUth Floridabeca me thehu bolronv<r<i on l.obomo-

ries and the use of crack spread to the rest of the United
States, supported at first by after-hours cocaine clubs, then
by freebase parlors, then by crack houses (1984). and finally
by curbside distribution. 66
Initially, in the New York City area, three-fourths of new us-
ers were young White professionals or middle-class youths
from Long Island, New Jersey, and Westchester County
(mostly freebase users). Because of the low per-unit price of
crack, however, the use of this form of freebase soon spread
to less affiuent neighborhoods. It was estimated in the late
1980s that 10,000 gang members were dealing cocaine (and
other drugs) in some 50 cities across the United States. 18
Crack is cocaine. Freebase is cocaine.
They have been slightly altered, chemically,
to make them smokable.
Some attributed the spread of crack to media attention.
Others thought that the basic properties of smokable cocaine
were the cause of the epidemic. The fact that the use of
crack remains a severe problem despite vastly curtailed
media coverage speaks to the addictive nature of smokable
cocaine rather than to the media attention.
By the 1990s the drug was vilified as the main cause of soci-
ety's ills: gang violence, AIDS, crime, and addiction. Then
the epidemic began to wane. At the beginning of the twenty-
first century, an older, smaller core of crack abusers had be-
come entrenched in society, many in lower-income groups.
In one study about two-thirds of the women seeking treat-
ment for addiction were 35 or older, and 42% had been using
for 11 years or more. 67 Although three or four times as
many cocaine abusers snort or shoot the drug rather than
smoke it, 70% of those actually admitted for treatment are
crack smokers due to the intense compulsive nature of the
drug. Users seeking treatment for crack use has dropped
dramatically in recent years. 67
Uppers 3.17
The crack cocaine in this close-up is off-white,
but the color can vary widely depending on
diluents or the substance used to alter the
cocaine hydrochloride to freebase cocaine,
such as baking soda.
Courtesy of the U.S. Drug Enforcement Administration
I
Pharmacology of Smokable Cocaine
In the early 1970s, South American cocaine lab workers real-
ized that cocaine paste, an intermediate step in cocaine
refinement that contains more than 18 other chemicals from
the coca leaf, could be smoked without destroying the eu-
phoric and stimulating effects. Chemically, the cocaine in
paste is freebase cocaine. The doughy, off-white substance
also contains such chemicals as kerosene, sulfuric acid, and
sodium carbonate. Historically, people in the middle- and
lower-income classes usually smoked it in tobacco or mari-
juana. When smoked in a marijuana joint, it is called "ba-
zooka," "basuco," or "pasta." The effects are similar to
snorted cocaine but more intense and immediate.
of
"A~er a few minutes intenseenjoqment, theq developed
anxietqand vehementwishesto continue smokin9,leadin9to
repeatedor chain smokin9. When the~ run out of 'paste,' the~
trq to obtain or buq more in a state of compulsiveanxietq.The
userdoes not sleep, has no appetite, and his/heron/~ wish is
to continue smokin9. Some patients from the verqfirst puffs
experienceperceptualdisturbances(visualhallucinations)."
Journal of Psychoactive Drugs , 1992c;s
For a number of years, this pattern of use diminished, but in
recent years, the practice has exploded in South America,
particularly Brazil, due to a new cocaine-derived drug called
oxidado, also called "oxi" or "rust." It is cheaper per hit
than other forms of cocaine and is easy to make. It has been
around for more than 20 years (formerly called "basuco"
and "pasta"), but the renewed interest by authorities was
prompted by its appearance in more-affluent parts of Rio de
Janeiro and Sao Paolo and because Brazil is host to the 2016
Olympics. In Rio Branco, Brazil, a city of 320,000, it is esti-
mated that there are 8,000 "oxi" users, or one in 40
people. 68A,688 The mental effects seem to be more debilitating
than those from cocaine hydrochloride or crack. The spread
of the drug could also be attributed to excess publicity and
 :5.18 CHAPTER 3

hyping of the dangers of the drug. This is similar to alarm-
ism by the media concerning the crack epidemic in the
United States in the 1980s.
Freebase (a solid form of cocaine suitable for smoking),
involves dissolving cocaine hydrochloride in an alkali solu-
tion and heating it to create pure crystals.
"Cheap basing" or "dirty basing" involves dissolving co-
caine in a solution of baking soda and water and heating it
until crystals precipitate out. This method does not remove
than cocaine. They are not. Crack and freebase are just dif-
ferent methods to make cocaine smokable. Paste cocaine is
also considered a form of freebase. According to users,
crack is more addicting because it induces a more powerful
craving.
"It tastes like more becausethat is all ~ou want-more.
Not like if ~ou smokea joint. ~ou'rehi9h. Youain't lookin9for
no more, but this, this is a trip becausethis little bitt~ thin9
that costs $20 is 9one in three minutes, ma~be five."

I
as many impurities or residues as freebasing, so contami-
nants like baking soda remain. The chunks of smokable
cocaine made by this method are called "crack" because of
the crackling sound that occurs when it is smoked, or "rock"
because the product resembles small rocks.
The converted freebase cocaine, made by either the "basing"
method or the crack method, has four chemical properties
that make the drug more attractive to users.
• It has a lower melting point than the powder (98°C vs.
195°C), so it can be heated in a glass pipe and vaporized.
Too high a temperature destroys most of the psychoac-
tive properties of the drug.
• It reaches the brain faster because it enters the system
directly through the lungs.
• It is more readily absorbed by fat cells in the brain,
causing a more intense reaction.
• Users get a much higher dose of cocaine in their sys-
tems over a short period of time because of the very
large surface area of the lungs (about the size of a football
field).
In addition to the names "crack," "rock," and "freebase,"
smokable cocaine has also been called hubba, "gravel,"
Roxanne, "girl," "fry," and boulya. There is a frequent
misperception that crack and freebase are different drugs
36-year-old female recovering crack user
Effectsand Side Effects
The effects of smoking crack are similar to those of snorting
or injecting cocaine; but because smoked cocaine reaches
the brain more quickly, the effects and the side effects seem
more intense. The bad news for crack smokers is that about
50% of the cocaine is lost to the air when smoked in a ciga-
rette and about 75% when smoked in a glass pipe, so more
cocaine must be smoked to achieve the same effects gained
from injecting. 68 c Smoking and IV use produce similar blood
levels of cocaine; but because the drug is so short acting (15
to 20 minutes), continued use is necessary to keep the brain
reacting. It is easier and less painful to maintain a high by
smoking rather than by injecting.
Smoking crack produces a rush that lasts as little as five to
10 seconds and a subsequent euphoria, excitation, and
arousal lasting several minutes more. After five to 20 min-
utes, these feelings are replaced by irritability, dysphoria (a
general feeling of unease), and anxiety, which drive the user
to smoke again to try to recapture the high.
The physical unwanted side effects of smokable cocaine
include thirst, coughing, tremors, dry skin, slurred speech,
and blurred vision. As use becomes chronic, chest pain, sore

Cocaine
Absorption
0
500

E
a; 400
CL

E -- Intravenous
-- Smoked

!a;
C
300
--
--
Nasal
Oral
"[§
200
8
0 This graph shows the plasma levels of cocaine
after equivalent doses were taken through different
] 100 methods. Whereas smoking gets cocaine to the
brain slightly more rapidly than Nuse, injection
0:: puts a larger amount into the system at one time.
0 When coca leaves are chewed, peak blood plasma
0 60 120 180 240 300 levels are about one-fourth to one-eighth the levels
Minutesafterdose obtained by smoking.

NIDAResearchMonograph99, ResearchFindings on Smokingof AbusedSubstances,1990


throat, black or bloody sputum, hypertension, weight loss,
insomnia, tremors, and heart damage can occur.
Some of the other, more unusual physical side effects
include:
• crack keratitis, or abras ions of the eye due to the anes-
thetic effects of cocaine that make the user unaware of
damage caused by excessive rubbing of the eye
• crack thumb and crack hands, caused by repetitive use
of butane lighters to heat up crack pipes; a callus builds
up on the thumb, and the hand suffers mu ltip le burns
• superficial crack burns to the face and hands from the
small torches used to melt rocks of crack or freebase in a
short glass pipe
• severe body burns that result from the ether exp loding
during the freebase process
Unwanted psychologica l effects of chronic use include
paranoia, intense craving, h igh-risk sexual activity, antiso-
cial behavior, attention problems, irr itability, drug dreams,
hyperexcitability, visual and auditory hallucinations, depres-
sion, and cocaine psychosis. 69 ,70
Respiratory Effects
Inha ling th is extremely harsh substance can cause chest
pain, pneumonia, cough, crack lung, and other respiratory
complications, including hemorrhages, respiratory failure,
and death due to the drug's effect on the medu lla (respiratory
contro l center) of the brain. Crack lung is a relative ly new
syndrome defined by the pain, breath ing problems, and fever
that resemble pneumonia. 36 Many crack users smoke the
tarlike black residue in crack pipes, which overloads their
breath ing passages and makes it difficult for the lungs'
norma l clearance mechanisms to function. The result is
black or dark brown sputum. 71 The already comprom ised
res p iratory functions are further aggravated because the
majority of users also smoke cigarettes. Irritation, destruc-
tion of mucous membranes, and lung cancer are often conse-
quences of this combination.
Polydrug Abuse
The intense stimu lation caused by smokable cocaine in-
creases the potential for the abuse of depressants, especially
alcohol.
"Crackwas m~ dru9of choice. I wouldhavea drinkto mellow
m~selfout. If the drinkwouldn't do it. I would90 9et me some
heroinand snort it. It would make me come down, but it would
be a wholedifferenthi9h and it wouldmakeme sic( becauseI
don't do heroin/"
36-year-old female recovering crack user
Polydrug combinations are hard to keep track of. The same
term might have two different meanings. Some smokers
combine free base an d marijuana in a com b ination called
"primos," "champagne," "caviar," gremmies, "fry daddies,"
"cocoa puff," hubba, and "woolies." Users sometimes mix
crack with ketamine or PCP in a nasty mixture called space
Uppers l.19
basing, "whack," and tragic magic. The addition of freebase
cocaine to smokab le tar hero in makes a smokab le speedba ll
called "h ot rocks" or Belushis. Crack or coca ine hydrochlo-
ride is used with wine coolers for an oral speedball known as
a crack cooler.
Overdose
"A friend was freebasin9heavilq,and he started9oin9 into
convulsionsand throwin9up blood. It was real awful. I was
real/~scaredand I thou9ht he was9oin9to die. Me and
I
m~ other friend, we just kept freebasin9
. .and then when
he came out of it, he started freebasin9a9ain."
l 6-year-0ld female recovering crack user
The most frequent symptoms of overdose are mild: a very
rapi d heartbeat, hyperventilation, a sweaty and clammy
skin sensation, and a feeling of impen d ing deat h . Most
people survive, and on ly 2% to 3% die annually from a
cocaine overdose. 54 Deaths result from cardiac arrest,
seizure, stroke, respiratory failure, and even severe h ype r-
thermia (extrahigh body temperature).
Other Consequencesof Crack Use
Economic Consequences
Crack dealers increased their revenues in the 1980s by using
the most successfu l sales strateg ies of a free-enterprise sys-
tem: reduce the price, increase the sales force to cover the
territory more efficiently, encourage free trade to avoid tariffs
an d impoundi ng, and create appealing packaging to make
the p roduct attractive to a wider segment of the popula-
tion .72 Oxidado's popularity was in part due to the p rod -
uct's low price.
Crack is not cheaper th an cocaine hydroch loride; it is just
sold in smaller units . One gram of cocaine hydrochloride,
the standard street quantity, goes for $50 to $100. By com-
parison, one-tenth of a gram that has been converted to
crack or "rock" sells for $10 to $20, a manageab le sum for
teenager's budget but almost twice the price of cocaine hy-
droch loride when figured on a per-gram basis. A h it of ox i-
dado is just $ 1 or $2. The economics of crack cocaine created
mo re dea lers and increased the availability of the drug.
Dealing creates and cultivates an addiction to the money
and the lifesty le that comes with dealing .
"I (now it's jive. I (now it's ne9ative
. I'm trappedin somethin9
here. But I'm used to the mone~.What else can I do? You
9onna send me to McDonald's?A~er I'm aeneratin9this kindof
mone~ever~da~. I can't90 backto McDonald'sfor $8.50-
what is it?- $8.75 an hour toda~. whichis still insultin9
."
16-year-old crack dealer and user
With more than 100,000 gang members in over 1,000 gangs,
Los Angeles has had the nick name "gang cap ital of America."
The gangs include bikers and white supremacists as well as
African-American, Mexican-American (Sureflos), Italian,
Russ ian, Asian, and Cuban ethnicities.
 3.20 CHAPTER3
Drug Gangs
"Collaboration
betweenU.S.9an9sand Mexico-based
transnationalcriminalor9anizations(TCOs) will continue
toincrease
, facilitatin9wholesaledru.9tra(Fckin9
into and
withinthe UnitedStates."
1
National Drug Threat Assessment , U.S. Depanment of Justice
More than 15 U.S.-based gangs have ties to the TCOs in
Mexico, conspiring together to traffic wholesale quantities of
I
not only cocaine but marijuana, methamphetamine, and
heroin as well. The most powerful are the Surefios, Hispanic
street gangs that are active in Southern California; most are
loyal to La Erne, the California-based Mexican Mafia. Other
gangs include the 38th Street gang from Los Angeles and the
Texas-based Barrio Azteca prison gang as well as the more
established Bloods, Crips, andJamaicans. 18
Cocaine-related arrests account for 42% of all U.S. drug ar-
rests. 73 The Department of Justice estimates that there are
785,000 gang members in the United States. Other coun-
tries, such as Mexico, Colombia, and even England, are also
plagued by drug gangs. 18
Although a handful of younger dealers buy new cars and
"bling" (expensive jewelry) to show off their wealth, the ma-
jority of small-time dealers make just enough to support
their own habit. On August 3, 2010, the federal penalties for
possessing or dealing crack cocaine were equalized with
those imposed for possession of powdered cocaine. Because
crack is more widely used by minorities, there were claims
that the earlier laws were influenced by racism.
Social Consequences
"ItseemslikeeverqtimeI wouldhit the pipe,mq dau9hterwould
saq, 'Mommq.'And so I wouldsaq, 'Whqareqoubotherin9
me?' It real/~made me craZ1f. I mean, m~ son, he would just
pick on thin9s and make noise or somethin9just to bother me
becausehe knewthat I wasdoin9this."
32~year--old recovering crack user
Because of the compulsive nature of the drug, addictive use
of crack has devastating social ramifications that include
high rates of child neglect, abandonment, and abuse by
more single- and even no-parent families and an increasing
number of burned-out grandparents who care for their
crack-addicted grandchildren. Addiction has led some
women to trade sex for crack.
"It'stwo t~pes of women usin9 cocaine. One's a 'tossup'
[ a woman who trades sex for crack]. The~'re the ones who are
downthere. Theqdonelosteverqthin9
theqhave.Theqhaveno
self-respect. Me and m~ sister,we'd worka brotherin a minute
to aet hisdope. Oncewe9ot hisdope- 'Go on, aet outta'
m~ house.' Me and m~ sister, we paid our rent, we paid our
utilities
, we fed ourchildren,we keptclotheson theirbacks,
we keptthe houseclean.We had not lostourself-esteem.
We had not hit rackbottomqet."
24-year--old female recovering crack user
R
A leaderin the NuestraFamiliagangis handcuffedby LosBanos
policein Californiaas part of a sweepof a gangthat has ties to
Mexicandrugoperations.
0 2011 RichPedroncelli.Associated Press.
In a study of 283 women who exchanged sex for money or
crack, 30% were infected with HIV.74 The high rate of crime
associated with crack use has had a major impact on the
families of users in some inner-city communities and is re-
flected in the high rates of imprisonment, violent deaths, and
child abandonment by addicts. Approximately 53% of all
prison inmates come from a home where no father is pres-
ent; 70% of incarcerated juveniles come from single-parent
homes. 75
Cocaine vs. Amphetamines
The physical and mental effects of cocaine and amphet-
amines are very similar, but there are differences.
Price A heavy user of cocaine spends $100 to $300 per day,
whereas a heavy user of amphetamine spends about $50 to
$100 a day. The costs are more comparable if the amphet-
amine user has developed a very high tolerance.
Quality of the Rush or High Smoking or injecting cocaine or
methamphetamine intravenously produces an intense rush
followed by a high or euphoria. Drinking or snorting either
drug produces the euphoria, but cocaine delivers a more in-
tense rush. It is hard to measure, but the majority of users
claim that the rush and the high from cocaine is greater
than that from amphetamines; however, amphetamines
generate greater amounts of prolonged energy.
"Cocaineis more euphoricbut not as intense as speed.
Speed is Yer~intense, and ~au're9oin9, 9oin9, 9oin9.
The coke is shorterlastin9, but the craYin9sare much worse.
When I wanted to do speed, it was main/~because I wanted
to 9et thin9sdone. I feltspeedhelpedmeperform.And the
cocaine,I felt likeI had absolutelqno choice.Cocaine
took me down real fast and real hard."
Crack cocaine smoker
Duration of ActionCocaine 's major effects last about 40 min-
utes; amphetamine's last four to six hours.

Manufacture Cocaine is plant derived whereas amphetamines
are synthetic.
Methods of Use Both drugs are snorted, smoked, and inject-
ed. Methamphetamine is also ingested. Cocaine used to be
ingested in cocaine wine and Coca-Cola. ®
Addiction Rate A survey of clients at one treatment center
showed that methamphetamine users fell into addiction
more quickly than cocaine users and entered treatment
sooner. 76 The slide to compu lsive use is much quicker
from smoking crack than it is from snorting cocaine hydro-
chloride.
Cocaine is more expensive and metabolized
more quickly than methamphetamine. Both
can be injected, while smoking crack is often
considered more euphoric.
Amphetamines
The growth of amphetamine abuse worldwide rose severely
during the early 2000s. It was estimated that in 2012 up to
34 million people worldwide used amphetamines and
methamphetamines at least once, contrasted with 19.4 mil-
lion using ecstasy or MOMA, 17 million using cocaine,
16.5 million using heroin, and 181 million using mari-
juana. 15In the United States, however, cocaine is more popu-
lar (4.6 million used cocaine at least once in the past year vs.
1. 1 million for meth) .19
"UN sa~s seizures of cr~stalmeth and meth pills in Asia reach
recordhi9hs in 2012."
Washington Post, Novem be r 7, 2013
"Police~nd methamphetamineprocessin9operationat
Phoenixhouse."
ABC News , Channel 1S, Phoenix , AZ, November 12, 2013
Uppers 3.21
Headlines about methamphetamines and amphetamines re-
flect the resurgence of the popularity of the drugs and their
expansion into Asian markets. But because all of these stim-
ulant drugs are synthetic, many headlines concentrate on
its manufacture: mom-and-pop or super meth labs, ephed-
rine and pseudoephedrine smuggling, embargoing the raw
ingredients, cleaning up contaminated drug laboratories,
and limiting access to the raw ingredients in drugstores. In
some areas of the world, especially Asia, methamphetamine
ranks third in use behind marijuana and alcohol. Current
I
headlines have also focused on bath salts, which are syn-
thetic, nondetectable methamphetamine-like drugs.
Classification
Amphetamines are known as sympathomimetic agents be-
cause they stimulate the release of neurotransmitters in the
brain that activate our sympathetic nervous system, which
controls our fight-or-flight response. They also stimulate the
survival pathway. Amphetamines are known on the street as
meth, "uppers, " "speed, " "crank," "crystal, " "ice, " shabu,
and "glass. " They are a class of powerful synthetic stimu-
lants with effects that are similar to those of cocaine but
which last much longer and are somewhat cheaper to use .
Amphetamines are most often snorted, injected, smoked, or
taken orally. Smoking methamphetamine has increased in
the past two or three decades because of more readily avail-
I
able street methamphetamine .
Starting with World War II, amphetamines have
been widely used to keep soldiers and pilots
alert and fighting.
There are several different types of amphetamines: amphet-
amine, methamphetamine, dextroamphetamine, and dextro
isomer methamphetamine (the most common). The effects
of each type are similar but the strength and the method of
manufacture differ. There is also a difference in the dominance
of psychological effects versus physical effects.
Crossrops, Bipheramine,® ("black beauties") ,
Dexedrin ~ ("bennies "), and Merhedrine®are
traditional tablet forms of amphetamine. For
the past 20 ye ars, the most common metham -
phetamine is "crystal " merh, which is stronger
than the traditional merhampheramin e. U is quire
pure, with just a trace of residual chemicals, as
shown in these DEA microphorographs.
Courtesyof the U.S.Drug EnforcementAdministration
 3.22 CHAPTER 3
History of Use
Like cocaine, methamphetamine has gone through several
cycles of heavy use. The first began in the 1930s, the second
in the 1960s, and the third in the 1990s.
Discovery and First Cycle of Heavy Use
Romanian chemist Lazar Edeleanu first synthesized am-
phetamine in 1887 at the University of Berlin in a system-
atic effort to find a substitute for ephedrine, a natural extract
of the ephedra bush that was used for centuries to treat
I
asthma. Methamphetamine, a variation of the amphetamine
molecule, was synthesized in Japan in 1919.
The stimulant qualities and the medical applications of
amphetamines were not utilized until the 1930s, when
Methedrine ® (methamphetamine) and Benzedrine ® (dextro-
amphetamine) inhalers were marketed as bronchodilators to
help asthmatics breathe. These drugs were also recognized as
stimulants that could energize the user, counter low blood
pressure, reduce the need for sleep, and suppress appetite.
Physicians prescribed the drugs to treat minimal brain dys-
function, a condition known today as attention-deficit/
hyperactivity disorder. As word of psychoactive uses of the
drugs spread (they could also be bought without a prescrip-
tion), different methods of use arose: pulling the drug-
soaked cotton from the inhalers and soaking it in a drinkable
liquid or chewing the cotton wicks and absorbing the solu-
tion on the gums or simply swallowing it. The inhalers were
sold over-the-counter until 1959, whereas Methedrine ® was
not taken off the market until 1968.
Amphetamines were widely used in pill form during World
War II by Allied, German, and Japanese forces to keep pi-
lots alert for extended missions and to keep ground troops
awake and more aggressive in battle. The Germans dis-
pensed 35 million doses of Pervitin, ®a methamphetamine, to
energize their troops. Toward the end of the war, they experi-
mented with a pill that contained a combination of cocaine
and an opiate painkiller in addition to Pervitin ®to try to cre-
ate a super-soldier. On the U.S. side, an estimated 200 million
Benzedrine ® tablets were legally dispensed to American Gis
during World War II and another 225 million during the
Vietnam conflict. 77 •78
Starting with World War II, amphetamines
have been widely used to keep sold iers
and pilots alert and fighting.
Amphetamines were also used to treat narcolepsy (falling-
asleep sickness), one form of epilepsy, and depression.
Amphetamines were used and abused by students cramming
for exams, truckers on long hauls, and workers laboring
long hours. The fact that amphetamines also induced eupho-
ria and elation did not hurt the drugs' appeal. As early as
194 3, more than half of the pharmaceutical company Smith,
Kline &: French's sales of Benzedrine ® were to people who
wanted to lose weight or counteract depression. It was one of
the first antidepressants available to physicians. 77
Abuse of amphetamine inJapan continued after World War
II, when large stocks of the drug were looted from military
supplies and sold on the black market. Although the enact-
ment of Japan's Stimulant Drug Program in 1951 brought the
problem under some control, amphetamine abuse contin-
ued. 79 Each year there are 1 million to 2 million amphet-
amine abusers in Japan and 15,000 to 25,000 arrests for
dealing and using. The Japanese crime syndicates (Yakuza)
smuggle the drug from China (e.g., Fujian Province),
Thailand, Myanmar, or the Philippines and control the sales.
Second Cycle of Heavy Use (diet pills and speed)
Recognizing the appetite-suppressing properties of amphet-
amines, U.S. pharmaceutical companies in the 1950s and
1960s promoted the use of amphetamine-based diet pills to
a growing segment of society that wanted to lose weight.
Advertising led to huge quantities of amphetamines and
methamphetamines, including Dietamine, ® Nobese, ®
Obetrol, ® Bar-Dex, ® Dexedrine, ® and Dexamyl, ® flooding
the prescription drug market. Worldwide legal production in
1970 was estimated to be 10 billion tablets. 14 In 1970 an es-
timated 6% to 8% of the U.S. population used prescription
amphetamines, mostly for weight loss. 80
"One of the main reasonsthat I was usin9 meth was to chan92
mqbodqimaae.I alwaqshatedbein9overwei9ht . I foundout
throu9hfriendsthat did it that it is a quickwaqto losewei9ht.
and it wasa waqto havethat bodqthat I alwaqswanted."
2S-year-old female recovering meth abuser
The 1960s were the peak years of the speed craze that was
the result of both diverted and illegally manufactured am-
phetamines. The power for the "Summer of Love," one of the
seminal events of the hippie movement, was fueled by the
energy chemicals released by amphetamines.
"For those who come to San Francisco,
besure to wearsome ~owersin ~our hair.
If ~ou come to San Francisco,
Summertimewill be a loYe-inthere."
John Phillips, ~San Francisco, ~ 1967
Starting in 1967 thousands of young people flocked to the
Haight Ashbury neighborhood in San Francisco to be a part
of the "hippie experience," which included LSD, marijuana,
STP, MDA, and particularly amphetamines. That same year
the Haight Ashbury Free Clinics came into existence to treat
the influx of users who had severe physical and mental reac-
tions to the unfamiliar drugs.
"Weactuallqopenedthe clinicdurin9the "world"s laraesthuman
dru9experiment.'We treatedsome400 peopleon the firstdaq
weopened.June 7. 1967, mostlqforamphetamines and LSD.
With the proliferation
of bathsalts, sqntheticdesi9nerdru9s.
and new ps~choactiYesubstances,we are in the midst of the
secondphaseof "theworld"s
lar9esthumandru9experiment.""
Darryl Inaba, PharmD, former CEO of the Haight Ashbury Free Clinics

Congressiona l response to the "world 's largest human drug
experiment" was the Comprehensive Drug Abuse Preven-
tion and Control Act of 1970, which classified many drugs,
especially amphetamines, and made it difficult to legally
buy them in the United States. In addition, prescription use
of the drugs was more tightly regulated. The street market
expanded to fill the need, so instead of buying legally manu-
factured amphetamines that had been diverted, people
bought illegally manufactured speed and "crank. " The purity
rose from an average of 30% in the early 1970s to 60% by
1983 despite the fact that the legislation also put controls on
most of the then-known immediate precursors necessary to
make methamphetamine. 9
The most popular form of street speed was the crossto p .
Also called "cartwheels " and white crosses , these tablets
were diverted or smuggled into the United States from
Mexico. In the early 1970s, they cost $5 to $ 10 per 100 tab-
lets; by the 1990s the price was $1 to $5 per tablet if they
cou ld be found. Today the real thing is rarely available , and
bogus (look-alike) crosstops containing either caffeine or
ephedrine are passed off as poor substitutes.
Weight loss was the main driving force for
legal amphetamine sales in the 1960s.
Amphetamine use for energy and euphoria
were the main reasons for restriction of
amphetamines in 1970 and beyond.
The late 1980s and 1990s saw a resurgence in the availability
and the abuse of illicit methamphetamines, particularly
"crank" (methamphetamine sulfate) and "crystal " (meth-
amphetamine hydrochlori de). Once stymied by the tight
contro l of chemica ls needed to produce illegal amphet-
amines, the resourcefu l street chemists of this era learned to
produce speed by altering common ly available chemicals
meant to treat colds and asthma.
Uppers 3.23
CopyrightRobert A~man, •celebrate"
Third Cycle of Heavy Use and "Ice"
As the 1990s began, a highly potent and smokable form of
methamphetamine, dextro isomer methamphetamine ("ice, "
"glass, " batu, or shabu), emerged as a major drug abuse
trend. By the mid-2000s this type of methamphetamine in its
hydroch loride salt form had become the predominant street
speed widely abused across the United States. Besides its
smokabilit y, greater strength, and longer duration of effects,
"ice" had the appea l of any new fad. It cost two to three times
as much as other street methamphetamines, which is sur-
prising because it can be produced using a very simple and
fairly safe cr ystallization process.
By the mid-1990s virtually all U.S. street samples of meth-
am phetamine seized by the federal Drug Enforcement
Administration consisted of this new form of the drug. It
had a wide variet y of other street names, including "crysta l,"
"crystal meth, " "peanut butter ," "chalk ," tweak, yellow rock,
"glass, " and rose quartz speed.
Severe abuse problems began to surface in many Asian
countries due to "crystal " met h by the mid-2000s. Abuse of
dextro isomer methamphetamine was rampant in Vietnam
and South Korea . It is estimated that two-thirds of all prison-
ers in Thailand are incarcerated for drug-related offenses,
most of them for "crystal " meth-re lated crimes. It is known
as shabu or kakus eizai inJapan , bato in the Philippin es, batu
in Malaysia, philopon in South Korea , yaotou wan (head-
shaking pill ) in China, and ya ba or yaa maa in Thailand,
Myanmar, Laos, and Cambodia. Ya ha, a combination of
crysta l meth and caffeine that is manufactured in Asia (most-
ly Thailand and Myanmar), is taken orally or crush ed and
smoked on a p iece of foil.
The methamphetamine-like drug phenethylline (or feneth yl-
line ICaptagon ®]) is a pro d rug, a substance that is con-
verted by the body into metabolites that are also active
(amphetamine and theophylline). The drug was used as an
 3.24 CHAPTER 3
Armed paramilitary policemen assemble during
multiple raids on methamphetamine drug makers
in Boshe village in the South Chinas Guangdong
Province in 2013. Police raided 77 labs in the area
and seized 3 tons of crystal meth and 23 tons of
raw material. A total of 182 suspected gang
members were arrested. Three thousand officers
wen: mobilized for the raids.
0 20 13 Imagine China. Associated Press.
I
alternative to amphetamines because its card iovascular ef-
fects were less severe. It was used to treat ADHD, narco lepsy,
and depression until it was listed as a potentia l drug of abuse
in 1986 by the United Nations. Phenethylline has been
abused mostly in Arab countries, particularly Saudi Arabia,
in recent years. Illegal manufacturers stamp pills to look like
Captagon. ® Counterle it versions of the drug often contain
regular amphetamines and caffeine. Many news reports cite
phenethylline sales as fueling the 2013-2014 civil war
in Syria.
Current Use
Licit Use Currently, amphetamines and methamphetamines
are used to treat ADHD, narcolepsy, and occasionally
weight control.
Illicit Use Historically, stimu lant epidemics last 10 to 15
years and travel in waves from coast to coast. Due to the
intensity of the high and the severity of the side effects,
amphetamine abuse eventually becomes self-limiting and
the rapid increase in use levels out.
As of 2014 the current epidemic has yet to run its course.
From 2002 to 2012, the number of people admitted for
amphetamine addiction almost doubled; since then the
numbers have declined somewhat. 67 Although the use of
methamphetamine has actually declined in the United
States since 2002, the social and health prob lems remain. 1,81
"/ startedshootin9speed,and I couldn'tkeep9ettin920 bucks
from mq mo~, qou know. I had to eitherstart sellin9it or start
stealin9stuff causeI had a bi9habit.So I wasstealin9cars
and I wasjackin9stereosand I wouldripan~bod~off who9a,e
me mane~just to 9et m~selfhi9h."
17-year--old recovering IV meth user
The profile of the typical user is a White male between the
ages of 19 and 40, although in some parts of the West and in
Hawaii, an almost equa l number of meth abusers are women.
The majority of the known users in Hawaii are of Asian and
Pacific Islander descent. Meth abuse in the Black and Latino
communities has increased.
Meth use has been particularly rampant in the gay commu-
nity. A study of 2,335 gay and bisexual men in the New York
area found that 10.4% had used meth in the past three
months, a rate 10 to 15 times that of the overall popu lation.
After alcohol and marijuana, "crystal" meth is the drug of
choice. Meth is used more often by younger gay men, often in
gay bars, bathhouses, and sex clubs or at "circuit parties,"
which are highly organized events that emphasize sex and
drugs. 82,83 Tragically, the incidence of HIV/AIDS in the gay
community is also extremely high and due in great part to
IV use and the disinhibiting effects of meth. Homophobia,
fear of coming out, and fear of being oneself create emotiona l
problems often preva lent in the gay community, increasing
the tendency to use drugs to suppress feelings.
"As lon9 as I was h19h,and dancin9, or havin9sex, whatever,
I didn'tha,e to think.I didn'thaveto dealwithm~depression.
I didn't have to crin9ewhenevermq mom or dad called and
askedhow I wasdoin9."
25-year-old gay male recovering meth abuser
Methamphetamine Manufacturing
Historically. biker gangs (Hell's Angels and Gypsy Jokers)
controlled much of the street manufacturing and dealing of
methamphetamines. Bikers were partial to the drug, and
there was big money to b e made. The fumes were toxic, and
explosions cou ld and did occur if the chemicals were han-
dled improperly. The foul odors that emanated from the
"cookers" served as beacons to law enforcement agencies in
locating meth labs.
Any local hardware store can supply a street chemist with the
rock salt, battery acid, red phosphorus road flares, iodine, an-
hydrous ammonia, pool acid, mason jars, coffee filters, and
plastic tubing necessary to produce meth. 84 ,85 The availability
of supplies coup led with wide-open spaces to dissipate the
smell led to a proliferation of labs in rural areas. 86
In recent years safer, easier, cheaper, and almost odor-free
methods of producing meth have increased the number of
small-time manufacturers. Meth can be made on a stovetop,

using pseudoephedrine, a semisynthetic version of ephed-
rine. Using the "shake-and-bake" or the one-pot method,
the street chemist can make meth just about anywhere using
an empty 2-liter (L) soda bottle, a handful of cold pills, and
a few easily available chemicals. 87 According to the DEA,
there are now more than 300 ways to manufacture meth-
am phetamine using pseudoephedrine.
Meth varies radically in price from location to location.
Studies have found the price ranges from $2,700 to $5.400
for 1 oz. and from $200 to $300 (average $284) per pure
gram, depending on the locale. Although the price has
increased, the purity has decreased. 89 ,90
The Department of Justice knew that the pseudoephedrine
used to make meth was being purchased in large quantities
and diverted to illegal channels in Mexico. Ephedrine and
pseudoephedrine are manufactured in 8 plants throughout
the world (5 in India, 2 in China, and 1 in Germany). Most
of the illegal meth laboratories were small enterprises capa-
ble of producing only a pound or so of methamphetamine
per day, but those run by Mexican gangs (26% of the total
number of labs and mostly in the West) can cook 10 to 150
lbs. in just two days. The DEA estimates that the Mexican-
run superlabs manufacture three-fourths of the metham-
phetamine consumed in the United States. 85
The illegal synthesis of methamphetamine creates an envi-
ronmental danger due to the chemicals used in the manu-
facturing process even with the newer methods. Labs have
been found in apartments, rented hotel rooms, trunks of
cars---even in tents on public land. Often the "cooks" simp ly
abandon the property, leaving toxins and cancer-causing
agents such as acetone, red phosphorus, hydrochloric acid,
benzene, and lead acetate behind or secretly dumping them
into streams and landfills. There are 5 to 7 lbs. of toxic waste
for each pound of methamphetamine produced. It costs
thousands of dollars to clean up each raided laboratory.
In 2012 the DEA and state law enforcement agencies seized
11,210 methamphetamine laboratories, dumpsites, and man-
ufacturing locations. This is down 50% from 2004, and most
of the busts were mom-and-pop labs rather than megalabs. 91
Uppers 3.25
A member of the Federal Public Ministry (MPF)
looks at drums of precursor chemicals for
methamphetamine manufacture that were seized in
Queretam, Mexico. In another case, they seized
nearly 500 tons of precursor chemicals. Drug
cartels appear to be expanding methamphetamine
manufacture, trying to fill a gap left by the
breakdown of a rival gang.
0 2014 Attorney General's Office. AssociatedPress.
I
Methamphetamine Effects
Routes of Administration
• Snorting causes irritation and pain to the nasal mucosa,
especially when used to excess.
• Intravenous injection puts large quantities of the drug
directly into the bloodstream and causes a more intense
high than snorting or swallowing; however, it often
causes pain in the blood vessels. There is the attendant
risk of infection or disease posed by contaminated nee-
dles. One study in Los Angeles found the rate of HIV
infection among IV meth users to be three times higher
than among nonusers. 93
• Oral ingestion is not very common because it takes lon-
ger for the drug to reach the brain and because of the
extremely bitter taste of methamphetamines. When it is
taken orally, it is often put into an empty gelatin capsule
or wrapped in a piece of tissue .
• Smoking "crystal" meth or "ice" is similar to smoking
freebase cocaine (in a pipe).
Regard less of how the drug is taken, am phetamines last 4 to
6 hours com pared with only 10 to 90 minutes for cocaine.
Some of the effects of smoking "ice" are alleged to last at
least 8 hours, some say up to 24.
Neurochemistry
The use of amphetamines increases the levels of catechol-
amine neurotransmitters (nore p inephrine, epinephrine,
and dopamine).
• Methamphetamine forces the release of these neu-
rotransmitters from the vesicles in the nerve terminals.
• Then tiny pumps called transporters that normally re-
absorb neurotransmitters reverse their direction and
expel neurotransmitters in excessive amounts into the
synaptic gap.
• Fina lly, amphetamines block the enzymes that metabo-
lize the excess neurotransmitters, allowing the chemi-
cals to accumulate and cause continued overstimulation.
 l.26 CHAPTER 3

Surprisingly, the study also found that users' brains were

about 10% larger than normal due to an increase in white
matter, possibly due to methamphetamine-caused inflamma-
tion.95 Many of the methamphetamine-caused structural
changes such as hippocampal shrinkage disappear, but that
can take months or sometimes years. 96·97 Because of these
abnormalities, abstinence-induced depression and anxiety
must be addressed in recovery.98

"A lot oftimesI havetroublewithconcentration.

I
When I reada book,sometimesthe wordson the pa9e
lookliketheq'redancin9around,and I knowthat'sa
directresultofthe meth use. I knowthere'sdama9ethere.
It'ssomethin9that I'm learnin9to livewith."
43-year-old male recovering meth abuser

Studies at the University of California, San Diego used mag-

netic resonance imaging (MRI) to dramatically expand on
Firefighters battle a blaze in a meth lab explosion when the shake- the findings from studies conducted by Dr. Nora Volkow and
and-bake method of manufacture went awry in Union, Missouri. The
Dr. Edythe London, which recognized patterns in the brains
crude new method of making meth involves raw and unstable volatile
ingredients in a 2 L soda bottle. It is putting a heavy burden on many of recovering methamphetamine users that signaled a risk of
bum units in Missouri and other states. relapse. They found that users with a strong tendency to
© 2012 FranklinCountySheriffs Department.AssociatedPress.
relapse had low levels of activity in five different regions of
the brain (right insula, right inferior parietal lobule, right
middle temporal gyrus, left caudate putamen, and left cingu-
late), making it difficult for the subjects to solve two deci-
This last effect, overstimulation, causes the excess catechol- sion-making tasks. 99This implies that those with a tendency
amines to stay in the synapse for a much longer time than to relapse have an impaired decision-making ability and
when cocaine is used. This is the main reason why a meth- find it hard to resist craving until these areas of the brain
amphetamine high lasts so much longer than a cocaine have had time to heal.
high. 28 Continued use of amphetamines eventually causes
long-term and even permanent alterations in the body's
ability to produce these vital neurotransmitters.
It takes up to two yearsfor the brain of a heavy
meth userto repair itself ... but there still are
In animal studies, norepinephrine levels were still depressed differences.
three to six months after cessation of heavy use .9 Dopamine
levels also remained depressed after cessation of use.
Another study comparing former methamphetamine abusers
with a nonusing control group showed a 24% decrease in do-
pamine transporters, consequently causing a disruption in
movement control and feelings of pleasure. 94This leads users
to rely on artificial stimulants to keep their dopamine and
norepinephrine activities functioning in order to feel normal
but not high. In other words, prolonged amphetamine
use, in and of itself, alters brain chemistry in a way that
increases craving. The more methamphetamine or cocaine
that is used, the more that is needed.
In a study of 22 heavy users of methamphetamine, research-
ers found disturbing evidence that the brains of heavy users
had lost an average of 11.3% of their limbic gray matter,
particularly the hippocampus, cingulate gyrus, and paralim- Imaging studies of the brains of recently abstinent methamphetamine
bic cortex-areas associated with craving, emotions, mood, abusers show neurochemical changes that contribute to the relapse
and memory. 95 potential of meth users. Specifically, the amygdala-the emotional
center of the brain-is highly activated (red area); simultaneously, the
prefrontal cortex-the thinking area of the brain that helps control the
"Mqmemorq,oh mq God, I havenone.I couldn'teventell qou amygdala--exhibits very low activity (blue area). This means that
what I did fiveqearsa90,and that'ssad. Mq qounsestkid is when craving is triggered in the amygdala, the newly abstinent meth
9oin9to be 15 thisqear,and I can't tell qouanqthin9abouthis abuser's ability to control that craving is impaired.
lifeotherthan little9limpsesofit, littlepiecesofit." Courtesyof EdytheLondon,Ph.D.,UCLA
43-year-old incarcerated female meth abuser
 ----
- ~ --
'. '~--~
i~•··
PhysicalEffectsandSideEffects
Initial phy,iological effects ol ,m.a!l-to-mod<r>t< dos,s
of •mphru.mines includ e vn.-. energy . incrus,d h,on
r.1t<. r.li0<dbodyt<mp<ratuu,npidtt<piration,high<r

.
bloodpre .. uu,diU.tionoFbronchi.olv«><ls ,:an d•pp<tit<
suppuHion

"/-U~t"""''/'«da ntlfiiihtaft,,doi~ jti...,..l,J

[iffa•ina,dil,l,n,,lc., hich>em<propl,comp,,r,.,;th
,,...,if,,IUlfJ<And'r"'rh,artpow,ds.a.,Jl ·.,,,, np,,,pl,
octuo!Ljpm,oot~omha>in/jtoomt1Ch,pwLM~h,art.,,,.IJ
pow,J.and/...,..l,J,w,alandf!.tru,;h,..,..Jdp,m, antl
tht•l"""'ld;i,,tb,.,11j hiyl ,,,,,ffl·

n,., 1,,l,,..,.dtof4""\! -"""'""~""""'°""ri"'

.,.1M,.,..,.1ti
• 4n,.liojwld«prn,J""'l,""'"'dot<n<of<aS«oJ
The high <n<rJ!yandthedrug -inducedronfiden<:<fromth< •..,. 1,..,.c1t•an.l«>nr«<>t"!ttl ,,o;, IJ'Sy..,.,..,l "' l..dtood
• mphe wn in<>•r< twoofth< ru,o mwh) · >thlct<>u « th<m l>rnul,, w,xl, k,..,,mal • .,,~.,,,.-.,,~....,.,,.,,.,...,1,'"4!
Th< anoncctic (w,ight -lOH) eff«a m, th<""'°" why some !"f'l'l,Noadwo.-al,~""'~ar.l,u<d ,ag.l>ltt,l;ag.....dla/ttl<dg...u
wr<stl<n , gym=ts. •nd othu •thl<le5 who n<M to meet c,,_,,.,..,....,_...""""'....,
e<crt>
inw<i ghtrequincmen<>us,th<m
Methamphetamin, obuserogoonbingn , or "rum, • ,taying
up /or). ~. or 10 day, at • tim <, putting•><V<Cr<>trainon
th,irbodies. part irullllyth ,cnd iovasc u b randn<rvou.s, y,- inginronvul,iom , h)'J><Tth<rmia,strok< , cardiovascular
t<m>. Duringth<><rum,u,u,;expendth<ir<xces<<n<rgyin overucitotion , androll>p><
an)·w•ythcyc:an -- dm<ing,<>«rci,ing,diY>o<mbling•cu,
OTpoin tingth<hou « ·1,hot"""',p,,d"""' a/'1 in<M<diat<~ li.d a ><inlf,
App,,m,t!lj, '"~ O,art,wpp,d b<a"'\9
anti ti,, /'<"""
/....,w;1h""'~""""jch,,t.l _,,,,.,,al ,o«,,,./
l,l.,,:1-a.,d
- bl.,f!.tnatdoi, b. t ldidnt ,topu wig.·

\l."ithdr-.w•l From mctlamph<tamin« and rocoine coUK>

phy,ic.:t • nd <motional depu .. ion . <Xtmnt irriability .
nen,ou•n«•, • n<rgi.,.. :mh,doni.o,andcravi ng

Tolenntttoamph<t • min«ispronounc,d.Theu. ual d<»<

Mctlumphetamin <• bu0<ismor<pr<Vilrntinwom<n,un -
fOT•prescrib<d•mphru.m in , medicotion,uch uAdd,n ll•
lik<th<grndudi•trlbution!ittnwithoth<rdrugsof • buo,c;
is 13 to JO mg per day, buu long -term n><Tmight ak , ~.000 mo,t or< in the ir childbaring yur,_ Meth u« during pr<g•
mgor 3 gmover• H -hourp<riodduring •"•peed run ." Th is
rumcy significant ri,ks to both mo ther and fetus • nd
ut<ndedu,.e(ort h<u«oft. rg<q1Untitie, ) l<adstoutncm<
ro"'idenbl , con«qurnc:,,;tothebab)' ',p h)~iail • ndm<nl.al
depr<S<ionandl<tlu.lJ!Yb<can>< th<<Tl<IJ!)'n<urotnmmit -
devdopmrnt •ft<r binh . Th< damag, con stem from th<
t<r, la veb«ndq,lcted
di1tct effects of the dru g•• wdl u from the lifestyle
long-tumu,.ec•ncouS<C,lttpdeprivation,h<>rt•ndblood ron><qutntt• of m,th addic6on, ,uch u m.alnulrit ion ,
.,..,,.,ltoxkity,:and-ere1111.lnutrition.Th, blood v<>«I dom ,. ticviol ,nc, ,child• bus,,and infectiomfromrontam -
toxid tycon can><utemiv< da mag< toc<r<br> l, ..,..,i.,r< - inotedn « dl<,
,ultinginmul tiple•n <ury,m>and ,tro k<>.Ov<r th<long
tmn , theu « rc•n<xperi<r1ceh< • ct • rrhythmW , po"ibly
cou«dbyh<•nmu,clel , oion,. ' M•lnutri tion.cr.t,ingofor • irriabltbaby,yndrom, , whichindud"'nrono l.alintol -
sw«tfoods.poordenalh)'giene,= 1'r<orald ehydr>tion, ,r:,nc,tolight•ndtouch ,ttt mo ro.mu,cl e roordi n.otion
and th< cold um -l<Khing dfect, of amph<tamint OV<ru>< problem>, a bnormal r,ll,xe,, ,ucking a nd , w,llowing
oFtrnr<oultindi.,•ocdgums•ndrott<dtttth,knownH probl<m>,>nddisturbed.t«p;mor<oft<nm,th~po,,d
"muhmouth. " On,ofth , confirming,ign, olam ph<tamin< nron.otes, xhibitlowa • rou,il,higherlcth.olJ!Y. • ndmor<
•bu«i>•uniqueprnunofpoordrntalh,..lth. '"' ""'"thanotherint. n <>'°'
lf•U><Tlu.sn otbuiltup •to l, ra nc:<.isu nu,ually.,nsiti, ..,, • pr,mlltur<ddiveryandrong<ni ald<f ormities(dub
OTtak<>•wryl • 'l,rmount.•noverdos,canocc,_r,sult - loot•ndlim b•bnonrut liti<>)
 l.28 CHAPTER 3

• risk of placental separation and hemorrhage, potentially
lethal to both mother and fetus
• intrauterine brain hemorrhage and stroke
• increased risk of HIV and hepatitis B and C infection
Developmental risks of methamphetamine-exposed
include:
• growth and developmental delays
• learning disabilities
Excessive use of amphetamines or methamphetamines can
cause amphetamine psychosis; symptoms include halluci-
nations, loss of contact with reality, and pressured speech.
These symptoms are almost indistinguishable from those of
true schizophrenia or paranoid psychosis. The ability of
methamphetamines to release excess dopamine accounts for
infants
most of the symptoms. Conversely, psych meds that are used
to control the symptoms of schizophrenia limit or block do-
pamine release . The amount of amphetamines necessary to
precipitate a psychosis has been the subject of several inves-

I
• increased incidence of ADHD
• increased risks of rage disorder
• greater incidence of SIDS101A, 102
A study of 406 children born to 153 methamphetamine-
abusing women found a reported disability rate of 33%. 103
Mental and EmotionalEffects
Amphetamines initially produce a mild-to-intense eupho-
ria, alertness , sexual feelings, and a sense of well-being
and confidence. Prolonged use can cause irritability, para-
noia, anxiety, aggression, mental confusion, poor judg-
ment , impaired memory, and even hallucinations induced
by the unbalanced neurotransmitters .
Amphetamines release neurotransmitters that mimic sex-
ual gratification and are sometimes used to augment sexual
activity-particularly in the lesbian , gay, bisexual , and trans-
gender (LGBT) community-and by those prone toward
multiple partners or prolonged sexual interactions. The
rapid development of tolerance and the depletion of neuro-
transmitters, however, often cause an eventual decrease in
sex drive and performance. For many users the rush from
shooting or smoking methamphetamine becomes a substi-
tute for sexual activity.
"I didn't reall~!JOout with an~bod~whenI wasusing.I chose
the drugsoveran~girl.an~time.If I askeda girlout and she
told me to meethersomewhere . and m~ dealertold me to meet
him at the sametime. I'dgo with m~ dealerand tr~ to score
moredrugsratherthan go with her."
19-year-old recovering meth abuser
Aggression caused by excessive methamphetamine use de-
pends on the dose, the setting, and the user 's pre-existing
susceptibility to violence. Increased suspiciousness, para-
noia, and confidence leads to misinterpretations of others'
actions, often resulting in violent reactions . Taken to ex-
tremes, prolonged use can result in violent, suicidal, and
even homicidal thoughts .
"I couldjustgo off on m~girlfriendwhen I was high. I would
get superparanoid. I hit herso hard I bruisedm~ hand."
32-year-old meth abuser
This tendency toward aggression is tied to increased inci-
dents of child abuse and neglect. In Oregon, where meth use
is high, 80% of child abuse and neglect cases were associated
with meth use. 103
tigations. Early studies reported cases in which a mere 55 mg
precipitated a psychosis, but most often it takes 2,000 to
5,000 mg for others to reach that point. Half of the users in
one study experienced psychotic episodes within two years
of beginning use , and half after 10 years _77
"Ijust got so sickof it. ~ouknow. just beinghighfor so long. It
just messesup ~ourmind. I oncesta~edup for 23 da~swith no
sleep- not one hourof sleep. not one winkof sleep.When ~ou
sta~up for that long. ~ou'rejust likea pileof mush.Your brain's
just nothing.~ouknow.You can't eventalk,And it just doesn't
evenfeelgood. I don't want that feelingan~more."
17-year-old recovering meth abuser
Heavychronicmeth use can inducea
psychosisthat is hard to distinguishfrom true
schizophrenia.As abstinencecontinues,the
psychosisshould disappear.
The first notice of amphetamine psychoses occurred in the
late 193Os shortly after the drug came into common use.
More cases were noted during World War II and in the 195Os
and 196Os, when amphetamines became the drug of choice.
Amphetamine psychosis from excessive use and the severe
depression that often accompanies withdrawal of high-dose
intravenous use or heavy smoking of "ice" is usually not
permanent .
The disturbed user usually returns to a semblance of nor-
malcy after the brain chemistry is rebalanced, usually within
a few days or weeks, though some experience cravings and a
lack of energy along with depression and psychosis much
longer, especially if the user had a pre-existing mental condi-
tion. 104 Because extended use can also damage nerve cells, a
number of mental and emotional changes in long-term users '
brains can last a lifetime even without pre-existing mental
problems. 105
Dextromethamphetamine ("ice" or "crystal") stimulates
the brain to a greater degree than the other amphetamines
and methamphetamines but stimulates the heart, blood ves-
sels, and lungs to a lesser degree. The decrease in cardiovas-
cular effects (up to 25% less than that of regular "crank")
fools users into smoking more "ice" because they do not feel
the toxic effects in their bodies. This results in more "tweak-
ing, " or severe paranoid, hallucinatory , and hypervigilant
thinking, along with greater suicidal depression . The expe-
riences of detoxification clinics over the years have shown
that detoxification from the mental and psychotic symptoms
olexcu,.iv,"ice"uS<11,n.ially11ku.,.tr1ldayslong,,than
drtoJCifyi.ng&omr<j!Ubrmtthlmphttomlnt abusc

Amphetamine Congeners

~fol.tAOHD..,..,_lolM9'1'1wioDl>o>ltcr'J"'li-

~:..~•;:a:;nt.'~~~..t:r.t'
,tcrol,j,..,.J,a{oitio......,.,...ftH~io-'.lw,,,L·
--~ l. -ll , »U

Whm prescripOon use of ampht11mlncs .,.,.. KV<,dy

limi~bykdtnllcglsla-.physlclans1unwdioampht1-
:unin<cong•"''"'°"""'t'nlalncondldonl(RIAlnlyADHD
ondobot,ily)lhothodp,,,v\ow.lybttnm,01<d"1lhampbd-
ominn.Ampltfflmln<«>nc<n<r1ar<:11lmubn,dn,pthot
arechemlcallydiotimU1,lnnpharmacolop:ally«lat<dto
amph,wnine,andproduamanyofdtc .. ntc<IT«ubut
arenotao>lronK, Concemsugardlngpottntboli!lmulant
druR•buS<lnpot!enlflfUtedw!1hthtstcong<nnshlvte
b<m l<mper<d by .. -. .. 1midlts th11 found minimal abuse
but onlywhenuscdunder appropNlttm<dlc:al supcn,l.<lon
mddosag< .... Asw!thmanydrup,ltl11h<,xc..,,lnappro- tomogr.ophy)=n,,iopinpointbnolnoctlvlty st,,inlf)ing
pri.11<,ordiv,rt<duS<thatoau..,problem 1,a llhough0<r - AOHD. His d inic <nmin<S lhe br:ain oeansofsuspect<d
ta!ndietdrugs(fm-ph<n)c:auseddangeroushtandamage AOHD clien<> before and •fter using mtthylphcnldatt to
fromu,.,,.,m al prucrib<doS< ."' ,-.lidateadiagnoois ."' Dr. l(enncthBlumhuld<:r>IUlcd1pt •
cific g<n<S lhot con-tbte with AOHD •nd rea,mrncnds tlvit
ADHD,Methy!phenidate(Ritalin•), gcnctictestingb<donetovalid..ltc a diagnoois ofADHD. '"
andConcerta• MR!>1udiesofl5lchildrrn WhAOHDfoundthat I.hell'
Mcthylphmlda1<:(IU11lin")t1 1h<mootwldely......iamphrt- ccncbrwm "'= 3.H sm.aller lhon !hoeicin • control group,
amin<"""'l"ner ,ltbp,-..cnba:111boo.h1moodekn.torand ...-tu1ttheundcrlyingwlti1<1ru111<r-6'11,lt0l.The11!Wler
auntrner1tfoi butlllOSlofienk II pr,:s<tlba:Ifo,- bni.ndidnotsignlfylownint<lligm,ce. " 111'0ncof tht
atttntion-ddiclllhypmictMty disorder. Amphe11mir>a 1UCh 11Wnddici.ts...,.intbca,cutiv,,amuolpanol1hcbnln ;
;:~· ....i [)c,r.edrtn,e• ... also widely plffCl'ibed fo,- palimts..-.:rcind6ciat1lnalloatinc1hetraumt1on. "'
Oth..-T<:S<aJt:hindicateslhotina11<nliv,hehoriormlghthe
ductnlimitsonwoningmemcr,;<mpb,.iv.ngthenctdto
DiagnmisofAOHO constantly,~--· theasswnptil,noaboutthecausesand
fut.foiAOHDoftenrdyon1diacnmtlclr11..-.iew;and thtniolor;yofADHD. ''" ltwilltakemanyyun;ofaddl11onal
bttDIHnooplicitdlljnolllcttstttiSll ,«>n tJtnu•y T<:S<aJt:htoaccuntelydiagno5<ADHDanddetenntn<the
sllJTDIUldiJo&theUlfflt1ndth<5<"fflt)'oflhlsdbonlcr mostd£ccm-c1ra1mm1.Tbenthtque,.tic,nsoluuuncn1
mntinues. - Ditgnooll ispanlculatlydlfficult in early comttotht fon. ror.- =nstht ue of medications
childhoodb<aiuscOlheroondillonscanca,...manyoflh< 101rn1AOHOffDWns~bu1com111011 .

....
.. ,.,, symptoms. Foi •xamplo, lnanmtion olt<n """'"
amongchildTtr1wilh1lowlQ11-ll11!hoeic..-ilhhJ&h
intelligmco,..t,o.,.placedlnundtm!mulatingcTWbun- The~Cta,.,iji,-<fO.-(ICO-JO)of1he
mmu..Othtr....,.rch>hows1hantXC<M1.-.fidgfli1111by
hypcnct;...• kids b not mnnmglas movcmen, bu,•~,., ,,.,,..
World lkallh Oipr,iz:ation (WHO) claoilics ADtto Ullo

hclpfocu,on•pr¢blemuhond. '.._,.. 1.hypeooncticdisordcr

To obuin mort·prtclsc diagl>OHI, AOl!O specWIIH, lnclud - l . disturbanceof:activity•nd•Uer>tlon
ir>RD,. 0.niel Amen, uS<va!'loUf b,-ln lmag!ng tcehnlqua, 1. hyperkincticconductdisorder(which!ncludc ,
especially SPECT (single-photon tmllllon computttlz<d l a ndl) "'
 3.30 CHAPTER 3
In the United States, the three subtypes of ADHD, according
to the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM-5), are:
1. ADHD, combined presentation
2. ADHD, predominantly inattentive presentation
3. ADHD, predominantly hyperactive-impulsive
presentation
A person with ADHD, predominantly inattentive type (also
known as attention-deficit disorder, or ADD), has six or
I
more of the following symptoms:
• inattentive to details
• difficulty sustaining attention at work or play
• does not appear to listen when spoken to directly
• lack of follow-through when given instructions and
failure to finish schoolwork, chores, or duties
• difficulty organizing tasks
• avoids tasks that require sustained mental effort
• often loses things necessary for tasks
• easily distracted by extraneous stimuli
• often forgetful in daily activities
A child with ADHD, predominantly hyperactive-impulsive
type (hyperactivity disorder, or HD):
e fidgets
• leaves seat at inappropriate times
• runs about or climbs where it is inappropriate
• is unable to play or engage in leisure activities quietly
• is often on the go, acting as if driven
• often talks excessively
• often blurts out an answer before a question has been
completed
• has difficulty waiting his or her tum
• interrupts or intrudes on others
In diagnosing any type of ADHD, the following must be true.
• Some symptoms must be present before the age of 12.
• Symptoms should show up in at least two different
settings .
• There must be evidence of impairment of social func-
tioning.
• Symptoms are not better accounted for by other mental
disorders (or simply childhood rambunctiousness). 49
Epidemiology
Because diagnostic judgments are necessarily subjective,
estimates of the prevalence of ADHD vary widely.
• More than 8% (5 million to 6 million) of all school-
age children in the United States have been diagnosed
with ADHD compared with a worldwide rate of 2% to
20 This figure is up more than 50% in the
9.5%.49.11s.119A.1
past 10 years.
• ADHD is twice as prevalent in boys as in girls. 118
• Of all children receiving psychiatric treatment, 40% to
70% of inpatients and 30% to 50% of outpatients could
be diagnosed with ADHD. 121 -122 -123
• Anywhere from 2.9% to 16.4% of adults could be di-
agnosed with ADHD, depending on the breadth of the
definition. 124
e In addition, 10% to 50% of children with ADHD will
continue to have symptoms in adulthood . 125
Pharmacotherapy for ADHD
It seems contradictory, however, that in small doses many
stimulants have the ability to focus attention and control hy-
peractivity. It is theorized that dopamine depletion is one of
the main causes of ADHD, and amphetamines or amphet-
amine congeners force the release of dopamine and prevent
its reuptake and metabolism . In addition, stimulants in-
crease the activity of serotonin in the brain, which explains
their seemingly calming effect on those with ADHD.126
Methylphenidate works in the same brain areas and affects
the same neurotransmitters as cocaine and amphetamines. 127
It is estimated that schoolchildren and a number of adults
received more than 51.5 million prescriptions for ADHD
medications in 2013, up 53 percent from just 10 years earlier,
and the figure is growing. Those drugs cost $7.2 billion per
year 128 and include:
• amphetamine stimulants: Adderall ® (+XR), Dexedrine, ®
Dextrostat, ®Vyvanse® (iisdexamfetamine, time release)
• methylphenidate stimulants : Ritalin ® (+SR, +LA),
Focalin, ®Methylin ® (+ER), Metadate ® (+ER, +CD),
Concena, ® Quillivant XR,® Daytrana Patch ®
• non-stimulants: Strattera ® (atomoxetine), Intuniv ®
(guanfacine ER)
• antidepressants: Wellbutrin ® (+SR, +XL), Tofranil, ®
Pamelor, ®Aventyl, ®Norpramin ®
• blood pressure medications : clonidine, Catapres, ®
Kapvay,®Tenex®
• other: pemoline (Cylert ®)
The two main drugs used for treatment
of ADHD are methylphenidate (Ritalin ®) and
amphetamine (Adderall ®).
Alternative Therapies
Dietary changes and nutritional supplements are the most
common alternative therapies for treating ADHD, either as
a replacement for or as a supplement to drug therapy .
Other treatments include education, exercise, lifestyle
changes, behavior modification, psychotherapy, parenting
classes, parent support groups , and limiting TV and elec-
tronic games. 129
Research by the National Institutes of Health studied the ef-
fectiveness of methylphenidate alone , methylphenidate in
conjunction with behavior management therapy, behavior
management therapy alone, and standard therapy available

in the community. Working at six separate sites, researchers
found that for those with ADHD alone, methylphenidate by
itself was as effective as methylphenidate and therapy and
was more effective than therapy alone. For the 70% of the
children studied who also had other problems, such as de-
pression and anxiety, behavior therapy provided significant
benefits, especially when used in combination with
methylphenidate. 129A
Concerns Regarding ADHD Pharmacotherapy
In 2006 an advisory group of the Food and Drug Admin-
istration (FDA) received several hundred reports of psycho-
sis or mania, especially hallucinations, among patients
(mostly adolescents) who used ADHD drugs and who had
no other risk factors. This prompted a closer examination of
the drugs' labeling and warnings to determine if the risk of
psychosis or mania was clearly expressed.
Although methylphenidate and other amphetamine conge-
ners were used appropriately in medical settings, their diver-
sion to nonmedical use led to a growing abuse of these sub-
stances by the mid-2000s. 130J 31 Some believe that more high
school students were using the drug nonmedically than
those for whom it was prescribed. In one college study, 31%
of students abused their own supply or sold it to others. 132
Methylphenidate is sold on the street and used as a party drug.
A few teenagers even appropriate their younger siblings ' sup-
ply to take to parties or to sell. When sold on the street, meth-
ylphenidate tablets (called "pellets." vitamin R. and rids) sell
for $3 to $10 each.
"At colleB' m~ roommatewould 90 to the health serviceand B't
a prescriptionfor Ritalin® and then sell it to other students on
a per-pillbasis. He made a lot of mone~. He even9ot them to
switch him to Addera/1® and made e,en more mane~ with that."
21-y rar-old male collegemulent
Because of concerns about ADHD therapy, the U.S. military
decided to bar from military service anyone who used
methylphenidate in adolescence (after the age of 12). The
policies have changed in recent years and now exclude only
those who used ADHD drugs in the past year or who show
significant ADHD symptoms. The irony of this position is
the fact that most governments, including the United States,
have historically made amphetamines readily available to
soldiers in combat. 133
Methylphenidate is a Schedule II drug (as are amphet-
amines), which means it has strong addiction liability. Users
who abuse methylphenidate develop a tolerance quickly and
continue to increase the dosage. Some even snort or inject the
drug to uy to recapture the original effects.
There are also grave questions about the long-term effects of
giving strong stimulants to children and whether it leads to
dependence on these kinds of drugs. Interestingly, studies
have shown an increased risk of alcohol and drug abuse
among adults with untreated ADHD. 121 Finally, in a group of
adolescents in treatment for substanc e-abuse disorders, about
Uppers 3.31
I
0 SandyHuffaker. CagleCartoons.
half also had diagnosable ADHD. 134 The high occurrence of
ADHD in drug abusers might have several explanations.
• Their drug use could be an attempt at self-medication.
• It could be that ADHD leads to social alienation and
problems with self-esteem , both of which are predictors
of problems with alcohol and other drugs.
• There could be a pre-existing mental condition, making
one more inclined toward compulsive behavior.
• Psychoactive stimulants foster acceptance of the idea of
taking drugs to alleviate mental problems.
• Finally, there are genetic factors common to both ADHD
and substance-abuse disorders.
One study found that the chance of an identical twin's having
the disorder if his brother has it is 11 to 18 times greater than
that of a non-twin sibling. 135 Another study , at the University
of Oslo, found that heritability factors accounted for 80% of
the differences between those with the disorder and those
without it. Other researchers found a strong genetic link be-
tween ADHD and other addictions or impulse-control disor-
ders, including gambling , compulsi ve overeating, heavy alco-
hol and drug use, and Tourette 's syndrome. 136, 137
Nearly half of the children with ADHD have oppositional
defiant disorder: they are stubborn or act defiant, overreact
to slights, and can have outbursts of temper. If left untreated,
this can progress to more-serious conduct disorders , includ-
ing stealing , vandalism, and arson. 25J 38
On the positive side, a Harvard Medical School study showed
that boys (six to 17 years old) with ADHD who are treated
with stimulants, including Ritalin, ® are 84% less likely to
abuse drugs and alcohol when they get older compared
with those who are not treated. 135 J 39
Over the past few years , attention has focused on the contin-
ued presence of ADHD in large numbers of adults. Though
earlier research showed a reduction in the continuation of
ADHD symptoms after pubert y, new research indicates the
need to treat some ADHD patients with drugs like methyl-
phenidate throughout their lives. The efficacy of the various
medications is similar in adults and adolescents. 140 The esti-
mated prevalence of ADHD in adults is about 4.4 %.141
 3.32 CHAPTER3
Diet Pills
Worldwide obesity has nearly doubled since 1980. In 2014
an estimated 528 million people worldwide were considered
obese and 1.4 billion were overweight; of those about
150 million were living in the United States. The Centers
for Disease Control and Prevention ( CDC) estimated that
a whopping 68% of the U.S. population was either over-
weight or obese (35.7%). The explosive number of over-
weight Americans is finally slowing down and leveling off.
Obesity contributes to 300,000 U.S. deaths every year and
I
costs our economy in excess of $150 billion annually in
healthcare costs.
At any given time, 24% of men and 38% of women in the
United States are trying to lose weight, spending more
than $65 billion on supplements, pills, and exercise equip-
ment. 142 The market for people who want to lose weight is
vast, and pharmaceutical companies have aggressively pur-
sued this population segment with a wide variety of pre-
scription and over-the-counter (OTC) medications.
Although only 2% to 3% of those people actively pursuing
weight loss currently use diet pills, that still amounts to
nearly 3 million people. History shows that each wave of
diet-drug use creates problems. In the fifties, sixties, and
seventies, amphetamines and methamphetamines saturated
the market and caused heart problems, malnutrition, and de-
pendence. Amphetamine congeners with names like Adipex ®
and Obetrol ® were the next wave that flooded the market,
accompanied by claims that they were safer than amphet-
amines and methamphetamines. The stimulation, mood
elevation, and loss of appetite induced by amphetamine
congener diet pills are usually weaker but similar to the
effects (and the side effects) of amphetamines (excitability,
nervousness, and increased respiration, blood pressure,
and heart rate). If used to excess, convulsions, heart irregu-
larities, and (rarely) stroke, coma, and death can occur.
When taken alone without other weight-control activities,
stimulants resulted in only a temporary weight loss that
was undermined by weight gain as tolerance to the drugs
developed.
>
Amphetamine congener diet pills only work
for a short period of time. Many of them have
bad side-effects.
On September 30, 1999, as the defendant in a class-action
lawsuit in federal court, American Home Products agreed to
pay $3. 75 billion to $4.8 billion to patients who had used
two amphetamine congener diet pills-fenfluramine
(Pondimin ®) and dexfenfluramine (Redux ®)-and suffered
or may suffer heart-valve damage . The combination of phen-
termine and fenfluramine or dexfenfluramine was known
as "fen-phen "; and like other diet pill fads, a severe price was
paid for a pharmacological shortcut to weight loss.
Other popular amphetamine congeners used as diet pills in-
clude pemoline (Cylert ®) and diethylpropion (Tenuate ®and
Tepanil ®). Pemoline and atomoxetine (Strattera ®) can cause
liver damage. Despite their widespread use to control appe-
tite and shed weight (there is significant weight loss in the
first four to six months), users usually regain and even sur-
pass their starting weights.
In general, diet pills (amphetamines and amphetamine con-
geners) are recommended only for short-term use, so care-
ful monitoring by physicians is very important. Long-term
and high-dose use of diet pills has been associated with the
development of abuse and addiction.
Look-Alikeand Over-the-Counter
Stimulants
Look-Alikes
The look-alike phenomenon of the 1980s contributed to the
abuse of stimulants. By taking advantage of the interest in
stimulant drugs, a few legitimate manufacturers began mak-
ing legal OTC products that looked identical to prescription
stimulants. These products contained ephedrine and occa-
sionally pseudoephedrine (anti-asthmatics), phenylpropa-
nolamine (PPA, a decongestant and mild appetite suppres-
sant), and caffeine (a stimulant). These look-alikes were
combined, packaged, and sold as "legal stimulants" in a de-
liberate attempt to misrepresent them as controlled drugs. 143
The same chemicals were also showing up as amphetamine
look-alikes, such as "street speed, " "cartwheels," and
"crank," and as cocaine look-alikes, such as Supercaine, ®
Supertoot, ® and Snow.® The cocaine look-alikes often con-
tained benzocaine or procaine to mimic the numbing effects
of the actual drug.
The danger that look-alike products pose is their toxicity,
especially when overused or when two or more of the drugs
are combined. Also, an amphetamine-like drug dependence
developed in users who chronically abused them. 144 The
physical ramifications of abuse, especially cardiovascular
problems, could be severe because large amounts were
required to get a speed- or cocaine-like high. For these
reasons, in the early 1980s the FDA banned the OTC sale of
products containing two or more of these ingredients. Some
manufacturers circumvented the combination ban by com-
bining herbs that contain ephedrine, caffeine, or PPA rather
than using the drugs themselves (e.g., Herbal Ecstas y®).
Other OTC Stimulants
On the counter of any convenience store in the nation, there
are dozens of stimulant products for sale in liquid and tablet
form, offering hours of alertness. Caffeine and other herbal
stimulants (also containing caffeine) are primary ingredi-
ents. In the past the OTC drugs of choice were pseudoephed-
rine and phenylpropanolamine, which have decongestant,
mild anorexic, and stimulant effects. These were previously
found in hundreds of allergy and cold medications (often in
combination with antihistamines, such as Benadryl ®) and in
OTC diet pills like Dexadiet ® and Dexatrim. ® Individuals
who ingest these drugs and consume coffee or other caffein-
ated beverages often experience anxiety attacks and rapid
heartbeat. After restrictions were placed on pseudoephed-

rine and phenylpropanolamine to avoid using them to man-
ufacture meth, pharmaceutical companies began using
drugs, such as phenylephrine, which cannot be made into
amphetamines. They also have fewer stimulant or other un-
wanted side effects.
Caffeine has been sold in tablet form as an OTC
for years with trade names such as NoDoz ® and
The FDA is continuing to examine all of these
issuing warnings, and sometimes banning them
The debate continues.
Miscellaneous Plant Stimulants
Most Americans believe that caffeine from the coffee bush
and cocaine from the coca bush are the only principal plant
stimulants, but dozens of plants or their extracts with stimu-
lant properties have been used worldwide for centuries by
hundreds of millions of people. These plants, found in the
Middle East, the Far East, and Africa, include the khat bush,
the areca (betel) nut, the yohimbe tree, and the ephedra
bush.
Khat and Cathinone("qat,""shat,"and "miraa'')
"Somali Pirates launderin9
billionsin Ken~a'miraa' [khat]
trade."
Standanl Digital, November 4 , 2Q1J H5A
'Thirst~plant steals waterin d11fYemen: farmers9row narcotic;
drou9htfuelscon~icts"
Nfw York Timi:s,November 1, 2009
Growing khat is one of the few ways starving Yemeni farm-
ers can make a living. More than half of this poor African
country 's water supply is used to grow the water-hungry
khat bush to feed a Middle Eastern addiction to this stimu-
Djibourians rush to buy the daily fresh khat supply shortly after it is
flown in to Djibouti City. Khat, a leafy stimulant that is illegal in the
United States and many Western countries, dominates male life in the
tiny Muslim nation of Djibouti.
Photo by Evelyn Hockstein/MCT Getty Images. By permission.
Uppers 3.33
lant. But as Yemen's population grows (24 million), the wa-
ter is running out. Like the cocaine cartels in Mexico, the
khat mafia runs roughshod over law and order. Immigrants
from Middle Eastern countries bring their habit to the United
States. Communities that use and smuggle khat are com-
posed of East African and Middle Eastern immigrants living
stimulant
in large enclaves in Dallas, Los Angeles, New York, San
Vivarin. ®
Diego , Seattle , and Washington, D.C., where khat branches
products,
with leaves are sold in bundles in certain stores and restau-
outright.
rants. 145San Diego has seen an eightfold increase in the
I
amount of khat leaves seized from its Somali population
over the past few years. This increased smuggling activity
prompted California to join 27 other states and the federal
government to ban khat. 146 In 2013 Great Britain banned
khat, angering the large immigrant populations from
Somalia, Kenya, and Ethiopia as well as the tens of
thousands of farmers living in those countries who make
their living from khat.
ln the horn of Africa and parts of the Middle East, khat is
a regular part of life, used much as Americans use coffee or
tobacco. The khat shrub is 10 to 20 ft. tall; the main active
ingredient is cathinone , a naturally occurring amphetamine-
like substance that produces a similar mild euphoric effect,
along with exhilaration, talkativeness, hyperactivity, wake-
fulness , aggressiveness, enhanced self-esteem, and loss of
appetite. 147 Khat loses potency quickly once the leaves and
the sprouts are harvested. The fresh leaves and the tender
stems are picked early in the morning, kept moist, and
quickly transported to market, where they are sold by noon.
Fresh khat is chewed, and the juice is swallowed. Dried
leaves and twigs are not as potent as the fresh leaves and are
crushed for tea or made into a chewable paste . 148 J 49
Khat use is a regular part of daily life in the
Horn of Africa and parts of the Middle East,
much like coffee and tea in America and
Europe or coca leaf in South America.
Khat's effects can be more potent than a very strong cup of
coffee or a beverage made from coca leaves. Cathinone has a
half-life in the body of about 90 minutes, so the leaf must be
chewed continuously to sustain a high. Excessive use produces
physiological side effects, including anorexia , tachycardia , hy-
pertension, dependence , chronic insomnia , and gastric disor-
ders as well as behavioral effects such as irritability, anger , and
violence . 150
Chronic khat abuse can result in physical exhaustion and
suicidal depression upon withdrawal. The symptoms are
similar to those from amphetamine withdrawal. There are
also rare reports of paranoid hallucinations and even over-
dose deaths. In a study of monke ys in which the animals
were allowed to self-administer the drug to determine its po-
tential for addiction, cathinone was shown to have a po wer-
ful reinforcing effect. The binge pattern characterizing co-
caine and amphetamine use was replicated in experiments
with monke ys and cathinone . 151
 3.34 CHAPTER3

In Somalia a large percentage of the population chew the
leaves, twigs, and shoots of the khat shrub (Catha edulis). In
Yemen more than half the population uses khat, and it is not
unusual for people to spend more than one-third of their
family income on the drug. Khat is used mostly by men in
the countries in which it is cultivated. It is the driving eco-
nomic force in Somalia, Yemen, and a few other countries
in eastern Africa, southern Arabia, and the Middle East.
References to khat can be found in Arab journals from the
thirteenth century. The leaves were used by some physicians
nervous system and muscle problems, such as Parkinsonism
(a dopamine-deficiency disease). 15 5
The alteration of the cathinone molecule is the basis for
bath salts, a whole series of methamphetamine-like drugs.
Abuse of methylmethcathinone, a variation of methcathi-
none, also known as mephedrone and M-KAT, increased rap-
idly in the United Kingdom, and by 2010 several deaths were
linked to its abuse. By April 2010 the United Kingdom
deemed mephedrone a class B drug and use was banned. 153
After the mephedrone ban went into effect on April 16, 2010,

I
as a treatment for depression, but khat was and is used pri- another synthetic drug, methylone, or MDAI (5,6-methyl-
marily in social settings. Many homes in Middle Eastern enedioxy-2-aminoindane), was made available to replace
countries have a room dedicated to chewing khat, similar to M-KAT as a legal high. 154 Other bath salt formulations in-
British homes that have a tearoom or parlor. Khat-chewing clude chemical derivatives of MDPV (methylenedioxypy-
gatherings in these rooms are called "majlis parties." rovalerone) and methylone or other synthetic stimulants
like naphyrone (NRG-1), methylenedioxy aminoindane, and
Hundreds of millions of dollars are spent on the drug
benzylpiperazine (BZP). and 5- or 6-(2-aminopropyl) ben-
worldwide, even in poor countries. The stimulation and the
zofuran ("benzo fury"). All are more powerful than cocaine
subsequent crash caused by khat has health and economic
and methamphetamine. 154 A
impacts, including malnutrition, reduced work hours, de-
creased production, and lost income.
"It'sthe nextthin9and the nextthin9and the nextthin9.So,
Methcathinone and Bath Salts it's ver'/.di(Fcultto sta~on top of it becauseit'sa hu9' industr~
that offersa businessmanand a chemist in an under9round
Each year the number of teens and young adults who use
laborator~a wa~ to make millionsof dollars.Youn9 teen rec-
synthesized versions of the cathinone molecule to create
reationaluse and explorationis somethin9that is alwa~s9oin9
other methamphetamine-like stimulants grows larger.
to be a part of human nature; however,the dan9ersthat are
Relevant information about these drugs is shared over the
attached to these substancesare quite concernin9."
Internet. Methcathinone, the most well-known of these
Lisa Marzilli, Pharm.D., former head of applied clinical research and
drugs, sometimes known as "cat," qat, M-KAT, "drone,"
education for Dominion Diagnostics
"plant food," and "meow," is synthesized by street chemists
from ephedrine and pseudoephedrine, the same precursors
used to manufacture methamphetamine. 85
Alteration of the cathinone molecule,
Methcathinone (4-methylmethcathinone) was originally
the active ingredient in khat, is the chemical
synthesized from ephedrine in 1927, but it was not patented
basis for most bath salts.
until 1957 by Parke-Davis in the United States and was sub-
sequently rejected for production due to side effects. The for-
mula became widely known in Russia, and by the early 1980s Bath salts are also sold as plant food, jewelry or glass cleaner,
methcathinone manufacturing led to widespread illicit use. insect repellant, spot remover, lady bug attractant, and even
At one point 20% of illicit-drug abusers in the Russian as "legal" synthetic cocaine. All have labels that say the con-
Republic used methcathinone. 152 tents are "not for human consumption" to avoid any govern-
ment restrictions. Federal legislation in 2012 banned me-
In the United States, methcathinone is a Schedule I drug.
phedrone and MDPV, and new chemicals continue to be
Street laboratories in the Midwest began to manufacture it in
added to that list. Legislation that goes after the intent rather
the early 1990s and began selling it on the street as an alter-
than the specific chemical formula would probably be more
native to methamphetamine. The white powder is usually
effective but more difficult to make a case for prosecution.
snorted but can also be taken intravenously, mixed in a liq-
uid and swallowed, or smoked in a cigarette, joint, or crack
'The on/~wa~we can dealwiththeseever-chan9in9 desi9ner
pipe. It is cheap to manufacture, and 1 gm of the drug sells
dru9sis to keepdevelopin9 testsbut not disclosethe chemicals
for $40 to $120 compared, with methamphetamine, which
we are testin9 for.Toda~ m~ clientscan 90 on the Internetto
sells for $40 to $200. "
our urine-testinpproviderand viewthe list of specif;cchemicals
Using methcathinone instead of khat is similar to using the~'retestin9for and then90 to a headshopand bu~some
cocaine instead of the coca leaf. Methcathinone is much other chemicalto use to avoid testin9 positive."
more intense than khat, so its addictive properties and side Darryl Inaba, Pharm.D., Addictions Recovery Center , Medford, OR
effects can be more intense (similar to the effects of meth-
amphetamine). Side effects last four to six hours and By 2014 only about five of the several dozen bath salt stimu-
include nervousness, labored respiration, and lack of coordi- lants can be tested for in urine or blood. Bath salts can be
nation. PET scans of long-term methcathinone users show snorted, smoked, injected, or swallowed. They act like stim-
lasting reductions in dopamine production that can lead to ulants, delivering alertness, extra energy, and raised heart
 Uppers 3.35

The number of products containing bath salts (mostly variations of the cathinone molecule) increases so quickly that the United Nations simply
refers to these drugs as "NPS," or new psychoactive substances. In addition, the UN World Drug Report for 2013 also talks about the growth of
amphetamine -type stimulants , especially in Asia.
Courtesyof the U.S.Drug Enforcement Administration
I
rate and blood pressure; they can also cause headaches, heart
palpitations, and nausea among other symptoms. Because a
slight change in formulation can dramatically alter the
strength and the quality of reactions, there is a danger of
unexpected hallucinations, paranoia, panic attacks, and
violent behavior. Heart attacks, kidney failure, liver failure,
dehydration, and other symptoms of methamphetamine
overdose are also possible. If a patient winds up in the ER,
it is difficult if not impossible to discern what was in the
drug he or she took, so accurate epidemiological studies
are scarce. Much of the information is anecdotal.
A study on the potency ofMDPV in late 2012 found it to be 10
time.s more powerful than cocaine and methamphetamine. 1546
The areca nut from the betel palm is found mostly in Asia. The nut is
Betel Nuts chewed, often in combination with a peppermint or other leaf to help
absorption.
for
"China'shu9e industr~suppl~chain areca nut- more com- 0 2008 CNS Production, Inc.

mon/~ known as betel nut-involves 2.3 millionfarmersin the

of
southern island province Hainan and more than 400,000
workersin Hunan's betel nut-processin9industr~,which has a
productionvalueof near/~10 billion~uan[US$1.6 billion]."
Guangzhou-based Time Weekly reports , October 25, 2013
Worldwide, estimate.s of betel nut use range from 400 mil-
lion to 600 million people. It is mostly chewed as a recre-
ational drug but also as a medication. The common name
betel nut is technically incorrect: it is the areca nut from the
betel palm, Areca catechu. The nut is widely used in India,
Pakistan, the Arab world, Taiwan, Malaysia, the Philippines,
New Guinea, Polyne.sia, southern China, and some countries
in Africa. In Taiwan 17% of men and 1% of women-an esti-
mated 2 million people-chew the nut on a regular basis.
Evidence found in Thailand indicate.s that people have
chewed the.se nuts for 12,000 years; specific reference.s to the
areca nut date back to Herodotus, who in 340 B.C. first
described its use as a stimulant.
The betel palm is widely cultivated in tropical climate.s, usu-
ally on large plantations. Each palm produce.s about 250 seeds
per year. The main active ingredient, arecoline, increases
brain levels of the stimulant neurotransmitters epinephrine
and norepinephrine. The effects of the.se CNS stimulants are
similar to those from nicotine or strong coffee and include a
mild euphoria, excitation, and a decrease in fatigue.
Maximum effects occur six to eight minutes after chewing be-
gins. Some users claim that betel chewing lowers tension, re-
duces appetite, and induces a feeling of well-being. 156
Abusers chew from morning until night, whereas other users
chew only in social situations, much like people in Western
countries chew gum or drink cola. This drug can produce
psychological dependence. 157 A certain physical dependence
also develops because there is a prominent and identifiable set
of withdrawal symptoms similar to those experienced during
withdrawal from caffeine.
 3.36 CHAPTER 3
I
A Laotian woman carryingfirewood shows her mouth and teeth
stained with the reddish juice that comes from chewing the betel nut.
She lives in the village of Nakai Tai, Laos.
0 DavidLongstreath.Associated Press.
The betel nut (husk and/or meat) is generally chewed in com-
bination with another plant leaf (such as peppermint or mus-
tard) and slaked lime to make it more palatable and to in-
crease absorption. The juice of this mixture stains the teeth
and the mouth dark red over time. In high doses arecoline
can be toxic. Another substance in betel nuts, muscarine, is
epidemiologically linked to esophageal cancer. Up to 7% of
regular users have cancer of the mouth and/or the esophagus.
Tissue damage to the mucosal linings of the mouth and the
esophagus is the most common consequence. 158
In the 1990s a product called gutka gained popularity and
was heavily marketed in India. Gutka is a sweetened mix-
ture of tobacco, betel nut, and betel leaves. It is sold at a price
affordable even to children (about 40¢ to 50¢) and packaged
to attract their attention. About 5 million children under the
age of 15 are addicted to it, and some as young as 12 have
been diagnosed with precancerous lesions in their mouths. 158
The revenues from the sale of this product exceed $1 billion.
Continuing attempts by various citizen and government
groups to ban the substance or at least one of the additives,
magnesium carbonate, have had only limited success.
More than 18% of Taiwanese youth 12 to 18 years old admit-
ted to betel nut chewing, and 7.3% were regular users. This
resulted from an expanded marketing effort of the substance
a few years earlier. "Betel quids," a mixture of betel nut, betel
peppermint leaves (piper
betel), and lime (calcium 400 to 600 million
oxide), were prepared by people worldwide
scantily clad young women chew betel nuts.
and sold out of glass-
walled road kiosks. 159These women were called "Binlang
Girls," "Betel Nut Beauties," or "Betel Nut Girls."
Yohimbe
Yohimbine, a bitter, spicy extract from the African yohimbe
tree (Corynanthe and Pausinystalia yohimbe, a member of the
coffee family) is brewed into a stimulating tea or used as a
medicine. It is reported to be a mild aphrodisiac. The active
ingredient is an alpha-2 adrenergic antagonist that seems to
increase the activity of the neurotransmitter norepinephrine.
This results in more penile blood inflow, which led to the use
of yohimbine as a treatment for erectile dysfunction in men
as well as for inducing sexual arousal in women, though its
effectiveness is unproven. 160The drug also increases blood
pressure and heart rate and has local-anesthetic effects.
Bodybuilders use it, often at high doses, for the stimulation
and to reduce body fat. High doses present a health risk to
the cardiovascular system, raising the blood pressure to dan-
gerous levels. 161Other side effects include digestive upset,
anxiety, headache, and frequent urination.
The yohimbe tree contains several alkaloids; yohimbine con-
stitutes 0.6% to 0.9% of the bark, which can be extracted and
formulated into either tablets or a tincture for oral inges-
tion. 162Yohimbine produces a mild euphoria and occasion-
al hallucinations; in larger doses it can be toxic and can
cause death by respiratory paralysis. 163The bark is available
at some herbalists' shops along with an array of yohimbine-
based medications targeted to males to increase potency,
with names like Male Performance, ® Yohimbe Power, ®
Manpower, ®and Aphrodyne ® (prescription only).
Ephedra (ephedrine)
The ephedra bush (Ephedra equisetina) is found in deserts
throughout the world and contains the drug ephedrine. This
mild-to-moderate stimulant is used medicinally to treat
asthma, narcolepsy, allergies, and low blood pressure.
Many use it to make tea; the Mormons brew it as a substitute
for coffee. Ephedrine, also known as marwath and ma huang,
has been used as a stimulant tonic and a medication in China
for more than 5,000 years and is still sold in herbalists'
shops. Ephedrine was isolated and synthesized in 1885, but
it was forgotten for almost 50 years before a scientific paper
recommended it for asthma; after that its popularity in-
creased dramatically because until this discovery epineph-
rine, which could only be injected, was the sole effective
medication used to treat asthma.
Natural ephedra, synthetic ephedrine, and pseudoephedrine
are also the main ingredients in the synthesis of metham-
phetamine and methcathinone; the high demand for these
precursors spawned a large illegal trade resulting in exten-
sive smuggling operations based in China and Germany.
Restricting the purchase of these chemicals and phenylpro-
panolamine to limited quantities as prescription or Schedule
III controlled substances in Oregon and other states makes
life difficult for street chemists, but it also makes it more dif-
ficult for those with legitimate asthma and cold symptoms to
gain access to medications that were OTC drugs until 2004.
Prescriptions or identification and signature for purchase are
required for many of these drugs today.
Although ephedrine has more-peripheral effects, such as
bronchodilation, and fewer CNS effects than amphetamines
(e.g., euphoria), one of the common side effects of excessive
ephedrine use is drug-induced psychosis. 14 Extract of ephed-
rine has been used by athletes for an extra boost, but over-
use can lead to heart and blood vessel problems.
 Uppers 3.37

A stud y of ER visits involving eph edra- conta ining botanical

products collected over a 10-year period (1993 to 2002)
found an almost threefold difference in toxic consequences
compared with products that do not contain ephedra or QUANTITY CAFFEINE
ep hed rine . 164 Th e ca rdi ovasc ular dan gers move d the Nat ional Coffee(8 oL)
Football leag ue to ban eph edrin e use by players, and many Decafcoffee 7 mg
states bann ed I.he sale of all ephedrin e-based produ cts. A
Instantcoffee 95mg
number of look-alike and OTC produ cts on the Internet ad-
vertise themselves as legal MDMA (ecstasy), amphetamine BreY1e
d coffee 135- 160mg
sub stitut es, or oth er stimulants (e.g. , Cloud 9®and Nirvana ®) Tea (8 OL)

I
and contain ephedrin e as th e active ingredient. Greentea 15- 30 mg
In an attempt to cater to the desire for abusable stimulants 5-minute brew 60 mg
and psychedelics, entr epreneurs have introdu ced stimul ant 1-minute brew 25mg
herbal products. These capsules and tablets combine the 40- 60 mg
Blacktea
herbal form of eph edrine (ephedra) and/or an herbal ex-
tract of caffeine (possibly from the kola nut) with other SoftDrinks (12 oz.)
herbs and vitamins. JollCoia
• 70mg
Mountai
n Dev-P' 54 mg

Caffeine Coca
-Cola9 or Pepsi
~ Cola 35-38 mg
Sun~Orange 42mg
Chocolate
"'Coffeeshould beblackas hell.
O,ocolalemilk(6 oz) 4 mg
stron9as death, and sweetas love."
Turkish proverb Milk chocola
le (4 oz.) 24 mg
Darkchocolale(4 oL) 80 mg
Caffeine is not only the most popular stimulant in the Bakingchocolate
(4 oz.) 140mg
world but also the world 's most popu lar mood -alt ering and
H~agen
Dazs®icecream(4 oz.) 32 mg
habit-forming drug. Caffeine is found in coffee, tea, choco-
late, soft drinks, energy drinks , 60 different plan ts, and hun- Energy Snacks
dreds of OTC and prescription medications. It is ingrained in CrackerJack®'D Powe
r Bites 100mg
so many cultures that efforts at any kind of prohibition or Energy Drinks
redu ction of use are doomed to failure. In the United Stat es,
RedBull• (83 oz.) 80mg
85% of th e populat ion consumes sub stantial amounts of
caffeine every day.16' Rocksla
r" (8oz.) 80mg
Slarbuc
ks" 2XShol®(6.5oz.) 105mg
As with many psychoactive drugs , th e ritu al surroun ding the
use of coffee or tea is often as important as its effects. Rituals SpikeShooler" (B.4oL) 300mg
include selecting the coffee and grind ing the beans; finding a 5-HoorENERG
Y"(2 oz.) 138mg
favorite drive-thru coffee kiosk; collecting dozens of cups, Otherl>tants
demitasses, or mugs; reading the newspaper; and finding the
Guaranatea(8 oL) 100-200mg
right pastry or scone to accompan y the morning brew or af-
ternoo n tea. From the breakfast coffee to the latte on the way Guaranasoftdrink (8 oz.) 20 mg
to work , to coffee and cola breaks to the tablet of NoDoz,lllto Male(8oz.) 35- 130mg
an energy drink on the drive home, and finally to the steam- Yoco(8 oz.) 100-200mg
ing cup of decaf (7 mg of caffeine) after dinn er, caffeine
Energy Packets
thrives on rituals .
r®(1 capsule)
UltimateEnergize 140mg

>
Caffeine in all its forms is the most popular Slacker"(1 capsule) 250mg
stimulant in the world: it is found in coffee, Medications
tea, cola drinks, and chocolate . Dexatrim
~ (1 capsule) 200mg
NoDo
z" Max(1 lablel) 200mg
Excedrin
• (1 Jablel) 65mg
Historyof Use
Miciol
• or Percocian
• (1 lab~l) 32mg
Tea
Tea is the mos t widel y consumed beverag e in the world
besides wat er. It is thought to have been present in China as
early as 2700 B.C., but the first written record dat es back
only to 221 B.C., when the Chin ese emperor Qin Shi Huang
 3.38 CHAPTER 3

TRUE! by Daryl Cagle Coffee was first cultivated in Ethiopia around A.D. 650.
Legend has it that the stimulant properties of coffee were
,, discovered when Kaldi, an Arab goatherd, noticed how frisky
his goats became after eating the red berries from the coffee
" bush. Arabs soon bega n making a hot drink from the berries
instead of simply chewing them. Use spread to Arabia in the
thirteenth century and finally to Europe by the fifteenth cen-
tury. The drink was so stimulating that many cultures
banned it as an intoxicating drug. Some in colonial America
suggested that the use of tea and coffee led to the use of to-

I
- ~---
Souree;ShapeMagazinequoting Gallup poll - are located in parking lots, gas stations, discount department
Onl y 28 pe rcent of us get eight or more
hou rs of sleep pe r night.
0 Daryl Cagle, Cagle Cartoons
placed a tax on tea. The Buddhist monk Saich6 brought the
tea plant to Japan in A.D. 801, but green tea did not become
an important part of Japanese culture until the fifteenth cen-
tury. The tea ceremony became an important ritual in
Japanese homes and castles. Its purpose is to invite partici-
pants to enter into a mental state to discover one's true self.
Tea was introduced to Europe around the end of the six-
teenth century and was immediately popular, particularly in
England and subsequently in the English colonies, including
America .166 In 1774 irate Bostonians threw tea into Boston
Harbor in protest over a tax on tea. This action reflected the
importance of this psychoactive substance in colonial life.
bacco, alcohol, opium, and other drugs (muc h as marijuana
is portrayed today as a gateway drug). 166 Coffee and tea gen-
erated large amounts of tax revenue, so pressure against
prohibition from bo th the government and the general pub-
lic was immense.
Today each coffee drinker in the United States consumes
about 20 lbs. of coffee per year. This is half that of Finland,
Sweden, and the United Kingdom (where tea is preferred).
Citizens of France and Italy drink about 10% more coffee
than is consumed in the United States.
The incredible growth in the number of specialty coffee-
houses in the United States bogg les the mind. Coffee kiosks
stores, and grocery chain stores. The number of coffee
beverage retailers grew from 200 in 1989 to more than
30,000 in 2013 and continues to rise. The largest of the
retailers, Starbucks, had 21,891 outlets in 62 countries as
of 2013, with net revenues of $13.3 billion. 167 •168 The com-
petition drove McDonald's and Burger King to upgrade their
coffees to premium roasts
and to offer specialty drinks
such as lattes to meet the
demand.
Starbucks has nearly
22,000 outlets in
62 countries .
I
The top coffee growers
are Brazil (50.82 million bags) , Colombia (9.5 million
bags). Ethiopia (8.1 million bags), India (5.25 million bags ),

'The powerandeffectof thisdrinkis that it dispelsimmoderate

sleep;but o~erwardthosein particular
feelw~ 900d whohave
overburdened theirstomachswithfoodand haveloadedthe
brainwith stron9 bevera9es."
Johan Neuhof , 1655

Today the primary exporters of tea are Sri Lanka, China,

India , and Kenya. The primary importe rs are Russia, the
United Arab Emirates, the United Kingdom, and the United
States. About 75% of the world's tea that is produced is black
tea and 22% is green tea.
Coffee People line up to buy coffee during a Starbucks grand opening on
March 1, 2013, in Taiyuan, a cHy of 4 million in northern Chinas
"Coffeeis a 9reat power in m~ life; I have observedits effects on Shanxi province. As of 2013, Starbucks had outlets in 62 countries
an epic scale. Man~ P.eopleclaim coffee inspiresthem,'but, as and more planned.
ever~bod~
knows,coffeeon/~makesb~rin9peoplemoreborin9
." Photo by ChinaFotoPress.Permission by GettyImages.
Honore de Balzac, On Modrrn St imulants , 1839

Guatemala (3.14 million bags), Indonesia (654,000 tons).
and Vietnam (561,200 tons). Worldwide the total market is
144.51 million bags Y 0
Cocoa
Residue in ancient Mayan pots found in Belize in Central
America, dating back to 600 B.C., showed traces of a cocoa be.v-
erage.171Other evidence backs it up to 1100 B.C. Cocoa from
the fermented, roasted, and ground beans of the cacao tree
(Theobromacacao) is ground into a mass of pure chocolate.
Chocolate was first used in the New World by Mayan and
later Aztec royalty as an unsweetened drink, as a spice, a
food, a stimulant, and even a currency. It played a key role in
religious and royal events. Priests gave cacao seeds as offer-
ings to the gods and served chocolate drinks during sacred
ceremonies. Hernan Cortes brought it to Europe in 1528.
Initial preparations in Europe were promoted as love drinks.
Widespread use of other preparations did not occur until the
nineteenth century, when the first chocolate bars appeared on
the market. Much of the chocolate available today is sweet
A plantation owner checks his cocoa trees in the southwestern Ivorian
village of Godilehiri. Coffee and cocoa account for 20 % of the
country~ gross national product. Western Africa produces almost
two-thirds of the world~ cocoa, half of it in the Ivory Coast.
Photo by lssouf Sanogo,courtesy of AFP/GettyImages
Uppers 3.39
chocolate containing cocoa solids, cocoa butter, and sweeten-
ers. Bitter chocolate is used for cooking.
There is a relatively small amount of caffeine in chocolate,
but the other active ingredient, theobromine, also has stimu-
latory properties (Table 3-3).
CaffeinatedSoft Drinks (colas)
Caffeinated soft drinks are carbonated beverages that some-
times contain a caffeine extract of the kola nut from the
African kola tree (Cola nitida or Cola acuminata) but more
I
often contain only caffeine extracted from the process of
decaffeinating coffee. By the late 1800s, cola drinks made
with carbonated or phosphated liquids, such as Coca-Cola, ®
became popular in the United States. 174
In 2012 the soft drink market was worth nearly $77 billion,
an increase of 1.3% from the previous year. In the United
States, which has the highest per capita consumption in the
world, the average American drinks the equivalent of more
than 701 eight-ounce glasses of soft drinks per year, and
most of those are caffeinated. 175 In addition to the caffeine, a
giant 44 oz. nondiet soft drink contains more than 400 calo-
ries. As part of renewed concerns over obesity in the United
States, a recent study of children's eating habits found that
simply avoiding sugared soft drinks led to modest weight
loss. Researchers also found that soft drinks weaken tooth
enamel and damage teeth. 176
EnergyDrink Phenomenon
"Scrutin~intensi~eson ener9~drinkmakers,Red Bull® faces
wronefuldeath lawsuitas Con9ressconsidersti9hterre9ulations."
Natalie Zmuda, Advertising Age online, October 28 , 2013
of
"Ahead an~ FDAcrackdown,some f1rmsare
researchin9wa~sto make humans respondmore stron9l~to
of
lowerdoses caffeine."
Smart Planet online (Charlie Osborne ) , October 22, 2013
"Stud~ ~nds more teens9ulpin9 down sports, ener9~drinks."
Los Angeles Daily News, October 13, 2013
Gatorade, ® formulated in the 1960s, was developed at the
University of Florida (home of the Gators) to replenish its
athletes ' fluid, carbohydrates, and electrolytes lost by physi-
cal exertion. Caffeine was not an ingredient. It was not until
1987 that the market made a giant leap with the creation of
the stimulant beverage Red Bull® by Austrian entrepreneur
Dietrich Mateschitz and Thai businessman Chaleo
Yoovidhya. In 2011 Red Bull ® sold almost 5 billion cans,
generating $3.4 billion in sales. The second most success-
ful energy drink, Monster, ® had $3.1 billion in sales.
Together they control 82% of the market.
With 80 mg of caffeine, Red Bull®contains more than twice
the amount found in a 12 oz. Coca-Cola ® (35 mg) but less
than 8 oz. of brewed coffee (135 to 160 mg). 177 In addition
to caffeine, it contains taurine, ginseng, guarana, glucose
 3 .40 CHAPTER 3
I
or glucuronolactone, B-com plex vitamins, minerals, sug-
ars, and even trace amounts of cocaine to p rovide a quick
energy boost. These herbs also contain caffeine, which in-
creases the tota l amount of caffeine in Red Bull® to greater
than 80 mg. Most sports/energy drinks do not list the caf-
feine content.
"M~13-~ear-old
dau9hter was ~ammerin9
at the breakfa
st table
and said she was on a su9ar hi9h from four Rock.star® ener9~
drinksshehad the ni9htbefore . She said shehadn'tsleptand
9i99ledall the while,but I hopeit's on/~ener9~drinks
."
41 -year-old father of en ergy drink er
The marketing of Red Bull® as an energy-boosting beverage
immed iately led to its worldwide popularity. Now a plethora
of energy drinks with trade names like Rockstar, ® Full
Throttle, ® Monster ,®Blast ,® Zoom ,® Wired ® X-3000, Bliss,®
SoBe® Adrenaline Rush , Killer Buzz ,® and even Cocaine ®
dominate the she lves of mini-marts, dance clubs, bars , gyms ,
and university shops. The increased consumption is fueled
by combining them with alcohol and other mixers in bar
settings , some with separate sections that ser ve on ly these
combinations.
The makers of energy drinks com b ine alcohol with other
ingredients, put the mix in a can and, in essence, sell en-
ergy drink "speedball " cocktails (e.g ., Four Loko ,• Spykes •
by Anheuser-Busch). A hue and cry against th is practic e has
had no effect. Because these drinks are aimed at a younger
crowd, state attorneys general and health groups are fighting
the trend vigorously .178 One 24 oz. can of Four Loko ® origi-
nally contained about 156 mg of caffeine as well as alcoho l
equa l to four or five glasses of wine. This resulted in many
toxic overdoses , and the product was banned by the FDA in
2011. The manufacturer has reformu lated it to contain less
alcohol and caffeine to get around the ban.
A stud y at the Un iversity of Florida of 802 bar patrons found
that those who drank alcoho l-laced energy drinks had a
threefold greater chance of leaving the bar believing they
were sober because the stimu lation of the energy dr ink ob-
scured the fact that they were indeed drunk. 179
The leading ene,gy drink manufacrurers
are Red Bull®and Monster,®wHh 80% of
the market. Further behind in sales are
Rockstar,®Amp, ®NOS,f1land Full
Throttle.®
0 2014 CNS Productions, Inc.
Red Bull• and Monste r® account
for 80% of sales for the energy
drink market.
Desp ite the tremendous popu larity among consumers and
the huge profits realized by the manufacturers , the jury is still
out on whether energy drinks actua lly increase awareness
and performance along with energy. Some studies demon-
strate positive results and others find no benefits. 166 ,180) 81
If you ask most users , ho wever, the drinks do provide energy
from the sugar and the caffeine. The effects of the other ingre-
dients like vitamin B and guarana are sometimes hard to
disti nguish.
"I thinkthe~do 9ivemeener9~. but I havea crash later. /..,,tel~
whenI drinkthem, I feellikem~heart is racin9.And I can
real/~feelit. M~ heartstarts racin9 like I've been runnin9for
20 minutes . The~alsohavethesesmaller ener9~shots which
come in small Yials [2 oz.]. The one I use has no su9ar and
is supposed to be all natural. It doesn't make m~heartrace."
21-year-old woman
The high sales of energy drinks encouraged manufacturers
to come out with different forms of energy products in at-
tract ive packaging. The most popular by far, with $1 billion
in sales, is 5-hour ENERGY,® which comes in a 2-ounce
bott le contain ing 190 mg of caffeine, tyrosine, glucurono lac-
tone , and a few other energy-re lated chemicals.
Other Plants Containing Caffeine
Other plants conta ining caffeine include guarana (Paullinia
cupana), mate (Ilex paraguariensis), and yoco (Paullinia
yoco)-all found in South America. 165 Guarana is the na-
tional drink of Braz il. Made from the guarana shrub, it has
more caffeine (3% to 4%) than coffee beans (1 % to 2%) and
is made into sweet carbonated beverages containing 30 mg
of caffeine per 12 oz. (Coca-Co la® has 35 mg per 12 oz.). 172
Guara na beans are sold in health-food stores under names
like Zing and advertised as a folk cure, even though the main
ingredie nt is simp ly a hearty dose of caffeine.

Mate is the most popular caffeinated drink in Argentina;
and, after the tea plant, coffee bean, and cacao tree, mate
products are the fourth-largest source of caffeine in the world
(3% of the world's caffeine). It is a hot, tealike drink made
from the leaves of a certain holly plant and is often used as a
vehicle for other herbal medications. It is thought to
strengthen the stomach, treat rheumatism, and help heal
sores when used as a plaster. Mate leaves can be bought in a
number of health-food stores. Mate should not be confused
with mate de coca, which contains coca leaves instead of tea
leaves. Mate leaves contain about 0. 7% caffeine, whereas
yoco is about 2. 7%. 23 •165
Yoco is similar to yerba mate but has more caffeine. The
bark of the Paullinia yoco vine is scraped and squeezed to
extract the caffeine-containing liquid. It is used by some
tribes in South America as a stimulant.
Pharmacology
Caffeine is an alkaloid of the chemical class xanthines. It is
found in more than 60 plant species, including Coffea ara-
bica (coffee), Thea sinensis (tea), Theobroma cacao (choco-
late), and Cola nitida and acuminata (cola drinks). The white,
bitter-tasting crystalline powder (C 8 H 10N 4O 2) was isolated
from coffee by Friedlieb Ferdinand Runge in 1819 and from
tea eight years later. Tea leaves contain a higher percentage of
caffeine than do coffee beans, but less tea is used for the
average cup. Caffeine can be taken orally, intravenously,
intramuscularly, or rectally, though most consumption is by
mouth. The half-life of caffeine in the body is 3 to 7 hours,
so it takes 15 to 35 hours for 95% of the caffeine to be
excreted. School-age children eliminate caffeine twice as fast
as adults do. 182
Per capita consumption of caffeine in the United States is
300 mg per day (about two cups of regular coffee plus two
colas); in Sweden. 425 mg (85% from coffee); and in the
United Kingdom. 445 mg (72% from tea).
Computer model of a molecule of the alkaloid stimulant caffeine. The
molecules chemical formula is CJ-luµ 4 O1 .
Courtesyof PASIEKAReprinted with permission.
Uppers l.41
• About 60% of the per capita daily consumption of caf-
feine in the United States is from coffee, 17% is from tea,
and 16% is from soft drinks. The rest is from energy shots
and other odd caffeinated drinks. 182 ,1s3 ,1 94
• About half of all Americans drink three cups of regular
coffee per day (rather than specialty drinks like lattes
and espresso).
• 20% of U.S. adults consume more than 350 mg of caf-
feine per day, and 3% consume more than 650 mg.
I
• 65% of the hundreds of soft drink brands available in the
United States contain caffeine.
Physicaland Mental Effects
An individual's reaction to caffeine varies widely. Differences
in metabolism; a high level of tolerance; an illness that exag-
gerates the effects; or the use of other substances, including
alcohol, tobacco, or other stimulants-all can alter the reac-
tions to caffeine and make it difficult to predict specific
effects for any given person. 165
Medically, caffeine is used as a bronchodilator in asthma
patients. It has been used as an adjunct to pain medication
and to counteract a sudden drop in blood pressure. It is used
as a decongestant, a diuretic, an alertness aid, an appetite
suppressant, and an analgesic to control menstrual pain.
Caffeine constricts blood vessels in the brain, making it
valuable as a treatment for headaches, especially migraine
headaches (which are caused by dilation of vessels). A
recent study found evidence that drinking several cups of
coffee every day may counteract some of the liver damage
from alcohol and lessen the damage caused by cirrhosis. 185
Nonmedically, caffeine is most widely used as a mild stimu-
lant. In low doses (100 to 200 mg), caffeine can increase
alertness, dissipate drowsiness or fatigue, and facilitate
thinking. Even at doses above 200 mg, there can be increased
alertness and performance. Injecting 600 mg of caffeine is ap-
proximately equivalent to shooting 20 mg of amphetamine.
In addition to releasing the brain's own stimulant chemi-
cals, some of caffeine's stimulating properties are the result
of the drug's inhibiting effect on adenosine, a neuromodula-
tor that normally depresses mood, induces sleep, has anti-
convulsant properties, and causes low blood pressure, a slow
heart rate, and the dilation of blood vessels. Blocking ade-
nosine results in wakefulness, raised mood, high blood pres-
sure, fast heart rate, and vasoconstriction. 165 Because caffeine
users' reactions to the drug often depend on heredit y, the rise
in blood pressure is more pronounced in those prone to high
blood pressure. 186
Anxiety, insomnia, gastric irritation, high blood pressure,
nervousness, and flushed face can occur at doses of more
than 350 mg per day (three or four cups of coffee), depend-
ing on the user's susceptibility and tolerance. One study
tracked subjects given 500 mg of caffeine and found that
stress hormones were elevated about 32% above normal and
persisted hours after use. Coffee drinkers also felt more
stress on the days they did not consume caffeine. 187 At doses
above 1,000 mg taken over a short period of time, increased
 3.42 CHAPTER 3
heart rate, palpitations, muscle twitching, rambling thoughts,
jumbled speech, sleep difficulties, motor disturbances, ring-
ing in the ears, and even vomiting and convulsions can oc-
cur. Caffeine is lethal at about 10 gm (100 cups of coffee).
Because excessive use can trigger nervousness, people who
are prone to panic attacks should avoid caffeine. 166
Physicians and psychiatrists treating patients with symp-
toms of anxiety should ask about their caffeine consump-
tion. Too often physicians do not consider a patient's caffeine
consumption when treating for cardiovascular, sleep, and/or
I
gastric problems.
'When I was 14, a friendofmineand I 9ot a coupleof boxes
em
ofNoDoz® and downed the whole two boxesof betweenus.
We 9ot wa~ sicl ver~sicl wa~ more sick than I've ever9otten
off alcohol. The room was spinnin9and spinnin9and spinnin9.
Caffeineoverdose:not fun."
32-year--old caffeine abuser
Consuming 350 mg or more of caffeine can lower fertility
rates in women and affect fetuses in the womb (e.g., higher
blood pressure). A retrospective study at the University of
Utah of 2,500 pregnant women found that six or more cups
of coffee per day almost doubled the risk of miscarriage
compared with women who either did not drink coffee or
consumed only one or two cups per day. 188 Caffeine use can
make it harder to lose weight because caffeine stimulates
the release of insulin, which metabolizes sugar, thus reduc-
ing the level of sugar in the blood and triggering hunger.
Coronary artery disease, ischemic heart disease, heart at-
tacks, intestinal ulcers, diabetes, and some liver problems
are sometimes seen in long-term, high-dose caffeine users,
particularly those living in countries with very high per cap-
ita caffeine consumption. On the plus side, a study of
110,000 Japanese subjects found that daily coffee drinkers
had half the liver cancer risk of those who abstained.
Tolerance,Withdrawal,and Addiction
Tolerance to the effects of caffeine does occur. People react
to the caffeine in coffee or tea in many different ways. Coffee
drinkers might reach a level of tolerance where they need
three cups to wake up instead of the usual single cup. For
those with a high tolerance, a cup of coffee can even encour-
age sleep. PET scans of habitual coffee drinkers show that
they require coffee to activate their brains. 177 Continuous
caffeine use increases the number of adenosine receptor
sites, so it takes more caffeine to block them; this is one of
the main mechanisms for the development of tolerance. 190
Withdrawal symptoms do occur after cessation of long-term
high-dose use and can occur after levels as low as 100 mg per
day, which is one strong cup of coffee or two colas. These
symptoms appear within 12 to 24 hours, peak at 24 to 48
hours, and last two days to a week. The most prominent
withdrawal symptom is a throbbing headache that is wors-
ened by exercise but of course relieved by a cup of coffee.
Other symptoms include sleepiness, fatigue, lethargy, de-
pression, decreased alertness, sleep disorders, irritability,
and even flulike symptoms like nausea, vomiting, and mus-
de pain or stiffness. The subjects in one extensive experi-
ment had withdrawal symptoms when ceasing an average
intake of 235 mg per day, or two to three cups of coffee. 166
Withdrawal symptoms are observed in newborns whose
mothers consumed 200 to 1,800 mg per day. Irritability,
jitteriness, and vomiting occurred an average of 20 hours
after birth and then disappeared. 191
"Am I a caffeineaddict?/',e 9onethrou9hphasesran9in9
from bein9a coffee apcionado who knew the best beans, to
someonewho drinksthat awful instant crap, and pnall~to a
cola addictdrin/«n910 cansa daf B~ the timeener9~drinks
camearound, I had had heartproblemsfromm~obesit~and
had to 9iveit up an~wa~."
SB-year-old male caffeine abstainer
Dependence can occur with daily intake levels of 500 mg
or more (about five cups of coffee, 10 cola drinks, or eight
cups of tea). 165 Coffee creates a milder dependency than that
of amphetamines and cocaine. It interferes less with daily
functioning and is less expensive than the stronger stimu-
lants, although a $4 latte three times a day is pushing the
limits. Two-thirds of those treated for excessive caffeine use
(caffeinism) relapse after treatment.
Sixty-five percent of all soft drinks sold in the United States
contain caffeine and the reason is unclear. It is not for the
flavor: one study found that only 8% of soda drinkers could
taste the presence of caffeine. 192 Concerns about the amount
of sugar as well as caffeine in soft drinks led a number of
school districts, particularly the Los Angeles School District,
to restrict soda sales. 193 Many schools are moving toward
limiting or banning the use of energy drinks.
Nicotine
In 2014 the surgeon general's office released the thirty-sec-
ond report on smoking: The Health Consequences of
Smoking-50 Years of Progress. It examines the tragedies
and the triumphs over the past 50 years in the war on
smoking. t9 sA
Tragedies:
• 480 ,000 Americans die prematurely every year from use
of tobacco (20 million since the first report in 1964).
• Smoking affects every organ and tissue in the body.
• New findings have added new illnesses aggravated or
caused by smoking to the dozens already known: liver
cancer, colorectal cancer, diabetes mellitus, rheumatoid
arthritis, and immune function.
• Aggressive marketing strategies, initiated and sustained
by the tobacco industry, deliberately misled the public
about the dangers of smoking and led to the worldwide
epidemic of tobacco abuse.
• Secondhand smoke has been linked to a variety of ill-
nesses and 40,000 premature deaths each year. 195A

50!!1
Anniversary of ei~are«e health warnings ...
The llcaJth Co
Smoking- 50~sec1ucncesof
earsof Prog~ess
' " CJ:lono
ft hesu~
On January 11, 1964, Luther L. Terry, M.D., the ninth surgeon
general of the United States, released the first report on the health
consequences of smoking. Fifty years later, in 2014, the thirty-second
report,The Health Consequences of Smok ing-50 Years of
Progress, was released.
Triumphs:
• A proactive public and government have cut the smok-
ing rate in half, from 44% in 1964 to 22% over the past
50 years.
• Scientific research has provided a critical scientific
foundation for public health action and legislation to
reduce tobacco use and prevent tobacco-caused illnesses.
• New restrictions on tobacco use have dramatically
diminished Americans' exposure to secondhand smoke.
• The United States has developed the knowledge and
the will to end the tobacco epidemic. 195A
Smoking and chewing tobacco cause
more deaths than all other psychoactive
drugs combined.
The continuing battle between the tobacco industry and the
public triggers weekly headlines.
"CDC Makersof e-ci9arettes,littleci9arstaraetkids"
USA Today,November 6, 2013
"Smokin9at epidemicstaaein India"
Seattle Times, February 22, 2008
"Abstinentsmokers·nicotinicreceptorstake more than a month
to normalize"
NIDA Notes, Volume 22, 1
"90% of male lun9 cancerdeaths are due to smokina"
CDC Facts Sheet,January 15, 2010
Uppers l.4l
I
"NewYorkCit~ Councilraisesle9alaae for tobaccoto 21"
Bloomberg onl ine, October 30, 2013
"NYC, $11ci9arettes,Willsk~hi9hsmokin9tax makeNew
Yorkershealthier?"
CBS News, June 23, 2010
The frequent headlines and articles relating to tobacco em-
phasize the influence of nicotine on the world's healthcare
system, university research facilities, and legal system. About
22% of Americans are regular smokers; that percentage is
much higher in most other countries . If smokeless tobacco
is included, that percentage jumps to 26. 7% in the United
States. Some hospitalists estimate that 15% to 40% of their
patients ha ve tobacco-related diseases, but statistics tell on ly
part of the story. The experiences of those who have smokers
in their family make it personal.
"One of the sounds I rememberfrom9rowin9up in the forties
and f1~ieswas the sound of m~ dad's c19arettecou9h. It started
deep in the lun9sand ended in an explosionof air. I could tell
he wasapproachin9froma blockawaf I just acceptedit as a
for
fact of life. He later becameadvertisin9director American
Tobaccojust whenthe firstSur9eonGeneral'sReporton Health
and Tobaccowas releasedin 1964. He9a,e up smokin9in 1976
a~erretirin0but died of throatcancer17 ~earslater.causedb~
his ~earsof smokin9[accordin9to his oncolo9ist].Talkabout
mixedfeelin9s. tobaccosupportedour famil~.then took his
life and those of millionsof others. Incidental/~,m~ mother was
also a smokerand had died 18 ~earsearlierfrom lun9 cancer.''
William E. Cohen, co-author of Uppers, Downers, All Aroundcrs
History
American Indians and Tobacco
Tobacco is native to the western hemisphere . It was vener-
ated as a plant of the gods and used in spiritua l and health
rituals in ancient Mesoamerica (Mexico and parts of Central
 3.44 CHAPTER 3
I
This lithograph by Frederick William Fairholt is rilled Les Fumeurs
et les Priseurs , or Smokers and Snuff Users . He did this woodcut
and others for his 1859 book, Tobacco: Its History and Association .
Reprinted by permission of the GeorgeArents collection, New YorkPublic Library.
All rightsreserved.
America), South America, and some Caribbean islands.
Civilizations including the Maya (2500 B.C.) , Zapotec (1700
B.C.), Aztec (A.D. 1300), Inca (A.D. 1300), Arawak (A.D.
1400), and a dozen others-all cultivated and hybridized
various species of Nicotiana . The use of tobacco did not
occur in Europe and Asia until the late 1400s. 195
The explorers of the New World-Christopher Columbus ,
Amerigo Vespucci, and other French, Portuguese , and
Spanish adventurers-noticed that when the American
Indians "drank the smoke " of certain dried leaves, they ex-
perienced both stimulatory and sedative effects from the
process. 23 •196 Explorers , writers, and diplomats , such as Jean
Nicol de Villemain, Ram6n Pane , and Heman Cortes, intro-
duced tobacco to Europe, where it was used for recreation
and as a medicine . It was considered a cure for almost
every known illness, including ulc erated abscesses , fistulas ,
and sores. In this centur y it is considered the causeof just as
many diseases. Use spread by sailors, who carried the leaves
and the methods of use to Europe, Russia, Japan , Africa,
China , and virtually every other country in the world. 197
Originally, smoking tobacco in a pipe several times a day
was the most common form of use, but in the eighteenth
century chewing tobacco and using snuff (smokeless
tobacco) became popular in Europe and America. Smoke less
tobacco remained th e preferred method of use until the end
of World War I. 198 Interestingly , some of the reasons for the
switch to cigarettes were worries about the health risks of
smokeless tobacco , including the fear that chewing caused
tuberculosis , a dreaded disease in the nineteenth and earl y
twentieth centuries. 199 ,200
Growth of Cigarette Smoking
Technical and social developments increased both the use of
tobacco and the level of the active psychoacti ve ingredient ,
nicotine, in tobacco products. The developments included:
• improved cigarette-manufacturing technology (cigarette-
rolling machine)
• a milder type of tobacco that allowed for deeper inhala-
tion and more-continuous use
• lower prices due to mass production
• more-skillful advertising
• more-aggressive marketing techniques
• freebase nicotine, a more addictive chemical
Marketing strategies emplo yed during World Wars I and II
were targeted toward Gis. Cigarette companies took advan-
tage of the perception of patriotism by supplying free or
cheap cigarettes to soldiers; this generosity expanded their
markets as millions of Gis became addicted. England even
stockpiled cigarettes during World War II in case of invasion
or an intenuption in the suppl y. The populari ty of tobacco
increased not only the number of smokers but also the
amount of government revenue from excise taxes. Even
though the number of smokers has declined steadil y since
2000 , gross sales of tobacco products in the United States in
2005 were approximatel y $89 billion. 201
Milder tobacco, cheaper cigarettes or
chewing tobacco, and intensive marketing
and advertising greatly increased use and
therefore multiplied health problems .
In the late 1800s, when the average for most smokers was 40
cigarettes per year, the nicotine and the tars did not cause the
far-reaching health problems that we see toda y. The con-
sumption of an average heavy smoker is 20 to 40 cigarettes
per day, or more than 10,000 per year. Here are some stats
from 2011 alone.
• 29 3 billion cigarettes were sold.
• 124.6 million pounds of smokeless tobacco were pur-
chased .
• About 60 million Americans age 12 or older smoked
cigarettes in the past month.
• 36.9 million smoked cigarettes on a daily basis.
• 13.1 million smoked cigars.
• 1.88 million smoked tobacco in pipes.
• 8.67 million used smokeless tobacco.
• Worldwide, 5 trillion cigarettes are smoked annually.
 Uppers l.45

5,000

AdultperCapitaCigarette
Consumption
1900-2012
4,000 Nicotine
medications
i available
over-the-counter
] U.S.entryinto
WorldWarII messages
on Tobacco
Master
3,000
broadcast
media Settlement

I
j Accumulation
1986Surgeon
General's
Report on
ill,
v of evidence secondhand
smoke
0

1 2,000
linkingsmoking
to cancer

1,000

0 -1':":":';"; :;:;--, mmmmmmmmm~~~~~~~~~mmmmmmmmmm~~~~ = ~

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2012
Year

• $15.4 billion was collected just in state taxes. Federal

tax rates of $1.01 per pack generated about $17 billion
in revenue.

Historically, a 10% increase in the price of cigarettes decreases

consumption by 4%. 1•201

Smokeless Tobacco
Compared with the 57 million Americans who smoked
cigarettes in the past month, about 9 million used
smokeless-tobacco. Smokeless-tobacco use in the past
month among twelfth-graders dropped from 12.2% in
1995 to 8.3% in 2011; for tenth-graders those figures
decreased from 9. 7% to 6.6%. 218
The three major types of smokeless tobacco (also referred to
as "spitting tobacco") are moist snuff, powder snuff, and
loose-leaf.
Moist snuff is finely chopped tobacco that is placed in the More than 120 million lbs. of smokeless tobacco (moist snuff ,
powdered snuff and loose-leaf tobacco) , were sold in the United States
mouth next to the gums, where the nicotine is absorbed into
last year. That averages 20 lbs per user.
the capillaries. Popular brands are Copenhagen ®and Skoal ®
0 2014 CNS Productions, Inc.
Moist snuff is the most popular form of smokeless tobacco in
the United States.
Gutha is a form of moist snuff that is extremely popular in
India. It consists of betel nuts, betel leaves, tobacco paste, Powder snuff ( dry snufl) is a fine powder that is most often
clove oil, glycerin, spearmint, menthol, and camphor. Gutha sniffed into the nose or rubbed on the gums. Stems and
may be responsible for an even higher rate of cancer and leaves of the tobacco plant are fermented, dried, and then
health problems than American moist snuff. ground into powder. Dry snuff is available as plain, toast
 3.46 CHAPTER 3
I
Each of the four producrs from the makers of Camels is meant to
deliver nicotine ; and though the lungs are protected as compared with
smoking, the addictive properties of nicotine are just as powerful .
Once dependent, the user might switch to cigarettes.
0 201 4 CNSProductions, Inc.
(very dry), medicated (flavored with menthol, camphor, or
eucalyptus), and scented, as well as a German variety called
Schmalzler. American snuff is coarsely ground and is meant
to be "dipped," or applied to the gums for absorption.
Sniffing snuff is irritating to mucosal tissues and deadens the
sense of smell, so it is not as popular as smoking or chewing
tobacco.
Loose-leaf chewing tobacco is stuffed into the mouth and
chewed to allow the nicotine-laden juice to be absorbed . It
comes in three forms; twist , plug, and scrap. Brands include
Beech-Nut ® and Red Man. ® There are approximately 9 mil-
lion regular smokeless-tobacco users in the United States ,
generating annual sales of more than $ 1 billion. 1-20 1
In an attempt to address the smoke-free laws sweeping the
United States and to make using tobacco more socially ac-
ceptable, in 2006 the tobacco companies came out with
alternatives to traditional smokeless-tobacco products.
These include Camel ® Snus and Philip Morris's Tahoka. ®
These are tobacco pouches that nicotine users place in their
cheeks to absorb the nicotine . There are also Strips, ® Orbs, ®
and Sticks, ® which dissolve in the mouth over a period of
three to 30 minutes. Cynics say this is an attempt to recap-
ture young people's interest in using nicotine by designing
novelty products that are just as addicting but are not as
gross because there is minimal tobacco juice.
Smokeless tobacco is used by some professional and amateur
male athletes in the United States for both the stimulation
and the calming effect. Also these new forms of spitless
chewing tobacco are easier to hide from TV cameras and
the coach.
Botany and Pharmacology
Nicotine is found in the leaves and other parts of a plant
species belonging to the genus Nicotiana, a member of the
deadly nightshade family that also includes tomatoes , bella-
donna , henbane , and petunias. There are 64 Nicotiana species ,
but most commercial tobacco comes from the milder broad-
leafed Nicotiana tabacum plant and a number of its variants.
Though tobacco is available in cigarettes, cigars , pipe tobacco ,
snuff , and chewing tobacco , cigarettes account for 90% of all
tobacco use in the United States. In India smokeless tobacco
is more popular (75% of all tobacco use is smokeless) .
Whether it is smoked , che wed, absorbed through the gums , or
even used as an enema , this stimulant ultimately affects man y
of the same areas of the brain as do cocaine and amphetamines
though not as intensely.
Nicotine
Nicotine is the crucial ingredient in tobacco responsible
for cardiovascular effects, psychoactive changes, and de-
pendence. The average tobacco leaf (Nicotiana tabacum)
contains 2% to 5% nicotine, a bitter, smelly, colorless , and
highly poisonous alkaloid that , wh en mixed in water, is a
powerful insecticide . Inhaling smoke from a cigarette deli v-
ers nicotine to the brain in five to eight seconds. Chewing
tobacco or placing snuff on the gums deli vers the nicotine in
three to eight minutes.
• The average cigarette contains 10 mg of nicotine but
delivers only 1 to 3 mg to the lungs when burned and
inhaled. Chain smokers might get up to 6 mg in their
lungs before rapid distribution and metabolism put
a damper on high blood nicotine levels. About 70 mg
ingested at one time is fatal.
• By comparison one chew of tobacco will deliver ap-
proximately 4.5 mg of nicotine, and one pinch of snuff
about 3.6 mg. This potentiall y makes the addiction li-
ability of smokeless tobacco more powerful than that of
cigarettes.
• The actual blood nicotine level of one cigarette is mea-
sured as approximatel y 25 micrograms per liter of blood
(25 µg/L). The average smoker maintains a nicotine level
of 5 to 40 µg/L , depending on the time of day.202
• The nicotine in the first cigarette of the day raises the
heart rate by 10 to 20 beats per minute and the blood
pressure by 5 to 10 units.
I
It is the nicotine in tobacco that is responsible
for the addictive qualities of tobacco as well as
the cardiovascular and respiratory effects.
The addictive effects of nicotine are the main reason for the
widespread use of tobacco. Nicotine, a CNS stimulant, dis-
rupts the balance of neurotransmitters (endorphins, epi-
nephrine, dopamine, and particularly acetylcholine).
Acetylcholine affects heart rate, blood pressure , memory ,
learning , reflexes, aggression , sleep , sexual activit y, and
mental acuit y. Nicotine mimics acet ylcholine by slotting into
nicotinic acet ylcholin e receptor sites, exaggerating those
cholinergic effects. In contrast , the release of dopamine
mak es a smoker feel satisfied and calm : cigarettes both stim-
ulate and tranquilize .

BloodNicotine
Level
Eachpuff producesa
spike ofnicotine in
blood andbrain
0 10 12 14
Wakeup
24hours
''Ci9arettescalmme down,althou9hthe~don't9iveme a rush
or hilihlikecokeorevenmarijuana.I thinkwhat the~do is
sat/sf~m~ nicotineneed; and since I can't smoke in the house
an~more, it 9ets me awa~ from the kids.Also, it's somethin9
I can do b~m~self"
39-year -old female pack -a-day smoker
An intense desire to maintain a certain nicotine level in the
blood and the brain to avoid withdrawal symptoms is the
primary reason why people continue to smoke. In addition,
the authors believe that the very act of relieving withdrawal
symptoms can activate the nucleus accumbens, inducing a
certain sense of reward. Some suggest that this same effect
is delivered by the rush that comes from reversing heroin/
opioid withdrawal by using. 63
Freebase Nicotine
In the early 1990s, the tobacco industry publicly maintained
that nicotine was harmless and non-addictive despite vast
scientific evidence to the contrary; if it was addictive, tobac-
co companies said, they were unaware of that fact. They said
that brand loyalty, smoker satisfaction, and taste were the
main reasons why people preferred a certain brand. The re-
lease of internal memos and data to Dr. Stanton Glantz and
others showed that the tobacco industry not only knew of
the addictive nature of nicotine but also manipulated grow-
ing and manufacturing techniques to decrease the nicotine
content but increase its "impact. " 20 2A
"Dowe reall~want to tout ci9arettesmokeas a dru9? It is of
course,but there are dan9erousimplicationsto havin9such
conceptualization
90 be~ondthesewalls."
W. L. Dunn memo at Philip Morris, 1969
In addition, company documents that came to light due to
the Tobacco Settlement Act of 1999 showed how the addi-
tion of an ammonium compound changed nicotine hydro-
chloride to freebase nicotine in much the same way that
cocaine hydrochloride was converted to freebase cocaine in
the 1970s. This addition made the drug cross the blood-
brain barrier more swiftly and provided a quicker, more
addictive hit to the brain. 203 ,204
Uppers l.47
This chart shows the change in blood nicotine
levels in a heavy smoker for a 24 -hour period.
Notice how the overnight drop in the blood-
I
nicotine level might lead to an intense craving
for a cigarette and a cup of coffee the first thing
16 18 20 22 24 in the morning.
Sleep Wake up
"Asa resultof its hi9hersmokepH, the currentMarlboro,
®
despite a two-thirds reductionin smoke tar and nicotineover
the qears, calculatesto have essential/~the same amount of
free nicotinein its smoke as did the earl~Winston.®"
R.J . Reynolds memo, 1973
Evidence shows that the Philip Morris Company was aware
of and had used freebase nicotine since the early 1960s.
The addictive nature of the Marlboro ® brand was increased
by the manipulation of its nicotine to freebase nicotine while
an iconic advertising campaign (The Marlboro ® Man) cor-
nered the largest percentage of sales year after year (43.6% in
2012).
The manipulation of tobacco to create
freebase nicotine in the 1950s allowed it
to cross into the brain more quickly and
made it more intense and therefore
more addictive,
Other tobacco companies recognized the economic value of
making nicotine more addictive. As they watched Marlboro's
success, they made use of the same processing techniques for
their own products. In secret memos, company officials re-
ferred to this effect as producing greater nicotine impact.
Following Phillip Morris's lead, the other companies reduced
the amount of nicotine in their brands by using a greater
proportion of the freebase nicotine.
"It appearsthat we havesufficientexpertiseavailableto builda
loweredm9 tar ci9arettewhich will deliveras much 'freenico-
tine' as a Marlboro, Winston, or Kent without increasin9the
total nicotinedeliver~abovethat of a 'li9ht'product."
Brown & Williamson Tobacco Company memo , 1980
The controversy surrounding what the tobacco companies
knew and when they knew it is the subject of pending law-
suits and criminal prosecutions awaiting several Supreme
Court decisions. The distrust of the tobacco industry
prompted the Obama administration in 2009 to grant the
FDA the authority to regulate tobacco.
 l.48 CHAPTER 3
Other Reasons for Continued Use
Besides the craving caused by the nicotine and the mildly
pleasurable effects that smokers receive from tobacco, some
of the reasons for continued use are:
• social context (the smoke break at work, after meals, or
after sex)
• ritual aspects of lighting up and smoking
• perception of smoking as an adult activity
• desire to manipulate mood
I
• desire to be rebellious
• perception that smoking is sexually attractive
Weight Loss Because nicotine suppresses appetite and in-
creases metabolism, smokers weigh 6 to 9 lbs. less than
nonsmokers. 62 Withdrawal from smoking is often accompa-
nied by weight gain, and the fear of putting on pounds
keeps many smokers from quitting and causes relapse when
the number on the scale goes up. One hypothesis attributes
weight gain to the fact that nicotine raises the metabolic
rate to burn more calories as it lowers the inherited weight
set-point. 206
Self-Medication Research also confirms that smokers use to-
bacco to counteract depression. Major depression occurs
twice as often in smokers as in nonsmokers (6.6% to 2.7%).
Smokers who have had at least one episode of major depres-
"Your retirement package will give you plenty of
money for the rest of your days, provided you
start smoking three packs of cigarettes a day."
© 2007 John McPherson.Universa
l PressSyndicate.
sion are less likely to succeed when they attempt tobacco
cessation than those who have not (14% to 28%). 202 One
study found that nicotine raises mood by boosting brain do-
pamine levels about 8%.207 Genetic predisposition to nico-
tine addiction also occurs. A 2011 study discovered that a
gene linked to causing major depression was also correlated
to increased nicotine addiction .207A
"It calmsme down.Now I thinkI'mnot sureif it's mostlq
the calmor just the fact of gettingridof the stressof having
a nicotinefit... keepinJ.3
the nicotinelevelsup to a pointwhere
I don't stressout, or freakout, or bitchat anqbodq,or qell,
or scratchtheireqesout."
20-year smoker
Tolerance,Withdrawal, and Addiction
Tolerance
Physiological adaptation to the initial effects of nicotine
develops rapidly, some say more rapidly than to the effects
of heroin or cocaine . A few hours of smoking are sufficient
for the body to begin learning how to handle these new tox-
ins, probably through neural adaptation. Echoing users of
other drugs, smokers say that the first hit in the morning
is the best because their nicotine level rises more dramati-
cally in the morning after several hours of abstinence than
it does at any other time of day. Smokers who quit and then
stan again initially feel the dizziness and the nausea of a
novice user.
"I can't tellqouhowviolentlqI coughedwithmq first
cigarettewhenI was15 qearsold. I wasdizzqand nauseated,
but I had impressedmq friendsthat I wouldtrq it. Now,at the
ageof 25, I havea coughand a two-pack-a-daqhabitthat
costs about$4,000 a qear."
Two-pack-a-day smoker
Once smokers adapt to the initial effects of tobacco, they
reach a level of tolerance that does not increase over time.
One study showed that regular smokers who increased their
average intake by only 50% experienced dizziness, nausea,
vomiting, headache, and dysphoria. 208
Withdrawal from a one- or two-pack-a-day habit can cause
headaches, nervousness, fatigue, hunger, severe irritability,
poor concentration, depression, increased appetite, sleep
disturbances, and intense nicotine craving. The severity of
these symptoms is the main cause of relapse. 209 A true physi-
ological dependence develops through rapid tissue and
chemical alterations in the brain. One causal process is the
creation of more acetylcholine receptors, particularly the nic-
otinic receptors; so, when a smoker stops using tobacco, the
activity of acetylcholine is greatly exaggerated by all these
extra-activated receptors, making the user restless, irritable,
and discontent. When a user quits, the extra receptors raise
craving to a fever pitch because they are not being filled.
Researchers at Yale showed that it takes more than a month
for those extra nicotinic receptors to be pruned, leaving the
 Uppers l.49

low-nicotine brand, they often increase the number of ciga-

rettes they smoke to maintain their target nicotine levels.
Nicotine craving may last a lifetime. Continued use of a drug
to avoid negative effects of withdrawal is known as negative
drug reinforcement.

I
Addiction
For centuries, observers noticed the addictive qualities of
nicotine.

"/ cannot refrainfrom a few words of protest a9ainst the

astoundin9fashion latel~ introducedfrom America, a sort of
smoke-tipplin9, which enslaves its victimsmorecomplet elq than
an~ other form of intoxication, old or new. These madmen will
swallowand inhale with incredible ea9erness, the smokeof a
planttheqca/1 'herbaNicotiana ,' or tobacco."
German ambassado r to The Hague , 1627

The use of tobacco is the purest example of the addictive

This series of PET scans shows how nicotine lowers the overall activity
in the brain after one puff, three puffs, one cigarette, and three
cigarettes. Smoking attaches nicotine to some nicotinic receptors that
affect acetylcholine. The red and the yellow show an active brain; the
blue shows an inactive one. Because of this effect, smoking can disrupt
communication between the "go" and "stop" circuits, thus making it
harder to quit any addiction. For this reason smoking -cessation classes
are part of or at least offered in most treatment centers. 202A,ww . w2e
National Institute of Drug Abuse. Courtesyof AL. Brody.
smoker especially vulnerable to relapse. 210 ,2 ll Studies indi-
cate that abrupt withdrawal from nicotine results in a sig-
nificant dampening of the brain 's reward function, an effect
that lasts for days. 212 The resultant lack of a reward function
drives a person to crave nicotine when use is discontinued.
The sense of relaxation and well-being that most smokers
receive from a cigarette is actually the sensation of the
withdrawal symptoms being subdued. For this reason
smokers try to maintain a constant level of nicotine in the
bloodstream and the brain. If smokers switch to a low-tar/
process. The pleasure received from the direct effects of
smoking is not as intense as the initial pleasure derived from
alcohol, cocaine, or almost any other psychoactive drug. For
almost every first-time smoker, the negative feelings from
the initial tobacco use outweighed any perceived pleasure .
Nicotine addicts rarely identify their very first use of tobacco
as pleasurable.
"When I counsel recoYerin9 cocaine or heroinaddicts, the~ can
describethe hi9htheq9ot earlqon in their dru9-usin9
historq;
theqcan90 on and on, describin9the rush and the euphoria .
But whenI ask themto describe their tobaccohi9h,theq hem
and hawand saq that a~ertheq9ot usedto the cou9hin9,diz-
ziness, headache, and eYennausea, the~9ot a mild stimulation
or calmin9effect. And ~et nicotine is considered to be just as
addictin9 as heroin."
Darryl Inaba, Pharrn .D., co~author of Upprrs, Downrrs, All Arowulus
One of the strongest indicators of the addictive potential of
tobacco is the percentage of casual U.S . tobacco users who
become compulsive users compared with the percentage of
casual U.S. users of other psychoactive drugs who become
compulsive users.

Percentage
of U.S.Population
thatSmoked
Cigarettes
inthePastMonth
1965 I 51%
1974 460/o
1980 42%
1985 39%
1990 33%
1995 29%
2001 24.9%
2005 24.9%
2009 23.3%
2012 22.10/o
SAMHSA 2013
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55%
 3.50 CHAPTER3
• 3 7 million people tried cocaine; about 600,000 are
weekly users, and a tiny fraction are daily users.
• 111 million people have tried marijuana, but only 6.8
million use it weekly and a small percentage use it daily.
• 214 million people have tried alcohol, fewer than 60 mil-
lion binge-drink, and 17 million drink daily.
• 162 million people have tried cigarettes, 57 million
smoked in the past month, and 43 million smoke daily. 1
These figures show that almost one-fourth of those who ini-
I
tially smoked a cigarette became daily habitual users com-
pared with one-tenth of alcohol experimenters who became
daily abusers. In a British study, 90% of the teenagers who
had smoked just three or four cigarettes at the time of the
survey were compulsive smokers years later. This statistic
indicates that even the most casual use of tobacco can lead to
compulsive use.
The argument for smoking has always centered on the right
of personal choice; however, 80% of smokers interviewed
say they want to quit, and another 10% say they want to
limit the amount they smoke. That means that nine out of
10 smokers are unhappy with their smoking yet do not or
cannot stop because of nicotine dependence and addiction.
In many countries the rate of daily use (as opposed to
monthly use of 22.1 %) is higher than the 19% rate in the
United States. In China 60% of adult males but just 4% of
women smoke. In England and Japan, the figure is 22%.
Globally, 1 billion adults smoke: 4 7% of men and 12% of
women. Many more use smokeless tobacco. 213
Nicotine craving is more subtle and less noticeable to the
user than cocaine, heroin, or alcohol craving, but it is just as
powerful and may be associated with a "self-determined nic-
otine state of consciousness" or "state dependence." This
means that people will try to achieve a certain mental and
physical state that may be neither pleasurable nor objec-
tionable but a state with which they are familiar and one
that they, not others, have determined.
I
Research indicates that a genetic
predisposition to nicotine addic- 800/oof
smokers
tion makes tobacco use more diffi-
want to quit.
cult to stop for some than for
others. 209 ,214 Genetics also indicates
that each ethnic group has its own susceptibility to nicotine
addiction. 215
One of the suspect genes is the same survival pathway
gene-DRD 2A 1 allele-implicated in a predisposition to al-
coholism and other drug addictions. 216 This may explain why
smoking tobacco is so closely connected to the abuse of other
drugs. For example, an adolescent smoker is 3 times more
likely to abuse alcohol, 8 times more likely to abuse mari-
juana, and a staggering 22 times more likely to abuse cocaine
than a nonsmoking teen. 62 Scientists continue to examine
genes associated with acetylcholine, which affects various
aspects of smoking, such as dizziness from first cigarette,
pleasure from initial cigarette, age of smoking initiation, in-
creased risk of dependence, and lung cancer. 214 Based on
UsebyEthnicOrigin
Tobacco
PastMonth,18orOlder
ETHNIC
GROUP PERCENrAGE
OFETHNIC
GROUP
THAT
SMOKES
American
Indian or Alaskan 31.5%
vVhi
te 20.6%
Black 19.4%
Hispanicor Latino 12.9%
Asian 9.9%
SAMHSA, 20 13 Household Survey
these and other similar discoveries, research continues to
search for medications that halt nicotine craving.
Because tobacco addiction is just as serious as other addic-
tions, when an individual enters treatment for an addic-
tion, smoking cessation should be included in the treat-
ment plan. (All psychoactive drug use needs to cease.)
The states of New York and Oregon developed a full-scale
tobacco-cessation program for those being treated for alco-
hol and other drug addictions. Statistics indicate that when
smoking cessation is part of a drug treatment program, the
chances of recovery from all drugs greatly increases. 217
Age of FirstUse
The younger a person is when experimentation with alcohol,
marijuana, nicotine, or any kind of drug begins, the more
likely he or she is to develop a chemical dependency. This is
particularly true with cigarettes. The age of first use is the
best indicator of whether a person will carry the habit into
adulthood.
A youth who starts to experiment with nicotine (or any
drug) between the ages of 8 and 12 is five times more likely
to end up with a smoking/drug abuse problem at some point
in life than someone who delays experimentation until age
18 or 19; and that individual is 18 times more likely than
those who wait until they are 21 or older.
'We alsoknowthat a ~oun9personwhodoesn't startsmokin9
beforethe a[j'of17-ifthe~ don't9et cau9ht. and hooked,
and bu~intosmokin9of ci9arettes
before17or 18- the~
prohabl~are not 9oin9 to start acrosstheir lifetime."
Andrea Banhw ell, former depu ty drug czar under George W Bush
Prevention should be targeted to age of first use. Campaigns
like "just say no" targeted at youth support an important
message, but research proves that delaying the age of first use
results in fewer drug, alcohol, and nicotine addictions.
Side Effects
Cigarettes expose the smoker to other toxic substances along
with nicotine. Tobacco contains some 4,000 to 4,800 chem-
icals; 400 are toxins, and 69 are known carcinogens (can-
cer-causing substances, e.g., cadmium, hydrogen cyanide,
vinyl chloride, toluene, benzene, and arsenic). 219 When to-
bacco is burned in a cigarette or cigar, the smoke contains

fine particles and droplets of tar (a blackish substance that
has direct effects on the respiratory system) and nitros-
amines (some of which are carcinogenic). 220 ,221
Worldwide in 2010 tobacco smoking was estimated to
cause 5.4 million premature deaths. 222 This figure will in-
crease to 8. 4 million annually by 2020. In China alone about
3 million smokers (mostly men) will die prematurely each
year by the middle of this century. 213 ,223
In the United States, an estimated 438,000 smokers die
prematurely from smoking. Most of these deaths are from
lung cancer, heart disease, and lung disease. Another 41,280
nonsmokers die from secondhand smoke, for a total of
480,000 deaths due to smoking (278,540 men and 201,770
women). 19 sA,n 4,225About 8.6 million U.S. residents have at
least one serious illness caused by smoking; for every
smoking-related death, 20 more people are living with a
lower quality of life due to cigarettes. The 2014 Surgeon
General's Report on smoking reiterates that nicotine is toxic
to every organ in the bod y.195 A
The high figures reflect the fact that it often takes 20, 30, or
40 years for tobacco's most dangerous effects to become le-
thal. Most people who die from smoking have been using for
more than 20 years, so the immediate warning signs of over-
dose-heart palpitations, blackouts, hangovers, rage, para-
noia, and nausea---common with other psychoactive drugs
are missing. Except for the coughing, dizziness, initial nau-
sea, bad breath, green mucous, lowered lung capacity, and
lowered energy levels, there are no red-flag warning signs.
Unlike the very visceral, very immediate warning signs of
cocaine, heroin, or alcohol overdose, those due to tobacco
are very subtle and slow. The dangerous side effects of drugs
weigh directly against the pleasure received. Craving tobacco
can be somewhat countered by an intellectual appreciation of
the long-term dangers; however, the craving and the fear of
withdrawal usually win over common sense.
Residentia
l fires 620 Premature
Deaths
Caused
Secondhandsmoke ~=====:- 41,280
Perina
tal 1,013
Diabetes 9,000
Stroke 15,300
Other cancers 36,000
Chronic
lungdisease
Lungcancer
Heartdisease
50,000
People
Total number of estimated premature deaths caused by smoking and secondhand smoke is more than
480,000 per year. 19 ~"
Uppers 3.51
Smoking costs the United States more than $176 billion
each year in health-related economic losses. 195 A This works
out to about $4,000 to $6,000 for every pack-a-day smoker
per year.
Longevity
"It mi9htbe shortenin9 mq life, and I don't breatheas well.
I loveto hikeand that's diff,cult.I 9et shortof breathtoo
easilq.Get dill1j.I wantto bearoundwhenmqkids9et older,
mq future9randchild.I'd liketo bearound, and thesedon't
I
seem to be conduciveto that."
20 -year-old female smoker
An exceptionally healthy 75-year-o ld smoker does not con-
tradict the fact that smoking shortens life or impairs health.
The overall statistics show that, on average, the life of an
adult smoker in the United States is shortened by 14 years.
In the United States, 25 million people alive today will die
prematurely from smoking-related illnesses. 224 In the most
extensive study of smoking mortality, British researchers fol-
lowed a group of 35,000 doctors and found that, on average,
smokers ' lives were shortened by 10 years. 226
On average, the life of an adult
smoker in the United States is
shortened by 14 years,
Cardiovascular Effects
Smoking accelerates the process of plaque formation and
hardening of the arteries (atherosclerosis), the major cause
of heart attacks, by increasing low-density fats, increasing
blood coagulability, and triggering cardiac arrhythmia (ir-
regular heartbeat). The inhaled carbon monoxide created by
tobacco combustion also accelerates the process of athero-
sclerosis. In addition, because nicotine constricts blood
bySmoking
113,100
130,659
136,300
100,000 150,000
 3.52 CHAPTER 3

vessels, it restricts blood flow and raises blood pressure, in-

creasing the risk of a stroke (blocked or ruptured blood ves-
sel in the brain).
In 2008 in the United States. one-third of the 480,000
deaths from smoking-related illnesses were due to cardio-
vascular disease; 35,000 of those cardiovascular deaths
were caused by secondhand smoke. 227 Worldwide, smoking
is responsib le for 11% of all cardiovascular deaths. 228

"Probabl~
30% to 40% of m~patientsha,e a si9nircant
smokin9

I
histor~.The main problemis atherosclerosis,or hardenin9of the
arteries;even a few ci9arettesa da~ will insult the linin9softhe
arteries;the moresmokin9,the moreblocka9e . Peoplethinkthat
onl~afew ci9arettesa da~ won'thurt, but the oppositeis true.
One o the reasonsis that arter~blocka9edoes not pro9ress
littleb~littleup to a blockedarter~.resultin9in a heartattack.
The truthis usual/~that 80% of heartattacksstartas on/~a
20% blocka9e in the mornin9, but the plaqueon the wallof
the arter~ruptures , causin9thisdebristo blockthe arter~
completelf Because coronar~arteriesare so small, the~ are
o~en the ~rst to be blocked, but atherosclerosisforms in carotid
arteries,renal arteries,and femoral arteries. Even a few ci9arettes
a da~ raise the risk of death or heart attack more than 400 %.
lncidentall~, the other biBBestrisk factor is diabetes, most o~en
caused b~ overeatin9. No smokin9, 900d nutrition, and a little
exercise
and m~patientloaddropsdrasticallf"
Kent W. Dauterman, M.D ., FACC, chief of cardiology ,
Asante Rogue Regiona l Medical Center, Medford , OR

A report by the Institute of Medicine released in 2009 showed

that limiting secondhand smoke cut the incidence of heart
attacks by 6% to 4 7%, if earlier limits on smoking were
already in place. 229
Respiratory Effects
Cigarette smokers have a high rate of bronchopu lmonary
disease, such as emphysema, chronic bronchitis , and chron-
ic obstructive pulmonary disease (COPD). Children who
live with smokers have a much higher incidence of asthma,
colds, and bronchitis from inhaling secondhand smoke than
those who live with nonsmokers. Environmenta l pollutants,
such as asbestos and volatile chemicals, greatly contribute to
the rates of respiratory illness and cancer in smokers.
Approximately 80% to 90% of 130,000 COPD deaths are A normal lung (A) is pink and spongy.Smoking depositstar, other
chemicals,and irritants in the alveoli (air sacs) and destroysthe cilia
due to smoking. 330 Worldwide 650,000 deaths from COPD (fine hairs lining the membranes)that help removeforeign particles.
are attributable to smoking. 222 A smokers lung (B) is blackenedby these deposits.Many of the
Cancer chemicalsin tobacco,particularlythe tar,causecancer (C). More
than 100,000 smokers die prematurelyfrom tobacco-inducedlung
The increase in lung cancer since the 1930s, when the use of cancerevery y ear in the UnitedStates.
cigarettes started to accelerate, is startling. The rate has gone 0 2000 CNS Productions, Inc. Courtesy of Leslie Parr, Ph.D.
up nine-fold in women and fifteen-fold in men. Figure 3-8
juxtaposes the per capita smoking rate from 1930 to 2010
alongside the per capita death rate from lung cancer. In 1988
lung cancer deaths in women surpassed deaths from breast
cancer for the first time in history. • About 85% of men with lung cancer and 75% of women
• Men who smoke are 22 times more likely to develop lung with lung cancer smoke or had smoked.
cancer than men who do not. In 1979 in the United States, women composed 26% of lung
• Women who smoke are 12 times more likely to develop cancer deaths; by 2010 that number had grown to 45%, most
lung cancer than women who do not. caused by smoking. 224 ,23o,231
 Uppers 3.53

90
U.S.LungCancerDeathRate
vs.Cigarette
Sales
80

70

- Lungcancerratefor men
60 600
~- - Lungcancerrateforwomen
- Cigarettesales
50 500

I
.l"
1 40 400
0
'lll

j 30 300 rn
g
a
20 200 Because it takes 10 to 40 y ears for lung
s. cancer to develop, there is a delay in
're decreasing rates of lung cancer even though
10 100
i cigarette sales to men have been declining
for a number of years.
0 0 5Af..t1HSA,201
3
1930 1940 1950 1960 1970 1980 1990 2000 2010
Year

An estimated 1.42 million lung cancer deaths (1.18 million
men and 0.24 million women) occurred wor ldwide in 2008;
smoking was responsib le for 71% of these deaths. 228 ,228 A
The cancer-causing culprits are the tars and other by-prod-
ucts of combustion that the smoker inhales. Studies at the
University of California, Los Angeles show that precancer-
ous alterations in the bronchia l epithelium can occur from
habitual cigarette smoking and from habitual smoking of
crack cocaine, especially if the user also smokes cigarettes. m ,n 3
Pipe and cigar smokers are less likely than cigarette smokers
to get lung cancer but are more likely than nonsmokers to
get cancers of the mouth, larynx, and esophagus, though
many pipe and cigar smokers do develop lung cancer.
Smokeless-Tobacco Effects
Smokeless tobacco is just as addicting as cigarettes are,
even though the nicotine in its smokeless form takes three to
five minutes to affect the CNS when chewed or pouched in
the cheek compared with the seven to 10 seconds it takes
when inhaled from a cigarette . Smokeless tobacco delivers
more nicotine into the bloodstream and the brain (4 mg or
more) than does a cigarette (1 to 3 mg), and the rush is
somewhat more intense because many smokeless-tobacco
products have more nicotine, and more tobacco is used
when chewing or dipping. Smoke less tobacco is also formu-
lated with a higher pH, which promotes passage into the
capillaries and allows a greater concentration of freebase
nicotine to pass into the brain. Dipping snuff eight to 10
times per day can put as much nicotine into the body as
smoking 30 to 40 cigarettes. 234 The effects of chewing are
almost identical to the effects of smoking (except for the
coughing) and include a slight increase in energy, alertness,
blood pressure, and heart rate.
Choosing smokeless tobacco over cigarettes does protect the
lungs from the kind of damage caused by inha lation, lower-
ing the rates of cancer and other respiratory problems, but
other health complications caused by smoke less tobacco are
just as severe.
"/ can't thin( of a moredis9ustin9 habitthan chewin9tobacco.
I brokeup withm~bo~friend becausehe wasalwa~sdrippin9
tobacco juice, spittin9, and had those awful brownstains on
his clothin9. U9h."
17-year-old high school student
Smokeless tobacco irritates the tissues of the mouth and the
digestive tract. Many users deve lop leukoplakia, a thicken-
ing, whitening, and hardening of the tissues in the mouth.
Their gums can become inflamed, causing dental complica-
tions; and although the risk of lung cancer is reduced com-
pared with smoking, the risk of oral, pharyngeal, and
esophageal cancer is higher. In addition, because blood ves-
sels are constricted by nicotine whether the user is chewing
or smoking, circu latory and cardiovascu lar problems are as
grave with smokeless tobacco. One study found that dry
snuff has a higher oral cancer risk than moist snuff or chew-
ing tobacco. n 5 Data presented by the American Cancer
Society indicates that chronic snuff users have a risk of de-
veloping cheek and gum cancer that is 50 times higher than
nonusers. It is estimated that 25,000 new cases of oral and
other digestive system cancers were diagnosed in the United
States in 2010. 227
Fetal Effects
If a woman smokes while she is pregnant, her newborn will
have the same nicotine level as an adult smoker. About 15%
 3.54 CHAPTER 3

TheHealthConsequences
CausallyLinkedto Smoking
Cancers Chronicdiseases

rfii-li);ro.~ ---- Stroke

__,__
___ Blindness,
cataracts,
age-related
macular
degenera
tion
'Q'f,J~...i: f- --- defects-maternal
Congenital smoking:
orofacial
clefts
-----~
Oropharynx ---..1 Periodontitis

Larynx Aorticaneurysm,
earlyabdominal
aorticatherosclerosis
inyoungadults
-
Esophagus - -cc-,,,
"',.."".,~1/
i~I'.'---.. Coronaryheartdisease

I
Pneumonia
Atherosclerotic
peripheral
vasculardisease

Acute myeloidleukemia __.,..,IL'G-~

--4-
- Chronicobstructive
pulmonary
disease,
tuberculosis
,
asthma,andotherrespiratory
effects
Stoma ch - -++ -,1--='--------"'l'
Liver - -+. R- H-
Pancreas- f-lt-,h'f- ~f<--\J?~iS"----\\
:-k-k-1-
- Diabetes
Kidney - I-U--1-/-,
,__,,,
,..,,
Ureter -r- Ht--r.e-- "l -".c---W>----'-
l-Hip fractures
Reproductive
effectsinwomen(including reducedfertility)
--..~~ ---t----tr~ Ectopicpregnancy
Cervix
Bladder Male sexual
function-erectile
dysfunction
Colonandrectum---'--"'+ --- -,
Immunefunction
Overalldiminishedhealth

This is a compilation of the various diseases and conditions caused by smoking. Those in red are affected
organs and conditions that have been added since the initial reports.
USDHHS2004, 2006, 2012, 2014

of pregnant women smoke during pregnancy, causing their
babies to go through nicotine withdrawal. The carbon
monoxide and the nicotine in tobacco smoke reduce the
oxygen-carrying capacity of a pregnant mother's blood,
lowering the amount of oxygen her fetus receives, which
contributes to a lower birth weight and a higher incidence
of SIDS (sudden infant death syndrome). Research indicates
that expectant mothers who smoke heavily during preg-
nancy are twice as likely to miscarry or have spontaneous
abortions as nonsmokers. There is also an increased risk of
the child's developing early-onset conduct disorder and even
drug dependence. n 6
The 2004 Surgeon General's Report concluded that evidence
is sufficient to infer a causal relationship between active
smoking during and after pregnancy and incidence of SIDS,
fetal growth restriction, low birth weight, premature rupture
of membranes, placenta previa, placental abruption, pretenn
delivery, and shortened gestation. Smoking also reduces
fertility in women. rn
Benefits of Quitting
There are a surprising number of beneficial physiological
changes that occur when a smoker quits.
• Within 20 minutes of quitting, blood pressure and pulse
rate drop to normal as does the temperature of the hands
and the feet.
• Within 8 hours carbon monoxide level drops and oxygen
level increases, both to normal
• Within 24 hours the risk of a sudden heart attack
decreases.
• Within 48 hours ner ve endings adjust to the absence
of nicotine, and the senses of smell and taste begin to
return.
• Within 1 week the risk of heart attack drops, breathing
impro ves, and constricted blood vessels begin to relax.
• Within 2 to 12 weeks, circulation improves, lung func-
tion increases up to 30%, and the complexion looks
health y again,
• Within 1 to 9 months, fatigue, coughing, sinus conges-
tion, and shortness of breath decrease, and the lungs in-
crease their ability to handle mucus, thereby reducing
the chance of infection.
• Within 1 year the risk of coronary heart disease
decreases to half that of someone who is still smoking.
• Within 5 years the heart disease death rate is the same

as that of a nonsmoker, the lung cancer rate is half that
of a pack-a-day smoker, and the risk of mouth cancer
decreases 50%.
• Within 10 years the lung cancer death rate is almost that
of a nonsmoker, precancerous cells are rep laced, the in-
cidence of other cancers decreases, and the risk of stroke
is lowered to that of someone who never smoked.
• Within 10 to 15 years, the risk of all major diseases
caused by smoking is decreased to nearly that of some-
one who never smoked. 22 o,237 A
Health begins improving within
20 minutes of quitting and continuing
improving every day.
For those who began smoking in their teens, the potential
benefits to the lungs may not be as great once they quit.
Studies show that teens who smoke cause permanent genetic
DNA damage to their lung cells, leaving them at increased
risk of lung cancer for the rest of their lives even if they quit;
if they stop, however, that risk drops dramatically. Such
damage is less likely among users who started smoking in
their twenties. 238
The mental changes that occur when a smoker quits include
anxiety, anger, difficu lty concentrating, increased appetite,
and craving due to withdrawal. Most of these side effects,
with the exception of craving and appetite control, disappear
within two weeks. The nicotine addict's vulnerability to re-
lapse remains high for years after quitting, especially during
the first six months.
Treatment for Tobacco Addiction
The powerful addictive qualities of tobacco render most be-
havioral therapies unsuccessful. Instead many in the treat-
ment community and the general public have focused on
pharmacological treatments, occasionally in conjunction
with behavioral treatments.
Today the most popular smoking-cessation drug available
is varenicline (Chantix ®), a medication that controls crav-
ing. The initial success rate in Europe was 44%, with a
sustained rate of 22% to 23%. 239 ,240Another drug that con-
tro ls craving is bupropion (Zyban ®), with an initial success
rate of 30.5%.
Other pharmacological treatments involve nicotine replace-
ment therapy. These include nicotine patches, inhalers,
gum, nasal spray, and lozenges. Over a period of weeks or
months, these treatments slowly reduce the blood plasma
nicotine levels to a point where com plete cessation will not
trigger severe withdrawal symptoms.
Electronic cigarettes are being employed by a growing num-
ber of smokers to help them quit or at least cut back on their
smoking even though they were originally developed to let
people satisfy their nicotine craving in places where smoking
is banned.
A Massachusetts stop-smoking program targeting low-
income smokers cut smoking rates from 38% to 28% simply
Uppers 3.55
by counseling and paying for nicotine replacement therapy
for six months. Smoking-related illnesses and hospita l visits
among those treated also declined substantially. For exam-
ple, heart attack visits dropped 38%. 24 1
Researchers continue to search for vaccines that prevent nic-
otine craving by focusing on different receptors and genes
such as those that affect acetylcholine. The most effective
way to escape tobacco's hold is never to try in the first place.
The Tobacco Industry and Tobacco Advertising
I
The Business of Tobacco
The annual cost of a two-pack-a-day habit is about $4,380
per year based on an average cost of $6 per pack. Compromises
to the health of a smoker and the premature deaths that re-
sult from smoking are too numerous to mention, and yet
people continue to smoke. In fact, 80% of smokers believe
that cigarette smoking causes cancer, yet they continue to
lightup. 242
In 2008 U.S. cigarette sales were at their lowest point in 58
years-about 16 billion packs----causing tobacco companies
to look overseas to maintain and increase their sales reve-
nues. Cigarette and smokeless-tobacco use is growing 3%
per year in developing countries, raising the number of peo-
ple who use tobacco worldwide to 1.3 billion.
In the United States, a handful of companies control most
of the tobacco market:
• Altria Group, Inc. (Philip Morris: Marlboro, ® Virginia
Slims, ®and Basic®): 49.2% of industry
• Reynolds American, Inc. (Winston, ®Camel, ®Kool, ®Pall
Mall,• and Salem®): 27.8% of industry
• Loews Corporation (Lorillard: Newport, ® Kent, ® and
True®): 9. 7% of industry
By the 1980s the rising federal and state cigarette taxes made
smoking brand-name cigarettes expensive, so manufacturers
began marketing cheaper generic brands (e.g., Basic® by
Philip Morris). Other product developments were aimed at a
younger demographic and featured colorfully packaged fla-
vored cigarettes, using fruit, candy, or clove flavoring.
Health and consumer watchdog groups recognized the attrac-
tion teens would have to these novelty products and succeeded
in pressuring legislators to ban all flavoring but menthol.
Another attempt to expand the market took the form of hand-
rolled bidi cigarettes made of tobacco wrapped in a tendu
or temburni leaf (plants native to Asia). These innocuous-
looking cigarettes are made in India but are also sold in the
United States. The packaging is designed to be attractive to
children and teens, and the cigarettes come in flavors-
grape, chocolate, and root beer to name a few. The dark
Indian tobacco contains three times as much nicotine as
American-grown tobacco. Even carbon monoxide levels
were higher in some of the bidi smokers. The bidis are sold
for $1.50 to $3.50 for a pack of 20, often in convenience
stores and "head shops." In India bidis account for about
70% of the tobacco that is smoked, although more Indians
chew than smoke tobacco. The CDC estimates that 2% to
5% of U.S. teens have tried bidis.
 3 .56 CHAPTER 3
I
The packagingfor these brands ofbibi cigarettes has been designed to
appeal to teens.
0 20 14 CNSProductions, Inc.
Kreteks (clove cigarettes) come from Indonesia and contain
a mixture of tobacco, cloves, and other additives. Like bidis
they deliver more nicotine, carbon monoxide, and tar than
conventiona l cigarettes. 225 In 2009 the sale of kreteks in the
United States became illegal.
Electronic Cigarettes
Electronic or e-cigarettes began as another novelty nicotine
product, but their popularity has grown quickly. These
battery-operated electronic cigarettes deliver a fine mist of
nicotine in propylene glycol or glycerin along with other
flavorings and additives (the solution called "e-juice" or
"e-liquid"), packaged in refillable cartridges. Because
e-cigarettes do not release smoke, just mist, they can be
used in most places that ban smoking. These "vaping" prod-
ucts can fool novice users into thinking that because there is
no smoke, there are no health hazards. This ignores the fact
that all of the cardiovascu lar prob lems associated with
cigarette use are caused by the nicotine. 243
Electronic cigarettes are being used as an aid to smoking cessation, although the ingredients are not yet subject to intense scrutiny and regulation .
Nicotine and flavorings are the main ingredients .
0 2014 CNSProductions, Inc.
Because the products are relatively new, much of the industry
is unregu lated. 224 The FDA is redefining the definition of a
tobacco product to include e-cigarettes, while the industry
claims that it is an entirely different class of products. To date,
there is minimal regu lation regarding the content of the
liquids that are vaporized and inhaled. How much nicotine
enters the lungs when an e-cigarette is inhaled? What is the
effect of sidestream mist on nonsmokers? It is a bit amazing that
our laws specify and control tobacco but not its active sub-
stance, nicotine. E-cigarettes with nicotine can therefore be
sold to even middle-school and preteen youths. Various states
began addressing this loophole in the federal regulations in
2013 by enacting laws that prohibit the sale to minors. Some
cities are even enacting their own municipa l codes to regulate
e-cigarettes. Chicago has banned e-cigarettes, and New York
banned their use in public places.
Electronic cigarettes use a nicotine-soaked
solution that is free of the tars and other
chemicals found in normal cigarettes.
Unfortunately, the nicotine is responsible for
many of the health problems and the add iction .
E-cigarette sa les jumped to almost $2 b illion by the end of
2013, when 60% of the market was contro lled by smaller
companies. But when there is money to be made, the big
companies jump in. Lorillard Tobacco Company's e-cigarette,
Blu®, is expanding rapid ly and registering double -digit
growth every year. The Altria Group and Reynolds American,
two of the other top tobacco companies, have also entered
the e-cigarette market.
Some smokers are using e-cigarettes to help them stop smok-
ing or at least cut down on their consumption and to save
money. Higher prices and taxes could negate any financia l
savings gained by cutting back on tobacco use.
Advertising
In 2011 to bacco companies spent $8 .37 billion on advertis -
ing and sales p romotions (giveaways, premiums, promo-

Because of campaigns from false claims about the health benefits of smoking a certain brand to icons aimed at the younger set, cigareHe
advertising has been the object of criticism for more than 60 years.
tional allowances to retailers, and event sponsorships),
about $27 for every man, woman, and child in the United
States. 2-'I'>The five major smokeless-tobacco companies spent
$451. 7 mill ion for the same purpose.
Advertising works. As a resu lt of the Joe Camel®advertising
campaign in the l 990s, sales of Came l®cigarettes to teenage
smokers ages 12 to 18 more than tripled over a five-year
period while sales to adult Camel ® smokers remained the
same. The campaign was finally dropped in Ju ly 1997 due to
politica l and social pressure.
Even though Joe Camel ® made the b iggest media splash,
Marlboro ® is the most po pular cigarette among teenagers
and adults. In 2011 sales of Mar lboro ® were greater than
those of the next five leading brands combined. The market
shares for the top-three brands were 46% for Marlboro, ®
21.8% for Newport, ® 12.4% for Camel. ®245
Ethnically, the differences in brand preference are dramatic
among 12- to 17-year-o lds.
• 50% of Whites preferred Marlboro • while only 22.2%
preferred Newport. ®
• 33.3% of Hispanics preferred Marlboro • while 30% pre-
ferred Newport. ®
• 59. 7% of Blacks preferred Newport • while 30% preferred
Marlboro. ®H6
Women are another target market. Decades ago the tobacco
companies began extensive research and created campaigns
to appeal to women that featu red longe r, slimmer, and alleg-
edly "healthier" cigarettes. Worldwide smoking rates for
women are expected to increase 20% by 2025; rates for men
are falling.
Research confirms that if an individual begins to smoke as a
teen, the addict ion is much stronger than those who begin
smoking as adu lts. Tobacco companies target teen smokers
l.57
I
because they are less likely to break the habit during their
lifetime than an adult-onset smoker. 238 The CDC found that
approximately 80% of adult smokers started smoking
before the age of 18. 2-'17Marketing and advertising strategies
are created to appea l to new, young smokers. This confiden-
tial memo surfaced a few years ago, illustrating the measures
tobacco companies are willing to take to entice this lucrative
demographic:
"Thus, an attempt to reach young smokers, starters,
should be based, among others, on the following major
parameters:
• Present the cigarette as one of a few initiations into
the adult world.
• Present the cigarette as part of the illicit pleasure
category of products and activities.
• In your ads, create a situation taken from the day-
to-day life of the young smoker but in an elegant
manner have this situation touch on the basic
symbols of the growing-up , maturity process.
• To the best of your ability (considering some legal
constraints) , relate the cigarette to 'pot,' wine, beer,
sex, etc.
• Don't {their emphasis ] communicate health or
health-related points ."
>
About 80% of adult smokers
started smoking before the
age of 18.
In the early 1970s, the U.S. tobacco industry voluntarily
agreed to a partia l ban on advertising rather than face a tota l
ban or a requirement to surrender to the government $1
for every $3 spent on advertising to fund antismoking adver-
tisements. When done well, antismoki ng campaig ns are
 3.58 CHAPTER 3

extremely effective. In the 1990s anti-tobacco ads in Arizona,

California, Massachusetts, and Oregon reduced tobacco
sales by 43%---about twice the national average. In
Massachusetts $ 70 million spent on a prime-time TV anti-
tobacco campaign resulted in a 20% drop in cigarette sales
compared with a national-average drop of 3%.248 Lung and
bronchial cancer rates in California fell three times faster
than the national average. The adult smoking rate dropped
from 23% to 16%; high-school rates dropped from 22% to
13%. California spent $75 million on anti-tobacco advertis-

I
ing in 2005. The tobacco industry spends $36 million per
day on marketing nationwide.
In other countries, comprehensive bans that prohibit all to-
bacco advertising have had a significant effect on reducing
tobacco consumption. Four countries that enacted such ad-
vertising bans on tobacco-Finland, France, New Zealand,
and Norway----e.xperienced a per capita cigarette consump- Even though the smoking rate in most other countries is higher than
tion drop of 14% to 37%. 249 More and more countries are in the United States, many countries , such as Spain, have mandated
increasing limitations on where one can smoke. Even Cuba, more serious warnings on cigarette packages, along with graphic
well known for its cigars, banned smoking in public places images, and are enacting many laws that the United States already
has on the books, such as no smoking in public places and in the
in 2005.
workplace.
Laws and Lawsuits 0 2014 CNS Productions,Inc.

In June 2009 President Barack Obama signed the Family

Smoking Prevention and Tobacco Control Act, which has
been called a "sweeping antismoking bill." Among other re-
strictions, this act banned the use of any constituent, addi-
tive, herb, or spice that adds a "characterizing flavor" to the
tobacco product or smoke (e.g., flavored cigarettes). The aim
of the ban is to prevent children and teenagers from becom-
ing addicted to cigarettes at a young age. The U.S. Department
of Health and Human Services cites "stud ies showing that
17-year-old smokers are three times as likely to use fla-
vored cigarettes as are smokers over the age of25." Menthol
cigarettes are exempt from this legislation. The ban did not
extend to flavored nicotine vapor from e-cigarettes, which
are now exploding with "flavor of the month" inno vations in
the United States and the rest of the world.
The biggest assault on tobacco companies comes from law-
suits filed by state governments. Some suits are initiated to
cover the extra cost of healthcare due to smoking; others
accuse the industry of manipulating nicotine levels to keep
smokers addicted. In 1996 Brown and Williamson, then the
nation's fifth-largest manufacturer (Chesterfiel d®and Eve®),
settled a lawsuit by agreeing to pay 5% of its pretax profits
($50 million per year) toward smoking-cessation programs.
To resolve two major lawsuits and to deter further litigation,
the major tobacco companies agreed to settlements of $40
billion and $206 billion to help pay for the medical costs of
tobacco-induced illnesses, to finance smoking-prevention
campaigns (particularl y aimed at teenagers), and to support
other state programs. The money was to be paid over 25
years, but due to reduced state tax income in the early 2000s,
many state governments redirected the money from anti-
smoking campaigns into general funds. In desperation
several states decided to borrow against future monies, con-
sequently receiving only a percentage of the settlement. In
2001 every state received an average of $164 million from
the settlement, but only 6% went to tobacco -con trol pro-
grams instead of the 20% to 25% suggested by the CDC.
States with the highest smoking rates tended to spend the
least on these prevention efforts. 250
ln 2004 the U.S. government filed a $280 billion racketeer-
ing charge against the tobacco industry for allegedly mis-
leading and defrauding the public for 50 years regarding the
health consequences of smoking cigarettes. A federal appeals
court later ruled that the government cannot force the
tobacco companies to tum over $280 billion in profits.
The government was expected to reduce the figure to
$130 billion but in 2006 reduced the amount to $10 billion.
The decision was made over the objections of a number
of health advocates and congressional representatives. The
$10 billion was considered grossly inadequate to finance a
national smoking-cessation program designed to run over a
25-year period.
The number of lawsuits on behalf of deceased or living
smokers with cancer has increased, and many are being
won, although all jud gments are appealed.
Because of coughing and other health hazards that are caused
by secondhand smoke, numerous laws and statutes have
been passed at the local, state, and federal levels prohib-
iting the use of tobacco products in public spaces and
buildings (e.g., sections of restaurants, airplanes, some
businesses, and state and federal buildings).
From indifference to other people's habits in the early 1980s,
to a powerful crusade in the 1990s, to a growing tide of leg-
islation in the 2000s, public opinion toward smoking has
changed. Contrary to all the evidence, tobacco remains ex-

MA~leS.
~J~~"'
C 2009 Dave Margulies/eagle c.artoons
empt from laws protecting the health of Americans.
Congress is responsib le for exempting tobacco from the law
that declares, "no substance that causes cancer may be sold
for human consumption." Tobacco companies are heavy
contributors to federal and state legislators, funding politica l
campaigns in hopes of stalling or delaying laws that would
limit their profits. Given the addictive nature of tobacco ,
252
some think that such contributions are the equivalent of
methamphetamine drug organizations giving money to poli-
ticians to promOLe meth legalization .
Internationally, the European Union hea lth ministers recently
passed a ban on tobacco advertising on the radio, in print,
and on the Internet. Tobacco advertising had already been
banned on television.
Secondhand Smoke
In recenl years the drumbeat of opposition to secondhand
smoke has become louder. ll is e.stimated thal one person
dies from secondhan d smoke (mostly from cardiovascular
disease) for every eight smoker deaths, which works out to
40,000 to 50,000 deaths each year. When the issue was first
raised in the early 1980s, evidence was scanl; but since that
time , the U.S. surgeon general's office, the National Re.search
Council, the Occupational Safety and Health Administration ,
and the International Agency for Re.search on Cancer have
concluded that secondhand smoke doe.s cause lung cancer,
cardiovascular disease , and stroke. Re.search has connected
secondhand smoke to other illnesse.s, including asthma and
bronchiti s in the children of smokers. 251
Secondhand smoke is dangerous because the side.stream
smoke released from a smoldering cigarette when the user is
not inhaling has higher concentrations of substances, such
Uppers 3.59
as tar, thal cause re.spiratory problems. So
while secondhand smoke has small
amounts of nicotine, it has up to four
times the amount of carcinogens
found in mainstream (inhaled)
smoke. 253 Reports from bars and
restaurants that banned smoking
indicate a reduction in the kinds of
health problems caused by second-
hand smoke. A study of bar and
I
re.staurant employees in Ireland
conducted one year after a smoking
ban took e!Iect showed a 17%
decline in respira-tory ailments. In
Northern Ireland there was no
smoking ban, and no drop in respi-
ratory problems. 243
In 1996 California; Utah; Vermont;
FlagstafI, Arizona; New York City; and
Boulder, Colorado, bann ed smoking in
all bars and restaurants de.spite warnings
from the owners thal business would drop.
The re.subs of a study of several localitie.s
that banned smoking showed that , in fact, reve-
nues increased in four localitie.s, remained the same in four
localitie.s; and slowed down but did not decrease in one
locality.254 By 2014 virtually every state had multiple laws
forbidding smoking in public places.
Conclusions
Stimulants, except for cigareue.s, are emblematic of a society
in which cell phone.s, computers, fast food, hundreds of tele-
vision channels, multitasking, and acquiring as much wealth
as possible keeps us on a treadmill that never stops moving.
The body has finite supplies of energy; and whenever those
are released through artificial means, the body's natural
energy reserves are compromised.
Gaining energy and confidence through natura l methods,
wherein energy supplies are replenished through sleep, re-
laxation, exercise, good nutrition , and a healthy life.style,
crea te energy supplies before they are used up and allow
them to be replenishe d . Chemical methods drain the body
of its energy supplies, requiring the body to shut down to
recover. The natural methods work wilh the body time after
time. The chemical methods induc e tolerance and psycho-
logical dependence , so Lhe re.suiting excessive use damages
neurochemistry and disrupts or injures many body systems.
Our society must reexamine the obsession with stimulants.
In a country with coffee store.s and kiosks on every comer,
44 oz. Big Gulps ,• 100 brands of energy drinks , and media
that pre.sent fast-paced action 24/7, we could become a
nation deadened to the life-enhancing value.s of calrnne.ss
and serenity.
3.60 CHAPTER3
Introduction
Stimu lants are the world's most widely used psychoactive
drugs. In the United States last year, 4.6 million people
used cocaine, 1. 15 million used methamphetamine,
67.8 million smoked cigarettes, and 144 million drank
coffee daily.
General Classification
Uppers
• Cocaine from the coca leaf; includes freebase, crack,
and cocaine paste known as oxidado
• Amphetamines, e.g., biphetamine (Adderall ®), meth-
amphetamine, and dextromethamphetamine
• Amphetamine congeners: basically diet pills and
methylphenidate for attention-deficit/hyperactivity
disorder (ADHD)
• Plant stimulants: khat, betel nut, ephedra, and
yohimbe
• Bath salts, or "synthetic methamphetamines"; these
are variations of cathinone and methcathinone
• Caffeine: coffee, tea, chocolate, colas, and energy
drinks
• Nicotine: cigarettes, smokeless tobacco, cigars, pipe
tobacco, and electronic cigarettes
General Effects
• Stimulants force the release of the body's own energy
chemicals epinephrine and norepinephrine as well as
other chemica ls, especially dopamine, and stimulate
the brain's survival pathway.
• Emotiona lly, stimu lants can increase confidence and
induce euphoria or a rush.
• Stimulants also constrict blood vessels, increase heart
rate, and raise blood pressure. Pro longed use, espe-
cially of the stronger ones, eventually depletes en-
ergy resources, disrupts brain chemistry, and induces
exhaustion, depression, paranoia, anger, violence, and
intense craving.
Cocaine
• Cocaine is refined from the leaves of the coca bush
found almost exclusive ly in South America in Peru,
Colombia, Bolivia, and, to a lesser extent Ecuador, and
also Java in Indonesia. Most distribution, especially to
the United States, is hand led by Mexican cartels.
• Coca ine was popularized by Sigmund Freud, Mariani
wines, and eye surgeon Karl Kohler.
• Cocaine can be swallowed, injected, snorted, or
smoked. The coca leaf is chewed by the Indians living
in or near the Andes Mountains.
• Medica l uses are limited to the topical anesthetic
properties of the drug.
• Cocaine prevents the reabsorption of energy chemi-
cals, increasing their presence in the synapse and
thereby energizing the user.
• Cocaine increases sexual activity but can also increase
aggression. Many domestic violence cases involve co-
caine and alcohol, which when used together produce
cocaethylene.
• The cardiovascu lar system is most affected: constric-
tion of blood vessels, some damage to heart muscles,
and invo luntary writhing and jerking. Mentally, it can
cause paranoia and psychosis.
• Cocaine use is dangerous during pregnancy to both
mother and fetus. It can also cause denta l erosions.
• Cocaine has a true withdrawal syndrome, particularly
depression and craving. Overdose can occur but is
usually not fatal.
• Other complications arise from polydrug use, adulter-
ation, and contamination, especially with intravenous
(IV) use.
• Because it is metabolized so quickly, the high that co-
caine induces is quick ly turned to depression, result-
ing in an exaggerated up/down cycle like that seen
in bipolar disorder. The desire to avoid the crash can
lead to compulsive use and addiction.
Smokable Cocaine
( crack, freebase, oxidado)
• In the 1970s street chemists learned how to make
cocaine smokable without destroying the psychoac-
tive properties, by lowering the melting point of the
drug. The early product was called freebase cocaine,
made by disso lving cocaine hydroch loride in an alkali
solution.
• In the early 1980s cheap basing made freebase cocaine
by heating a solution of baking soda with cocaine.
In the 1980s an intermediate step in the refinement
of cocaine hydrochloride from coca leaves---called
basuco, cocaine paste, or more recently oxidadCr-was
discovered to contain freebase cocaine and 18 other
components of the coca leaf. Residual chemicals from
poor chemistry often end up injuring or even killing
the user.
• Because it is inha led and goes directly from the lungs
to the brain, smoked cocaine has a more powerful and
immediate effect on the brain and the body. It also
leaves the body more quick ly, so the up/down cycle is
much more rapid.

• The basic effects of smoking freebase cocaine are
almost the same as snorting or injecting cocaine
hydrochloride. Smoking crack is the most rapid-acting
method of use and creates the greatest compulsion.
• Side effects include chest pains, "crack lung," para-
noia, and intense craving.
• The social effects of crack are devastating to many
poor communities where the drug is rampant. Gang
and Mexican cartel activity are equally destructive and
dead ly to communities.
• Some of the differences between cocaine and amphet-
amines are: cocaine is more expensive; amphetamines
last longer; and cocaine is plant based whereas meth-
amphetamines are synthetic.
Amphetamines
• Longer lasting and usually cheaper than cocaine, these
synthetic stimu lants, including methamphetamine,
dextroamphetamine, and dextromethamphetamine
(meth, "crank," "crysta l," and "ice"), saw an increase
of use in the l 990s and 2000s.
• Amphetamines increase energy and sexual feelings,
spur confidence, cause euphoria, and deliver a rush.
• Amphetamine analogues (especially ecstasy, a psycho-
stimulant) increased in use and abuse by the 2000s.
Use has declined in recent years.
• Up to 34 million people worldwide used amphet-
amines and methamphetamines at least once, con-
trasted with 19.4 million using ecstasy or MOMA,
17 million using cocaine, 16.5 million using heroin,
and 181 million using marijuana.
• Amphetamine was first synthesized in 1887, meth-
amphetamine in 1919. Heavy use started in the
1930s in Germany.
• Amphetamines were used heavily during World War II
to overcome fatigue, then after the war for weight loss.
• Popular with the counterculture in the 1960s, they
inspired the Comprehensive Drug Abuse Prevention
and Control Act of 1970.
• Dextro isomer methamphetamine, called "crysta l,"
"crysta l meth," or "ice," is the most popular form of
methamphetamine.
• Meth is particularly popular in the gay community
because it stimulates sexual sensations. Most meth
manufacture is hand led by Mexican gangs and car-
tels operating superlabs that can make hundreds of
pounds of meth.
• The effects of meth last four to six hours, compared
with 10 to 90 minutes for cocaine, because meth
prevents the reuptake of energy chemicals and also
prevents their metabolism.
• It can take the brain up to two years to readjust its
chemistry back to normal.
Uppers 3.61
• Side effects include bad teeth, heart and blood vessel
toxicity, severe depression, lack of energy, and intense
craving. Amphetamine psychosis can also occur from
long-term and high-dose use.
Amphetamine Congeners
• Methylphenidate (Ritalin ®) and amphetamine
(Adderall ®) are used to treat attention-deficit/hyper-
activity disorder in children and adu lts.
• The different types of ADHD are: ADHD. combined
presentation; ADHD, predominantly inattentive pre-
sentation; and ADHD, predominantly hyperactive-
impulsive presentation.
• Treating ADHD in young people seems to reduce their
rate of drug addiction as adults.
• 5 to 6 million young people have ADHD.
• Diet pills, the other amphetamine congeners, are
used to control weight. Many health problems have
resulted from overuse of some diet pills, and multiple
lawsuits have been filed.
Look-Alikeand Over-the-CounterStimulants
• Counterfeit stimu lants, often containing only caffeine
or other mild stimu lants, are falsely advertised as am-
phetamines, cocaine, or even MDMA (ecstasy). Legal
mild over-the-counter (OTC) stimulants when used
to excess can have toxic cardiovascular effects.
MiscellaneousPlant Stimulants
• Extracts of plants-such as khat, yohimbe, bete l nuts,
and ephedra-are used worldwide in addition to cof-
fee, tea, and colas.
• Khat is a bush whose leaves are chewed, some-
what like coca leaves. It is used socially, much like
coffee and tea.
• The khat trade is very important to a number of coun-
tries, including Yemen, Kenya, eastern Africa, and
Somalia.
• Cathinone, the active ingredient in khat, has been
synthesized as methcathinone, similar to methamphet-
amine.
• Other variations of the cathinone molecule (e.g., me-
phedrone) have been used to make bath salts, which
are synthetic methamphetamines that can have dan-
gerous effects. New formulations are developed every
month to avoid detection.
• Betel nuts are used by 400 million to 600 million peo-
ple as a recreational drug. The main active ingredient,
arecoline, is a mild stimulant like coffee or cigarettes.
It is chewed or combined with tobacco (called gutka)
and chewed.
• Yohimbine, a bitter, spicy extract from the African
yohimbe tree, is brewed as a stimu lating tea or used
3.62 CHAPTER3
as a medicine. It is reported to be a mild aphrodisiac.
It can also produce a mild euphoria and occasiona l
hallucinations.
• Ephedra from the leaves of the ephedra bush is a mild
stimulant, used to treat asthma, some allergies, and
low blood pressure. It is also used in OTC stimu lants.
• Street chemists use ephedrine and pseudoephedrine
to make methamphetamine.
Caffeine
• Coffee, tea, chocolate, soft drinks, energy drinks, and
dozens of other products, such as OTC medications,
contain the alkaloid caffeine. Caffeine is found in
more than 60 plant species.
• 85% of Americans consume caffeine every day in
doses ranging from 60 mg for tea. 135 to 160 mg
for brewed coffee, 35 mg for Coca-Cola, ® 80 mg for
Red Bull• energy drink, and 80 mg for 4 oz. of dark
chocolate.
• The first written record of tea dates back to 221 B.C.,
but some evidence puts it at 2700 B.C.
• Coffee was first cultivated in A.D. 650.
• Starbucks, the largest coffee retailer, has more than
2 1,000 outlets in 62 countries.
• Caffeine is a stimulant that initially increases alertness
and facilitates thinking. It is a bronchodilator used
as a decongestant, a diu retic, and sometimes an
analgesic.
• Excess use of caffeine leads to insomnia, anxiety,
gastric irritation, and high blood pressure. It causes a
moderate dependence, and there is a true withdrawa l
symptom whose key feature is a severe headache.
• Cocoa comes from the cacao tree. The cocoa beans are
fermented, roasted, and ground into a mass, which is
used to prepare beverages and solid chocolate; solid
chocolate is sweetened for eating and unsweetened for
cooking.
• Energy drinks such as Red Bull® rely mainly on caf-
feine, taurine, sugars, B-complex vitamins, ginseng,
and a few other ingredients for their kick.
• Caffeine use disorder was added to the American
Psychiatric Association 's Diagnostic and Statistical
Manual of Mental Disorders(DSM-5) in 2013.
Nicotine
• In 20 14 the surgeon general's office released the thirty-
second report on smoking: The Health Consequences of
Smoking - 50 Years of Progress. It examines the trag-
edies and the triumphs over the past 50 years in the
war on smoking. It added new illnesses to the list of
those aggravated or caused by smoking, includi ng
diabetes and liver cancer. It said that though the rate
of smoking in the past 50 years has been cut in half,
480,000 Americans still die prematurely from the
effects of smoking and inha ling secondhand smoke .
• Nicotine is an addictive toxic alka loid found in the
leaves of the tobacco plant. It is native to North and
South America and was cultivated in Mexico, parts of
Central America, and some Caribbean islands. The
use of tobacco did not occur in Europe and Asia until
the late l 400s.
• About 22% of Americans are regu lar smokers of ciga-
rettes and another 4.7% use smokeless tobacco.
• Three factors that vastly expanded the sale of ciga-
rettes in the twentieth century were improved
cigarette-manufacturing technology (cigarette roll-
ing machine, freebase nicotine); the cultivation of a
milder tobacco plant; and more-skillful advertising.
• When tobacco is smoked or chewed, it first stimulates
smokers and then relaxes them.
• Hundreds of other by-products and additives in
tobacco, such as tar and nitrosamines, can cause
respiratory or cardiovascu lar diseases as well as
cancer.
• Smoke less tobacco comes in the form of loose-leaf
chewing tobacco; moist snuff, which is placed in the
mouth and absorbed by the gums; and powder snuff,
wh ich is often sniffed or rubbed on the gums.
• Nicotine is the main addictive ingredient in tobacco. It
affects the cardiovascular system by raising the blood
pressure and encouraging plaque buildup in vessels.
Maintaining the nicotine level is the main reason that
dependence develops.
• Use of e-cigarettes ("vaping") is expanding in the
United States. Nicotine is not federally regulated like
tobacco is, so e-cigarettes are often sold to midd le-
school-age youths.
Conclusions
• Though stimulants initially boost energy and drive,
they have a number of side effects and toxic conse-
quences and can cause problems due to addiction
wh en overused.
GeorgeCarlin on Drugs:
"That~ why there~ a drug
problem: there~ all those
drug stores. It~ no accident
that we're drug-oriented.
"They start you early with
the oral habit. 'A little
orange-flavored aspirin for
children? Two in the mouth
son.' 'Something wrong
with your head? Two in the
mouth.' Remember that. ..
head-mouth . 'These are
orange; there'll be other
colors later on."'
George Carlin , AM & FM album , 1972

© ChrisStein/GettyImages
 Downers:
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headlin to- Philip Seymour Hoffm2n (20 H), Cory Monttith (2013), Wh itn,y
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Ltdger(2006)
 4.2 CHAPTER4
• More than 4 billion prescriptions for drugs were written
in 2012 in the United States, at an estimated cost of
$340 billion. Worldwide that figure is expected to surpass
$1.1 trillion by 2014. 1
Unlike uppers, which stimulate the central nervous system
(CNS), downers depress the overall functioning of the
CNS, causing sedation, muscle relaxation, drowsiness, and,
if used to excess, coma. Some downers induce a rush/high
and often disinhibit impulses and emotions. Uppers release
and enhance the body's natural stimulatory neurochemicals,
whereas depressants produce their effects through a wide
range of biochemical processes at different sites in the brain,
spinal cord, and other organs such as the heart.
Some depressants mimic the body's natural sedating or inhib-
I
iting neurotransmitters (e.g., endorphins, enkephalins, and
GABA [gamma amino butyric acid]); others directly suppress
the stimulation centers of the brain; and some work in ways
that scientists don't fully understand. Because of these varia-
tions, depressants are grouped into subclasses based on their
chemistry, medical use, and legal classification.
• Major classes include opiates/opioids, sedative-
hypnotics, and alcohol.
• Minor classes include skeletal muscle relaxants, antihis-
tamines, and over-the-counter (OTC) downers.
Major Depressants
Opiates/Opioids
These drugs are refined from or are synthetic versions of
the opium poppy's active ingredients and include opium,
morphine, codeine, hydrocodone (Vicodin®), oxycodone
(OxyContin ®), Opana® (methyl morphine), methadone, and
heroin. They were developed mainly for the treatment of
moderate and acute pain, diarrhea, coughing, and a number
of other conditions. Most illicit users take these opiate/opioid
drugs to avoid emotional and physical pain, to experience
euphoric effects, and to suppress withdrawal symptoms.
Sedative-Hypnotics
Sedative-hypnotics represent a wide range of synthetic
chemical substances developed to treat anxiety and insom-
nia. The first, barbituric acid, was created in 1864 by Dr.
Adolph von Bayer. Other barbiturates (phenobarbital and
Seconal ®) followed, until more than 2,500 had been created.
Bromides, paraldehyde, and chloral hydrate were also widely
used until the late 1940s. Since 1950 dozens of different
sedative-hypnotics have been created, including meprobam-
ate (Miltown®), glutethimide (Doriden®) methaqualone
(Quaalude ®), flunitrazepam (Rohypnol®), GHB, and espe-
cially benzodiazepines (e.g., Valium® and Xanax®). All have
toxic side effects when misused and can cause tissue depen-
dence. Methaqualone and flunitrazepam are illegal in the
United States.
Benzodiazepines are the most widely prescribed sedative-
hypnotic drugs . Newer, non-benzodiazepine sedative-
hypnotics include the Z-hypnotics, such as zaleplon
(Sonata), zolpidem (Ambien ®), eszopiclone (Lunesta ®), and
zopiclone (Imovane ®). Other recent additions are pregabalin
(Lyrica®) and ramelteon (Rozerem ®), although over the past
15 years nonsedative antidepressant medications including
venla-faxine (Effexor®), citalopram (Celexa ®), and escitalo-
pram (Lexapro ®) have taken over a substantial share of the
market.
Alcohol (see Chapter 5)
Alcohol, the natural by-product of fermented plant sugars
and starches, is the oldest psychoactive drug in the world .
It has been widely used over the centuries in social, cultural,
spiritual, and religious practices as well as for a medical
remedy, from sterilizing wounds to lessening the risk of heart
attack. Abuse makes alcohol the world's second most
destructive drug in terms of health and social consequences.
Tobacco is the most physically destructive substance.
Minor Depressants
Skeletal Muscle Relaxants
Skeletal muscle relaxants that act on the CNS include cariso-
prodol (Soma®), chlorzoxazone (Parafon Forte®), cycloben-
zaprine (Flexeril®), and methocarbamol (Robaxin®). These
synthetically developed CNS depressants are aimed at
areas of the brain responsible for muscle coordination and
activity and are used to treat muscle spasms and pain.
Although abuse of these drugs is uncommon, their overall
depressant effects on all parts of the CNS produce reactions
similar to those caused by other abused depressants. One of
the more often abused formulations, carisoprodol, is metab-
olized to meprobamate (a controlled-substance Schedule IV
sedative-hypnotic) that has anxiolytic, anticonvulsant, and
muscle-relaxing properties.
Sometimes carisoprodol shows up in drug-screening urine
tests, often in combination with other drugs, particularly
benzodiazepines and opioids. Because of the drug's abuse
potential, 17 states rescheduled carisoprodol to Schedu le IV;
it remains an unscheduled drug at the federal level. Abuse of
carisoprodol caused more than 28,000 visits to emergency
rooms in 2011, up from 10,000 in 2002. 2 Other muscle re-
laxants are responsible for an additional 20,000 emergency
room visits each year.
Antihistamines
Antihistamines are found in hundreds of prescription and
OTC cold and allergy medicines, including Benadryl ® (di-
phenhydramine), Actifed, ®and Tylenol PM Extra.® They are
synthetic drugs that were developed during the 1940s for the
treatment of colds and allergic reactions; they are also used
to prevent ulcers and to treat shock, rashes, motion sickness,
and even symptoms of Parkinson's disease. 3 In addition to
blocking the release of histamine, these drugs cross the
blood-brain barrier to induce the common and oftentimes
potent side effect of depression of the CNS, resulting in
drowsiness. They are used in sleep-aids, to control anxiety,
and to temper the side effects of some antipsychotics.
Antihistamines are occasionally abused for their depres-

sant effects, often in conjunction with alcohol or opioids.
Because of their sedating effects, it is recommended that the
elderly use them only sparingly.
Over-the-Counter Downers
Nonprescription sleep-aids, such as Nytol,® Sleep-Eze,®
Unisom,® Equate, ® and Sominex,® are available everywhere.
Depres.sants that were used in the 1880s are marketed as
sleep-aids or sedatives today. Scopolamine in low doses, anti-
histamines, bromide derivatives, and even alcohol constitute
the active sedating components in many of these products,
and some are occasionally abused for their sedating effects.
When Whitney Houston died suddenly in 2012, the autopsy
showed high doses of cocaine and low levels of Flexeril®
(muscle relaxant), Xanax ® (a benzodiazepine), and
Benadryl ® (an antihistamine). The official cause of death was
drowning (in a hotel bathtub).
Besides alcohol and tobacco, the number
one cause of preventable deaths in America
is abuse of prescription drugs.
Michael Jackson 's death in 2009 was the result of cardiac ar-
rest, but the autopsy found a half dozen psychoactive drugs
in Jackson's system. He had taken four benzodiazepines and
two muscle relaxants, but the real culprit was Diprivan ®
(propofol), a powerful anesthetic administered for short-
duration surgical procedures. 4 His physician was convicted
of involuntary manslaughter.
In Heath Ledger's system were two opioid painkillers, three
benzodiazepines, and an over-the-counter sleep-aid.
These three high-profile cases illustrate how even those with
access to good medical advice and care can die from pre-
scription drug abuse. In overdoses it is rare that only one
psychoactive substance is involved.
Downers:Opiates/Opioidsand Sedative-Hypnotics 4.3
Prescription drug abuse has increased dramatically since
2004. Emergency room visits for CNS prescription medica-
tions went from 472,000 to 1,043,000 in 2011. 2 More than
half of these ER visits are due to opiates and opioids.
Another 425,000 are attributed to benzodiazepines. Deaths
from prescription drugs have climbed to 40,000, half from
opioid painkillers. We are in the midst of a prescription
drug-abuse epidemic, where the consequences of misuse can
be as deadly as those from any street drug.
'Toda~ the craze is pharmaceutical. . Ox~Contin, ® ox~codone;
and that's what ~ou'/1see a lot of ~oun9(ids comin9into detox
for, more so than for heroin. But when the~ run out of the
resourceto 9et the pills,then the~start shootin9dope. Then
the~see what the realstreetlifeand bein9downtownat 3
I
in the mornin9 just damnin9 the police and nowhere to 90.
The~ see what that's like."
45-year-old male recovering opioid abuser and drug counselor
Prescription drugs were once considered the abusable drugs
of choice for the middle and upper clas.ses, but that is no
longer true. Prescription drug abuse is seen in every class
and across every strata of society. The majority of abused
prescriptions are for pain and secondarily for sedative-
hypnotics (benzodiazepines) and, to a lesser extent, stimu-
lant prescription drugs (e.g., medications for attention-
deficit/hyperactivity disorder [ADHD]). But most depressant
psychoactive prescription drugs can create dependency in
those who inadvertently or deliberately overuse them. Once
dependent the abuser must divert legitimate prescriptions,
buy from street dealers, or find online sources.
"M~9randfatherhas rea/1~,rea/1~bad pain issues,and he is
prescribedmorphineand codeine,and so we alwa~shad that
in the house9rowin9up becausehe was9ettin9rea/1~larae
prescriptions. And ~ou know an~time we weren't able to aet
somethin9 from the doctor, we were stealin9 it from m~ 9rand-
parents. And when I sa~ 'we,' I mean m~ brotherand /."
22-year-old recovering opiate abuser
In the late 1800s and the early 1900s, tens of thousands of
patients in the United States and Europe became dependent
on a variety of psychoactive drugs containing cocaine, opium,
Whitn ey Houston, Michael
Jackson , and Heath Ledger
are just three of the stars
who lost their lives due to
psyc hoacti ve drugs, often
downers , and alway s more
than just one.
Copyrightand courtesyof the
New YorkPost
 4.4 CHAPTER 4

morphine, heroin, or Cannabis, which were often overpre-

scribed by their doctors (iattogenic addiction). As newer com-
pounds were discovered and as pharmaceutical companies
developed sophisticated manufacturing and marketing tech-
niques, use and abuse spread.

About 60% of users of illegal

prescription drugs get them from
friends or relatives.

In the first decade of the twenty-first century, the use of pre-

scription medications increased, due in part to their availabil-
ity. About 60% of users of illegal prescription drugs receive
them from friends or relatives, 17% from physicians who
believe they are treating legitimate aches or pains, and only

I
4.3% from dealers. 5 Although the number of people abusing
prescription drugs is still less than the number abusing alco-
hol and marijuana, it is increasing rapidly. The United Nations
estimates that the number of people abusing prescription
drugs worldwide is close to that of people abusing illicit drugs. ~e G/2At-1U)N\)© www.dawgranlond
.com
The misuse of prescription medications by young people is
cause for alarm. Besides believing that they are invincible,
tious, but there are unscrupulous, addicted, or naive medical
young people falsely assume that prescription drugs are safer
professionals who participate in unethical or inappropriate
than street drugs. They often raid their parents' or friends '
prescribing practices.
medicine cabinets and then trade the drugs with their con-
temporaries. Males 18 to 25 are the most likely to abuse
",\,\~re9ulardoctorand I partedpathswhenI found
opioid analgesics, followed by females 12 to 17. Studies
found that 20% to 40% of patients who receive long-term
of
another doctor who was in the business prescribin9whateYer
medicationI wanted.You pa~him. and he willtake care of
opioid treatment will likely end up abusing them.
~ourpharmaceuticalneeds."
Another pattern of illicit use results when a patient, treated 38-year-old recovering sedative-hypnotic abuser
for multiple medical complaints by a number of physicians,
obtains several prescriptions for sedatives or opioids and Because of their widespread use for a variety of medical con-
has them filled by different pharmacies. For example, a pa- ditions, sedative-hypnotic and opioid prescriptions are
tient could have a prescription for Dalmane ® for sleep, subject to forgery and manipulation (photocopying and
Serax® for anxiety, Xanax ® for depression, Valium® for mus- changing dosage or number of refills), which provides abus-
cle spasms, and Librax ® for stomach problems. Each pre- ers with enough drugs to divert to illicit street sales or to feed
scription in and of itself may be at a non-addictive level, but their own addiction. To combat this problem, many states
together they equal a large enough dose of benzodiazepines mandated triplicate prescriptions for benzodiazepines and
to create tissue dependence. Most physicians are conscien- added the same stringent mechanisms that were in place for

Rateof Prescription
PainkillerSales,Deaths.
and Substance-Abuse TreatmentAdmissions (1999-2010)
Sales

- Salesper kilogram per10,000people

- Deathsper 100,{XX) people
- Treatment admissionsper10,000people Source: CDC:PrescriptionPainkiller Overdoses in the
UnitedStates17
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
 Downers:Opiates/Opioids and Sedative-Hypnotics 4.5

opioids. Some physicians and psychiatrists consider tripli-

cate prescriptions an intrusion in to their medical practice
and an unnecessary obstacle for those with legitimate medi-
cal needs. A current measure to limit prescription drug abuse
involves integrated computer systems to keep a tighter
track of a person 's overall drug use with multipl e pharma-
cies and doctors.
Smuggling drugs and drug precursors that are legal outside
the United States is another form of diversion . Rohypnol®
(flunitrazepam) is smuggled in from Europ e and Mexico.
Ephedrine, used lo make methamphetamin e, is smuggled
through Canada and Mexico.
Misuse of both legally prescribed drugs and nonprescrip-
tion drugs causes toxic effects, adverse drug reactions, and

other negative physical and emotional consequences. A
study led by Dr. Bruce Pomeranz at the University of Toronto
estimated that each year between 76,000 and 137,000
Americans die and an additional 1.6 million to 2.6 million
are injured due to bad reactions from legally prescribed
drugs and OTC medications .10 The figures do not include
drug abuse or prescribing errors. While some disagree with
the magnitude of the numbers, they do agree that the prob-
lem is very real and widespread.
Prescription drug abuse can be reduced by:
• educating physicians more thoroughly about prescrip-
tion drug abuse and the drugs they prescribe
• educating physicians about ways to minimize opioid
use to control pain in the chronic sufferer
• increasing the role of the pharmacist , who is the key lo
identifying drug interactions, inappropriat e prescribing,
and patients who fill multiple prescriptions
• increasing communication among physicians and phar-
macies to spot the abuser and the addict
• making sure that the drugs prescribed to geriatric pa-
tients are not debilitating
• requiring duplicate and triplicate prescriptions for sched-
uled drugs
• curtailing drug advertising in consumer publications and
on TV
• encouraging patients to protect their prescription drugs
and safely dispose of unused and expired drugs
• integrated computer tracking of prescriptions for highly
abused medications
Introduction
The governor of Vermont delivered a remarkabl e State of the
State address on January 8, 2014. Governor Peter Shumlin
did not use the speech to make promises about the economy,
taxes, and the environment. Instead he devoted nearly his
entire speech to a rising scourge: heroin and opiate addic-
tion. "In every corner of our state, heroin and opiate drug
I
Opium growing and harvesting
is oft.enafamily affair.Above, a
family in Colombiais harvesting
their crop,mostly grownfor the
US market.
At left, an Afghan gir l plays
amongthe poppies.
C 2014 AlainLabrousse
addiction threatens us, " the governor said. "It threatens the
safety that has always blessed our state. It is a crisis bubbling
just beneath the surface that may be invisible."
After alcoho l, opiates/opioids are the oldest and best-
documented group of drugs. They are the principal drugs
used to treat pain (analgesics) , diarrhea , and cough. They
also induce euphoria , subdue emotional pain , and sup-
press opioid withdrawal symptoms.
They are also a source of continual and occasionally explo-
sive worldwide conflict: the nineteenth -century Opium
Wars, the rise of drug crime cartels, and the spread of AIDS
and hepatitis C from sharing infected needles. The slow-
growing worldwide use of heroin aided by bumper crops in
Afghanistan has given heroin a high profile, but prescription
opiates/opioids create just as many problems . The actual in-
cidence of opioid overdoses associated with hydrocodone
(Vicodin®), oxycodone (OxyConti n®), and methadone in
the United States is greater than that of heroin. Unfortunately,
the use of heroin in the United States has also exploded over
the past few years so while the use of OxyContin ®dropped in
half from 2010 to 2012 , the use of heroin rose almost 50%.
In the late 2000s and the 2010s , many professional papers ,
symposia, and newspap er headlin es focused on the delicate
balance of providing patients with effective pain relief
without leading them down the road to drug abuse and ad-
diction. When that balance tips to the side of abuse and
 4.6 CHAPTER 4

0 iates/0 ioids
GENERIC
DRUGNAME TRADE
NAMES STREET
NAMES
(opiumpoppyextract)
OPIATES
Opium(Schedulell) Pan
topon,Laudanum uo,nop, poppy,hop,midnightoil
Dilutedopium(Schedule
Ill) Paregoric
Morphine(Schedule
II) lnfumorph,
® Kadian,
® Roxanol,
®MSCantin, ® Murphy,morph,M, MissEmma
Duramorph,
® DepoDur,
®Astra
morph,® Kapanol®
Codeine(Schedule
Ill) ®withcodeine
Empirin Number4s(1 grain), pancakes
andsyrup
(alsocalledmethylmorphine) Tylenol
®withcodeine Number3s( 1h grain)
(usuallywith aspirin or Tyleno0 Doride
n®withcodeine
Robitussin
·®A-C
Thebaine(Schedule
II) None None

I
SEMISYNTHETIC
OPIATES
Diacetylmorph
ine(Schedule
I) Heroin Dope,smack,black tar,Chinawhite,junk,tar (chiva,
chapapote),Mexica
n brown,cheese, puro,goma,puta,
Harry,skag,shiLRufus,Perze,H,horse,dava,boy
Hydrocodone
(ScheduleIll) Vicodin,
® Norco,
® Hycodan,
® Lortab,
® LorceL
® Zydone
® vikes,vic.s,
Watson387,hydro,fluff
Hydromorphone
(Schedule
II) Dilaudid,
®Hydal,
Sophidone,
®Hydrostat
® Zydone
® Dillies,drugsto
re heroin
Oxycodone
(Schedule
II) Oxy(ontin,
® Percodan,
® Percoce
t®Tylox,
®Combunox,
® hillbillyheroin, oc.5, o~, oxy-SOs,
Perc.s, oxycotton,
Endocodone,® Oxydose,
®Oxyfast® Persolone,
® o'coffin,killers,oxies,oceans

SYNTHETIC
OPIATES
(OPIOI
DS)
Buprenorphine
(Schedule
V) Buprenex,
®Subotex,
®Suboxone
®(withnaloxo
ne) Bupe,sub
Butorphanol
(Schedule
IV) Stadol
®
Fentanyl
(Schedule
II) Sublimaze,
® Duragesic,
®Actiq,
® Sufenta,
® Sufentanil
® tivesare misrepresented
Streetderiva asChinawhite
Levomethadyl
acetate(LAAM) Orlaam~ (no longeravailable
in theUnitedStates) Lam0ong-actingmethadone)
Levorphanol
(Schedule
II) Levo-Dromoran
®
Meperidine
(Schedule
II) Demerol,
® Mepergan,
® Pethi
dine® Dummies
Methadone
(Schedule
II) Dolophine
® Juice,dollies.dolls
Oxymor
phone(Schedule
II) Numorphan,
® Opana,
®
Pentazoc
ine(Schedule
IV) Talwin
® NX.Fortwin,
®Talacen
® Tsandblues
Tramadol Ultram,® Ultrace
~

OPIOIDANTAGO
NISTS
Naloxone Narcan,
® Nalone,
® Narcanti
®
Naltrexone Revia,
®Trexan,
® Depade,
·~ Vivitrol,
® Naltrel
® (time-release)

addiction, hydrocodone, oxycodone, and methadone are Classification

usually involved . The National Household Survey on Drug
Abus e found that most heroin abusers began by abusing
Opium extracts and semisynthetic opium preparations are
prescription opioids. Today the treatment for opio id dep en-
referred to as opiates. Synthetic opiat es are referred to as
dence has expanded from drug treatm ent centers, to ph ysi-
opioids. Opioid is also used as a generic term for all drugs
cians ' offices, to Veterans Adm inistration facilities , wher e
in this category.
therapeutic drugs , particularl y bupr enorphine , are no w
dispensed . On th e positi ve side of th e opiat d opioid story is
Opium, Opiates, and Opioids
the discovery in the 1970s of the body 's own na tural pain-
killers-endorphins and enkephalins-which significantly Of the hundreds of varieties of poppies. only the opium poppy
changed our understanding of opiates/opioids as well as plant (Papaver somniferum) produces opium in sufficient
shed light on th e whole field of addictiono logy. bioch emical quantities to be used as a medicine. It is proc essed from th e
research , and pain management. milk y fluid of th e unripe seedpod of the plant. When the sap
 Downers: Opiates/Opio ids and Sedative-Hypnotics 4. 7

is exposed to air, it coagulates and turns brown or black.

This gummy sap is scraped from the poppy with a blunt iron
blade. The seedpod secretes fluid for several days and con-
tinues to be tapped until the sap is depleted. Smaller amounts
of opium are extracted from the rest of the plant (called
"poppy straw").
There are more than 25 known alkaloids in opium, but the
two most prevalent, called opiates , are morphine (10% to
20% of the milky fluid) and codeine (0. 7% to 2.5%). 6 .7-8
Although a small amount of opium is used to make antidiar-
rheal preparations (e.g., tincture of opium and paregoric),
virtually all the opium coming into the United States is
refined into morphine, codeine, and thebaine. The use of
opium has declined over the years due to the availability of
morphine, codeine, and other synthetic and semisynthetic

I
prescription opioids.
• Opiates: opium poppy extracts are alkaloids that in-
clude morphine, codeine, and thebaine.
• Semisynthetic opiates include heroin, hydrocodone
(Vicodin ®), oxycodone (OxyContin ® and Percodan ®),
and hydromorphone (Dilaudid ®) and are made from the
three opium poppy extracts.
• Opioids: synthetic opiate-like drugs include meperidine
(Demerol ®), methadone, and fentanyl (Actiq®).
Synthetic opioid antagonists such as naloxone and naltrex-
one block the effects of opiates and opioids. Buprenorphine
acts as an opioid agonist at low doses and an opioid antago-
nist at high doses. An Assyrian priest carries opium poppies as part of a ceremony to
sacrifice a gazelle to the gods; circa eighth century B.C.
© 1996 CNS Productions, Inc.
History of Methods of Use

Historians believe that the cultivation of opium poppies was
common in ancient Mesopotamia, Egypt, and Greece
around 3400 B.C. and spread east to Asia. The remains of
cultivated poppy seeds and pods from 4000 B.C. were dis-
covered in Neolithic villages in Switzerland, suggesting that
perhaps opium was first cultivated in Eastern Europe. The
opium poppy thrives and produces more of the active ingre-
dient (opium) if it is grown in well-cultivated soil, support-
ing the theory that, after wheat, opium was one of the earli-
est crops.
The ancient Sumerians and Egyptians and later the Romans
recorded in their medical texts the paradoxical nature of opi-
um, listing it as a cure for all illnesses, a pleasure-inducing
substance, and a poison. 9 The Greeks chronicled the gods'
use of opium for mystical or mythical purposes. Greek hero
Jason used opium to sedate monsters. Demeter, the Greek
goddess of agriculture, took opium to sleep and forget the
death of her daughter, Persephone. Hippocrates, the "father
of medicine," was more practical: he prescribed it for sleep,
diarrhea, pain, female ills, and epidemics. 11-12, 13 When
Socrates was ordered to commit suicide, he drank from a cup
that contained not only poisonous hemlock but also opium
to dull the pain of dying. Modern-day euthanasia and assisted-
suicide formulas often include morphine or other opioids.
The addictive liability of opium was recognized as early as
500 B.C. Greek philosopher Diagoras of Melos wrote, "It is
better to suffer pain than to become dependent on opium."
Erasistratus of Ceos wrote, "Opium should be completely
avoided" (due to addiction).
Over the centuries different methods of use, new refine-
ments of the drug, synthesis of molecules that act like the
natural opiates, and high-dose time-release versions of the
drugs, vulnerable to manipulation for rapid release, in-
creased not only the benefits of these substances but also
their potential for abuse.
Oral Ingestion
Opium, from the Greek word opOs,meaning "juice " or "sap,"
was originally chewed, eaten, or blended into various liq-
uids and swallowed. Although the seeds can be pressed to
yield oil and the residual can be used as fodder for cattle, it
is the medicinal properties that make it so valuable .
Historically , even though the drug was used extensi vely, the
abuse potential was relatively low because opium has a bit-
ter taste and low concentrations of active ingredients, and
the supplies were limited. When taken orally the drug trav-
els through the digestive system before entering the blood-
stream and reaches the brain 20 to 30 minutes later.
 4.8 CHAPTER 4

In ancient writings opium is listed as an ingredient in hun- Refinementof Morphine, Codeine,and Heroin
dreds of remedies. The use of opium in medications and po-
In 1804 and 1805 , a 21-year-old German pharmacist 's assis-
tions continued through the Middle Ages and into the
tant named Friedrich W. A. Sertii.rner isolated morphine
Renaissance (the early 1500s), when its desirability rose
from opium. He found it to be 10 times as strong as opium
again after Swiss alchemist Paracelsus concocted laudanum,
and therefore a much better pain reliever . For the first time ,
a tincture of opium (powdered opium in alcohol) prescribed
exact measured doses of an opiate anodyne (painkiller) were
for dysentery, pain , diarrhea , and cough. 14 Over the next three
possible . The strength and the purity of opium varied widely.
centuries , other opium mixtures were developed, especiall y
Morphine ( C 17H 190 3 N) eased the pain of wounded soldiers be-
paregoric (opium in alcohol plus camphor) for the treatment
ginning with the Crimean War between Russia and the
of diarrhea; it is still available today by prescription.
European powers. During the U.S. Civil War , poppies were
Smoking cultivated in Virginia , Tennessee , South Carolina , and
Georgia to provide the South with its own supply of mor-
In the sixteenth century, Portuguese traders set the stage
phine. Although wounded troops benefited from the pain-
for the widespread nonmedical use of opium with the in-
relieving properties, the greater strength of morphine and
troduction to Europe and Asia of the pipe from North
the intensity of intravenous (IV) use increased the potential

I
America. Compared with ingesting the drug, smoking deli v-
for opiate addiction (morphinism). Opium was also widely
ers more of the active ingredients into the bloodstream by
used during the war to treat diarrhea and malaria and was
way of the lungs; the vaporized opium reaches the brain in
eventually prescribed for anemia, asthma , cholera , nervous
seven to 10 seconds. The higher concentration of the opiate
dyspepsia, insanity, neuralgia, and vomiting.
produces a stronger sense of pain relief, euphoria, relaxation ,
and well-being, which encourages abuse. In 1832 codeine (C 18H21No) , the other major component of
opium, was isolated. Its name comes from the Greek word
The high cost of the drug limited opium smoking to the mid-
kodeia, which means "popp y head. " Because it is twice as
dle and upper classes in China, but the practice created so
strong as opium , it was often used in cough syrups and pat-
many social and health problems that it was banned in 1729.
ent medicines.
By that time the opium trade had become so lucrati ve that
enforcing the ban was incredibly difficult. In the early 1800s , ln 1874 British chemist C. R. Alder Wright refined heroin
prohibition was again tried. The Chinese Commissioner Lin , (diacetylmorphine [c 21H 13NO ~]) from morphine in an at-
appointed to control the trade , destro yed more than 3 mil- tempt to find a more effective painkiller that did not ha ve
lion pounds of opium in 1839. The powerful trading com- addictive properties. This powerful opiate (five to eight times
panies of the West (e.g., the British East India Company) more powerful than morphine) stayed on the shelf until
along with their governments waged the Opium Wars 1898 , when Heinrich Dreser , an employee of Bayer in
(1839-1842 and 1856--1858). however , forcing the Chinese Germany, proposed its promotion for coughs, chest pain ,
government to continue the trade and to cede Hong Kong to
the British. 15,i 6
As the supply became more plentiful , use increased. Opium
smoking was introduced to the United States by some of
the 70,000 Chinese workers who immigrated to build the
railroads and to mine gold , copper, and mercury. The big-
oted reaction to these Asian immigrants produced headlines
proclaiming them as "yello w fiends " and "seducers of white
women " and resulted in a spate of prohibitory laws that of-
ten focused on opium smoking-but not its use in patent
medicines and by physicians for middle- and upper-class
Whites.
In the twentieth century, heroin smoking increased as higher
grades became available . Another method of smoking is to
heat heroin on aluminum foil and inhale the fumes through
a straw and is called "chasing the dragon. " The abuse poten-
tial of smoking heroin and opium is extremely high.

"I had a ver~ close friend who I was associated with who was
smokin9a prett~ ,ast quantit~ <Yer~ da~,a half a aramto a
9ram <Yer~ da~, and he usedto real/~9et on me and tell me
that I was a junkie because I was puttin9 a needle in m~ arm.
And I wouldtell him, 'He~. aka~, m~methodis different,
but ~ou'rea junkie. too. You ha,e a habit."'
34-year-old recovering heroin addict
There were more than 1 million casualties during the Am erican Civil
War. For the wounded morphine was the painkiller of choice. In facr ,
H was basically the only painkill er other than anesthetics such as
ether. These Union soldiers are recoverin g at a hospital in
Fredericksbmg , Virginia. The widespread use of morphin e caused
many of the wound ed to develop dependence on morphine, a condition
known as "the soldiers disease."'
Courtesyof the Libraryof Congress(1864)

tubercu losis, and pneumonia and even as a cure for mor-
ph inism. 18The new drug created a subculture of compu lsive
users. It is estimated that shortly after the turn of the centu-
ry, between 250,000 and 1 million people abused op ium,
morphine, and heroin in the United States.
Injection Use
The development of the hypodermic needle in 1853 by Dr.
Alexander Wood of Edinburgh and Dr. Charles Hunter of St.
Georges Hospital in London had an impact on the way
opiates were introduced into the body. In itially, drugs were
injected on ly subcutaneously, but users found that injecting
intravenously delivered high concentrations of the drug
directly into the bloodstream through the veins. Pr ior to
the advent of plastic disposab le syringes, many morph ine
addicts were from the middle and upper classes because they
could afford the high cost of glass syringes and needles.
It takes 15 to 30 seconds for an inj ected opiate or opioid to
affect the central nervous system. If the drug is injected just
under the skin or in a muscle ("skin popping" or "mus-
cling "), the effects are delayed by 5 to 8 minutes. Ora l use of
This 1899 poster for King of the Opium Ring, a play about opium
abuse, reflected the widespread use of opioids in patent medicines in
that era.
Courtesyof the Library of Congress
Downers: Opiates/Opio ids and Sedative-Hypnotics 4.9
morphine (30 to 60 minutes to affect the brain) and opium
smok ing (7 to 10 seconds) induces euphoria and provides
relief from physical and emotional pain, but it wasn't until
the hypodermic need le allowed intravenous use that an in-
tense rush also occurred. The intensity of a user's first rush
from IV heroin injection makes compulsive drug-seeking
behavior more likely. Many IV heroin users spend their
who le drug-using careers trying to replicate the rush of eu-
phoria they experienced with the first inj ection.
Patent Medicines
Opiates were so popular in the 1800s that hundreds of ton-
ics and medications loaded with op ium, mor phine, an d
other psychoactive drugs came on to the market. Products
such as Mrs. Winslow 's Soothing Syrup, Dove r's Powder, and
I
McMunn's Elixir of Opium were sold as treatments for every-
th ing from tired bloo d and colicky babi es to coughs, d iar-
rhea, and toothaches. 19People were drawn by claims of natu-
ral rather than chemica l nostrums, but the dangers were still
there. 20 The worki ng classes often left the ir babies in the care
of baby minde rs, who kept these wee ones half- loaded with
opiate- laced syrups. The mothers would retrieve their ch il-
dren after 14 hours of work and give them another dose of an
elixi r so they could sleep and be ready for the next day's
work. The working class also used op ium-laced mixtures to
ease their own pain.
The use of opio ids for pleasure (recreationa l use) by the mid-
dle and upper classes came into vogue as the number of op i-
um parlors and the availability of newly concocted opiate
mixtures increased. Physicians were not fully aware of or
simply chose to ignore the addictive potentia l of opiate drugs,
which caused iatrogenic (ph ysician- induced) addiction in
many of their patients. Four to eight times as many opiate
prescriptions per capita were writte n at the start of the
twentiet h century compared wit h the p resent day. Surveys
from the 1880s showed that between 56% and 71% of opi-
u m ad dicts were wo men. 12 Among the well-known females
who tried opiates were pioneering social worker and Nobel
Peace Prize winner Jane Addams, well-known actress Sarah
Bernhardt, and writers Elizabeth Barrett Browning, Charlotte
Bronte, and Louisa May Alcott. Male writers and poets were
not immune to the drug. Samuel Coleridge, Charles
Baude laire, Lord Byron, John Keats, Edgar Allan Poe, and
Algernon Swinburne use d laudanum and other opiates. 21 •22
"I arrivedon the sta9e in a semiconsciousstate,
~etdeli9htedwiththe applaus
e I received."
Sarah Bernhardt , 1890
Snorting
In add ition to drink ing, eating, smoking, and inject ing op i-
ates, immigra n ts from Europe to the United States intro-
duced the habit of sniffing or snort ing heroi n (also called
insufjlation and intranasal use) . It takes 5 to 8 minutes from
the time the drug enters the nasal capillaries to reach the
CNS and 10 to 15 minutes to experience peak effects . From
the turn of the century until the 1920s, heroin addicts were
split even ly between sniffers and shooters. 8 Snorting requires
 4.10 CHAPTER4
more of the drug to get the same high produced by injection,
but heroin's low price encouraged insufflation, especially
among those who were afraid needles. This method was pop-
ular with heroin-using Gis in Vietnam because the drug was
easy to get and quite pure. More than half of all heroin ad-
dicts entering treatment began their heroin use by insuffia-
tion. 23 ,24 Modern prescription opioids such as OxyContin ®
and Vicodin ® can be snorted or injected after they are
crushed.
Twentieth and Twenty-First Centuries
At the beginning of the twentieth century, the growing num-
ber of opium, morphine, and heroin addicts spurred various
I
governments to action. Casual nonmedical use of opiates
was declared illegal by the international community through
the Hague Resolutions and by the United States through the
Pure Food and Drug Act in 1906 and made stronger by the
Harrison Narcotics Tax Act in 1914.
In the first two decades of the twentieth century, opioid
addiction was considered a medical problem and was
treated by physicians . Even though alcoholism was consid-
ered more debilitating and certainly more expensive than
opioid addiction, a number of heroin treatment centers were
opened. The federal government operated a treatment facil-
ity in Lexington, Kentucky, from 1935 to 1974, housing
approximately 1,400 narcotics addicts who had been con-
victed for their use or possession of drugs. Another federal
treatment facility in Fort Worth, Texas, operated from 1935
to 1972.
Historically, most drug laws were passed for political or
taxation reasons rather than medical considerations. By
1924 production of heroin in the United States was prohib-
ited, and any doctor not connected to one of the federal fa-
cilities was subject to prosecution for treating heroin addic-
tion as a disease. As the number of laws increased, so did
the prison population. Incarceration for federal violations of
the narcotics law rose from 63 in 1915 to 2,529 in 1928
(about one-third of all federal prisoners). 25 In 2011 the num-
ber of federal prisoners held for drug offenses was 94,600,
which represented about 51% of all federal prisoners incar-
cerated that year. In state prisons, 225,242 were serving
time for drug offenses (17% of the total of 1,353,198). 26 The
recent decision by Attorney General Eric Holder to limit fed-
eral drug prosecutions to the most serious cases will reduce
the federal prison population.
Historically, most drug laws
were made for political or taxation
rather than medical reasons.
The availability or prohibition of different opiates/opioids
shifted methods of use and type of drug. When the importa-
tion of smokable opium was banned in 1909, it produced a
shift to injectable heroin. 27 Restrictions limited supplies and
turned opium and heroin into valuable commodities, mak-
ing growing, processing, and distributing opiates/opioids,
especially heroin, major sources of revenue for criminal or-
ganizations like the Chinese triads, the Italian Mafia, the
French Connection, Mexican narcoficantes, African traffick-
ers, the Russian Mafia, Colombian cartels, Al-Qaeda, and
other terrorist and rebel organizations. Over the past few de-
cades, large-scale diversion through theft, bogus purchases,
forged prescriptions, loaned prescriptions, and uncontrolled
Internet drug sales has expanded the illegal market of legal
prescription opioids.
"/ went to differentph~sicians. I would rip off prescription
pads; and since I workedin the medical ~eld. writin9m~ own
prescriptionswas no problem, except that I committed a felon~
ever~time I did it, which was once a week. I never9ot cau9ht,
but I alwa~slived in mortal fear that the~ would 9et me."
38-year-old female recovering prescription opioid abuser
In 2012 an estimated 4.9 million Americans used prescrip-
tion opiates/opioids illicitly every month compared with
280.000 to 800,000 heroin abusers. 28 In 2010 records from
256,000 heroin treatment admissions showed that approxi-
mately 25% of the pa-
5.1 millions Americans tients inhaled the drug
use prescription and almost 70% injected
opioids every month. it. 24 Larger percentages
1
of "sniffers" and smok-
ers are found in the eastern half of the United States. Some
"snorters" mix tar heroin with water and snort it from a
Visine ® spray bottle. A few years ago, a heroin-laced powder
called "cheese" found a market. "Cheese" is a mixture of a
little bit of heroin (maybe 10%) and an OTC cold medicine
(such as Tylenol ® PM); a quarter gram sold for $2 to $5, a
full gram for $10.
Heroin:A Worldview
There are 15 million to 20 million regular heroin users
worldwide. The United States consumes 3% (12 to 20 met-
ric tons) of the world's supply, a number that has remained
stable for the past few years. The United States and a dozen
other countries continue the battle to eliminate the growth,
use, smuggling, and exportation of heroin and other opiates/
opioids.
The number of users is the result of plentiful supplies of the
drug; more-sophisticated drug-trafficking organizations,
particularly in Mexico; and the legal/illegal growth of pre-
scription opioids. Since 1986 worldwide production of illicit
opium, the raw ingredient used to make heroin, has more
than doubled. 28
The major grower of illicit opium is Afghanistan, half of
what was formerly called the Golden Crescent (Afghanistan
and Pakistan). According to a United Nations survey,
Afghanistan grew about 3,700 metric tons of opium in
2013, the equivalent of about 370 metric tons of heroin, or
more than 92% of the world's supply. 28 It provides about
one billion dollars in income for the farmers of Afghanistan,
an extremely lucrative amount compared to other food crops
that they could grow. Most Afghani heroin is exported to
Europe and Asia. Opium supports the majority of the

Taliban's counterinsurgency in Afghanistan, prompting the
United States to step up the effort to destroy the Taliban's
source of income. About 17% of heroin brought to the East
Coast is from Afghanistan, but the bulk of U.S. heroin
comes from Mexico (18 metric tons) and Colombia (about
5 metric tons). 28 Colombian imports have dropped signifi-
cantly in the past five years, but Mexico's have more than
doub led.
Southeast and southwest Asian heroin has a relatively small
share of the market. Countries in the Golden Triangle in
Southeast Asia-Myanmar (Burma), Thailand, and Laos-
are also significant growers of illicit opium (424 metric
tons of opium, or 42 metric tons of heroin). 28 Other coun-
tries produce heroin for smaller and more-regional markets.
The addict populations in many of the countries that grow
opium have exploded. There are an estimated 1.9 million
opioid users in Pakistan and 1 million in Afghanistan.
Thailand and Myanmar have 0.5 million addicts each.
Mexican Heroin and Mexican Cartels
Since the 1940s Mexico has been a major supplier of heroin
to the United States. Perhaps the 2,000-mile-long U.S.-
Mexico border is more porous than other routes. Mexico
became the number one supplier when the Turkish opium
fields dried up in the early 1970s. Back then most of the
heroin was light or dark brown powder and not as pure as
Golden Triangle white heroin. When Mexican heroin,
known as tar or black tar, came on the scene in the 1980s, it
took over a large part of the market in the western United
States. Tar heroin is 40% to 80% pure, but it has more plant
impurities than the Asian white, Mexican brown, or
Colombian white refinements of the drug. A small black or
brown chunk the size of a match head is enough for two to
five doses and sells for $20 to $25. Tar heroin, also called
"chapapote," "puta," "goma," "chiva," and, "puro," is unique
in that it is sold as a gummy, pasty substance rather than a
powder. Tar heroin is cheaper to produce than powder, dis-
The three ty pes of heroin are brown powder, white powder, and black tar. White heroin (also called China white) comes from Colombia,
Afghanistan , and the Golden Triangle. Brown heroin can come from anywh ere. Mexico is the only source of black tar heroin.
Courtesyof the U.S.Drug EnforcementAdministration
Downers:Opiates/Opioidsand Sedative-Hypnotics 4.11
solves easily in water, and is more like ly to be smoked than
are other types of heroin.
"/ came from the Midwest, wherewe mostl~9et China white,
and that to me was a whole lot cleanerthan tar. I'd neverseen
an abscessor an~thin9likethat. Peopleon the West Coastha,e
abscessesall the time becausehere it is black tar. The stuff I see
whenI breakit down-there's so muchcrapin it. It's like, ~uck,
I can't believeI put that shit in m~veins,but I did it an~wa~."
27-year-old female heroin addict
Many of the present-day Mexican cartels and gangs---e .g.,
Sinaloa, Los Zetas, Gulf, and Juarez (major cartels) and BLO,
LFM, and Tijuana (lesser cartels)-have expanded their U.S.
I
territory to the Southeast and the Eastern Seaboard to cap-
ture a larger share of the market. They all handle marijuana
and cocaine, while only four of the cartels handle heroin
and three handle methamphetamine. According to the
Department of Justice, Mexican cartels have ties to gangs in
hundreds of U.S. cities. 29 Violent battles and even behead-
ings have become common among those gangs and between
the police and the Mexican military. The current death toll is
estimated at 60,000 over the past five years.
Mexico has been the main
supplier of heroin to the United States
since the 1940s.
The containment approach of the current president of
Mexico, Enrique Peria Nieto, has changed from attacking
and arresting the heads of the cartels to reducing the vio-
lence, murders, kidnappings, and extortion by expanding
the police forces and placing them under one command. He
has also promised to minimize U.S. involvement in Mexico 's
affairs. Critics hope that the success of this approach is not
dependent on making "accommodations " with the cartels as
was done in the past .30
 4.12 CHAPTER4
I
Joaquin "El Chapa" Guzman , leader of the Sinaloa cartel , the largest
drug cartel in Mexico, was arrested in February 2014 , 13 years after
escapingfrom jail , in a surprise raid. His cartel has been blamed for
thousands of murders and has led a bid to take over most of the drug
traffic and smuggling routes in Mexico. Authorities fear a resurgence
in the violence in a fight to take over the "business."'
0 20 14 Eduardo Verdugo.Associated Press.
Note: For the rest of this chapter, the generic term opioids is
used to denote both natural and semisynthetic opiates and
synthetic opioids.
Effectsof Opioids
Medically, physicians most often prescribe opioids to:
• deaden pain
• control coughing
• stop diarrhea
Nonmedically, users self-prescribe opioids to:
• drown emotional pain
• get a rush
• induce euphoria
• prevent withdrawal symptoms
Pain and Pleasure
The impact of opium on pain and pleasure has been experi-
enced, desired, and exploited for thousands of years.
"HereI cannotbut breakout in praise of the9reatGod,
the9iverof allijoodthin9s,whohath9rantedto the human
race, as a comfOrtin their afflictions,no medicine ofthe value
ofopium, either in re9ardto the numberofdiseasesit can
control, orits e(rcienc~in extirpatin9them."
Thomas Sydenham, English physician, 1660
"For
me it started off for
pain because I went throu9h a sur9er~.
It thenwentfrompainto, I had reallqbadanxietq... social
anxietq. and I realizedthat whenI tookthismedication,
I didn'thave it anqmore."
22-yea r-ol d male recovering opioid addict
The desirability of opioid effects has led to the discovery and
the development of stronger opioids but only recently has
the complexity of the brain's neurochemical effects on pain
and pleasure been understood and connected to this desir-
ability. Advances were made possible in the 1970s with the
discovery of the body's own natural opioids, endorphins,
and enkephalins. Subsequent advances in imaging of the
brain's neurological functions (functional magnetic reso-
nance imaging [fMRI]) and other neurological discoveries
are expanding our understanding of ho w genetic changes
(epigenetics) and allostasis (atypical balance of the body 's
systems) are brought about by the use of opioids.
One example of insightful research occurred in 2013 when
researchers at the University of Colorado and Columbia
University developed a way to "see" an individual's pain on
an fMRI brain scan. They were able to measure intensity ,
determine the nature of the pain (physical or emotional),
and measure how well an opio id or other drug relieved the
discomfort. What they found is that the pain is real, that
opiates can relieve it, and that a person's judgment of the
comparative levels of pain (from 1 to 10) is usually accu-
rate and can be used as a tool to help guide treatment. 30A
The discoveryin the 1970s of the body's
own natural painkillers-endorphinsand
enkephalins-significantlychanged our
understandingof opioids and pain.
Functional MRI imaging shows that sensations of pain are
usually not imagined or blown out of proportion. They are
real. They are directly linked to neurochemical and physi-
cal changes in the CNS and are not just a ploy to get more
opioids.
'When I was in the hospital forsevereburnsover60% ofm~
bodq,the painwouldwellup and I wouldaskthe nurseforpain
medicationsoonerthan was scheduled, and she had the nerve
to tellme. 'Oh. qoudon't needthe meds... I'vebeenthrou9h
of
this dozens times before,and ~ou don't need them.'
I wasn'tverqpolite whenI told herI did."
33-year-old female burn victim of a car fire
Researchers explain the different kinds of physical pain
signals sent to the brain:
• Nociceptive pain is pain caused by stimulation of spe-
cific pain receptors , mostl y by external noxious stimuli
such as heat, cold, vibration, stretching, various physical
injuries, and caustic substances.
• Non-nociceptive pain is pain caused by nerve cell dys-
function that arises within the peripheral and centra l
nervous systems (e.g., pinched nerves and nerve dis-
ease). Chronic pain is often non-nociceptive. 3 1
To understand the specific effects of opioid drugs, it is neces-
sary to first understand the central nervous system's own in-
ternal opioids. All human beings have multiple endogenous
(internal) opioids (e.g., endorphins , enkephalins, and dyn-
orphins) , which produce many of the same effects caused

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byexternal(exog=ou,)opioiddrugo.Therecq,tonfor
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I
Tohaveaneffect.rndorphin,mu51ottxhthem,elvntoopi -
oidrecq,tors,principallymu,delta,kappa,andnociceptin
l'.achrtteptorhasdiffuentlunctions
• Murettptoro a rethemostimporunt.Theyblockp aln
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• Noci«ptin receptors a n, in,'Olved with most oom,uic
and vi>cer•I pain signaled by,uhs tance Thi, r«<ptor,
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l'.achop ioiddrughasanaffinityfor,pedficm:q,torsite>,oo
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tor>),will,ubdu e painmo reeff ecti,.,lythmheroin , which
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TherapeuticPain Control
vs. Hyperalgesia
Opioid•buse,ti>ouedq,endrnce,mdaddictionoftenoccur
inthel egitimat<pursuitolrelidfromchronicpain . Ane>ti-
,,,.,,,!""1of1M 1111.t<d116 million Ameri cans ,uffer from chronic pain,
•ndfor!Omillionth<epa ini,pn•io trntandoft<nd i>-
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 4.14 CHAPTER4
supply of prescription opioid painkillers, according to the
American Society of Interventional Pain Physicians; that
amounted to 219 million opioid prescriptions in 2011 in
the United States. Perhaps this is due to a culture that seeks
easy solutions to complex situations; instant pain relief qual-
ifies as one of those solutions.
Since the beginning of the twenty-first century, there has
been an increased recognition of severe problems when
treating pain, particularly chronic pain, with opioids. New
research is redefining different types of reactions to pain that
involve unwanted physiological and neurochemical changes
in the nervous system when exposed to longer-term use of
opioids.
The United States consumes 80%
I
of the world's supply of prescription
opioid painkillers.
• Hyperalgesia is a temporary increase in the sensitiv-
ity of nerve cells. The nervous system overamplifies the
sensory signal to the brain, warning it to do something
to lessen the pain. This exaggerated pain often occurs in
opioid abusers. The pain usually disappears when the
injury or damage heals.
• Hyperpathia is an abnormal increase in pain as a re-
sult of a repetitive or damaging stimulus. The difference
is that the pain can persist after the nociceptive pain
stimulus is removed or healed.
• Allodynia is a painful response to a normally innocu-
ous stimulus such as a light touch on the skin. Because
sensitivity is overamplified, the pain is as intense as that
caused by a noxious stimulus. This often occurs in those
who abuse opioids.
• Hyperkatifeia is opioid misuse in the context of pain
management, which produces a hypersensitivity to
emotional distress_ 11,1
1,1s,19,40,41
Extendedopioid use increasessensitivity
to pain (processescalled hyperalgesia,
hyperpathia, allodynia, and hyperkatifeia).
'Well once I started abusin9Jain medicationsand became
dependenton them, I woul B't to the pointwhereif I didn't
havethem, I couldn'ttouchmqskin;like.it wouldbepainful.
Thin9slikeheadachesor thin9slikethat. that a normalperson
wouldtakeTqlenol®far. the onlqthin9that wouldwork
farme wouldbepainpills."
26-year-old female recovering opioid addict
In summary, when external opiates are taken to reduce
pain over a period of time, the body adapts by creating a
greater sensitivity to pain. As the pain threshold lowers ,
the intensity of pain continues and escalates because over
time, modest amounts of external opiates don't provide
sufficient relief. This is the point at which a person increases
the frequency of use. 41,42
"/ felteuphoriafromusin9the dru9,but if I wasn'ton the dru9,
I wasin sometqpeof pain.I wasin phqsicalpain,psqcholo9ical
pain, emotionalpain, some t~pe ofpain."
S2-year-old female recovering opiate addict
Each person is different, each pain is different, and each re-
action is unique, but pain signals are real They are warn-
ings , telling us to do something to limit the pain, but they
do not heal damaged tissue or nerves.
"/ had backsur9erqin 1991(discectomq
and fusion). and I
was prescribedm~ prst opioids, mostl~Vicodin.® I also was
prescribedSoma® (a muscle relaxant), Neurontin® for nerve
pain, cortisoneinjections,and an electricpain stimulator
(whichdidn'twork).And eventhou9hI wentthrou9ha pain
manaaementcourseand was aware ofopioid dependenceand
addiction,I endedup duelin9withmqpainand the dru9sfar
the next14 qears.constantlquppin9the medicationsuntilI
in 2005 and the doctors
reallqcrossedthe linephqsiolo9icallq
wereprescribin9morphine,Norco® (an opioid), more Soma,®
manqinjections, and phqsicaltherapq.I'msureI wasopioid
dependentin the prst qear. 1991.but sinceall I wantedwas
painrelief,I woulddo almostanqthin9to be freefrompain.
Recent/~, I moved to Ore9on and came under the 9uidance of
a pain specialist,and I si9ned a pain mana9ementcontract.
Unfortunatelq, mq medswerestolen(real/qi),and I ranout
of morphineand Norco.® Becauseof the contract, I had to
essentiallq90 coldturkeqwithjust the helpof non-opioidmeds.
clonidine,Flexeri/.® and hqdroxqzine . whichhelpedcontrol
thesqmptomsof what I pnallqrealizedwasfull-blownopioid
withdrawal.It washellfarsevenor ei9htdaqs. but pnallqit has
started to abate, so for the prst time in 22 ~earsI am opioid-
free. I had had a new electro-stimulatorput in a ~eara90 and
have found it to be much more effectivenow that I am clean
of opioids.I had beena functionin9 addictwitha re9ularjob.
With chronic use even small pains wereampliped to the point
ofintolerance.I have entered addiction treatment, which is the
prst effectiveand repeatablechronicpain treatment in m~ life."
SO-year-old recovering chronic pain pa tient
Physicians and nurses rely on patients to self-rate their pain
on a scale of 1 to 10, with 10 being the worst. Many clini-
cians have added a parallel self-rating schedule for stress in
recognition that stress and emotional pain are actually linked
to one's perception of pain. 48Based partially on these ratings,
morphine, different opioids, or other painkillers are pre-
scribed. Several other concerns affect the amount of medica-
tion the physician will prescribe:
• fear that tissue dependence and addiction might develop
• fear that a recovering addict might relapse regardless of
his or her drug of choice
• concern that the opioid will mask clues to a serious
disease
• concern that prolonged use will oversensitize the patient
(hyperalgesia)
• concern that the patient may be faking symptoms to get
drugs to supply a habit (purposive withdrawal)

Chronic
Pain- Hyperalgesia
(PainSensitivity
Increases)
This representation of the effectivenessof opioids on pain illustrates recent researchconcludingthat long-tenn use of opioids readjusts the
sensitivity of nerve cells and, over time, can diminish their pain-killing ability, increase pain overall, and evencreate pain.
© 2014 CNSProductions,lnc.
These are valid considerations and might prevent some phy-
sicians from prescribing sufficient pain medication even
when appropriate. A survey of primary care physicians found
that the majority were comfortable prescribing opioids to
terminal cancer patients but less comfortable prescribing
opioids to patients with low-back pain and to those with a
history of drug or alcohol abuse .43
The fear of government action for overprescribing is also a
factor in the undertreatment of pain . Today the potential
abuse of oxycodone, hydrocodone, methadone , and other
opioids makes adherence to medically sound prescribing
practices difficult. To provide guidance to physicians, the
Federation of State Medical Boards, the American Society of
Addiction Medicine (ASAM), and other professional organi-
zations have adopted policies and guidelines for the use of
controlled substances in treating pain .
For example, the Pain Patient's Bill of Rights enacted into
law in California states the following:
• Inadequate treatment of acute and chronic pain is a sig-
nificant health problem.
• A physician should prescribe in conformance with the pro-
visions of the California Intractable Pain Treatment Act.
Downers: Opiates/ Opioids and Sedative-Hypnot
ics 4.15
Overtimemostpeople developa tolerancefor
chronic painandlearnto livewith it. Solongas
the injury or nervedamage doesnotprogress,
the pain becomes moretolerable.Being
completely pain-freeis usuallynot possible.
Time
If opioidsare usedonlyfor a fewdaysand/orin
limiteddoses,paincan usually be managedto a
bearable leveland toleranceto thedrugwill not
adva nce.
I
When opioidsaretakenfrequently, tolerance
develops.Atthatpoint it takeslargerand larger
amounts to keep the pain atthe lower level.
Time
As tolerancedevelops due to theuseof more
and more opioids, hyperalgesia occurs,which is
the increased sensitivity of nervecells,causing
even more pain in spite of theincreaseduseof
opioids.The increased sensitivitycancauseeven
the slightest painto bemagnified to thepoint of
being unbearable.
Time
• The physician may refuse to prescribe opiate medication
for a patient who requests the treatment for severe chronic
intractable pain; however, that physician shall inform the
patient that there are physicians who specialize in treat-
ing that kind of pain with methods that include the use
of opioids .44
Policies and guidelines aside, there are pill mills where li-
censed physicians with valid Drug EnforcementAdministration
(DEA) numbers write prescriptions for large amounts of opi-
oids. Their patients are generally younger, are drawn from a
broad geographic area, and pay in cash . In Florida the DEA
has closed more than 254 such "pain clinics ."
American Society of Addiction Medicine guidelines, first
issued in 1997, encourage physicians to use their own
judgment when prescribing and suggests that they not be
held responsible if a patient cons them into prescribing un-
needed opioids. ASAM also suggest correcting both overpre-
scribing and underprescribing through education rather
than sanctions since the latter has the potential to interfere
with the practice of good medicine. 45
 4. 16 CHAPTER4
Mary's threshold '\ A
for pain was so low
it hurts to put
lipsticK on ...
I
© 2014 DaveGranlund
"Ver~little has been publishedon the populationof patients with
co-occurringpain and addiction. We know that of patients
who attend methadone clinicsfor opioid addiction, 40% report
moderateto severechronicpain. The questionin the methadone
population is 'Is methadone actuall~makin9the pain worse,or
do these patients have more-severeph~sicalillness?'We don't
know the answerto the questionspecificall~.but we do know
that patients are d~ingin numberssreater than everbefore."
Andrew Mendenhall, M.D., pain specialist, medical director,
Hazelden Clinics, Beaverton, Oregon
Today iatrogenic addiction is rare because physicians are
more knowledgeable about the risks of long-term opioid use
than they were at the turn of the century.
"I had been maskingthe pain for so long that
I didn't know how much pain I had or didn't have;
and when I didn't reall~have pain, I still used."
37 -year-old recovering prescription opioid addict
Some level of tissue adaptation occurs with even the initial
dose of an opioid, so care must be taken when prescribing.
To lessen the risk factors of addiction, physicians must be
aware of their patients' :
• physical health (e.g., kidney and liver function)
• drug-abuse history, medical drug use history, and mental
health history
• possible hereditary factors that make the patient more
susceptible
In addition, the physician must:
• develop a diagnosis and treatment plan
• discuss with the patient risks vs. benefits and compliance
• be current on recent trials of medications or consult with
others familiar with the drugs
• ask for feedback from the patient as to effects, efficacy,
and side effects
• be willing to modify the type of medication and dosages
• keep accurate records concerning effects and patient
reactions 46
Suggestions from the American Pharmacists Association for
alternatives to opioid pain medication include: 47
• nonsteroidal anti-inflammatory drugs (e.g., ibuprofen,
Aleve,® Clinoril®)
• acetaminophen
• norepinephrine reuptake inhibitors-antidepressants (e.g.,
Cymbalta,® Effexor®)
• anticonvulsants (e.g., Topamax, ®Neurontin,® Tegretol ®)
• steroids (e.g., prednisone, Decadron, ®hydrocortisone)
• muscle relaxants (e.g., Flexeril,® Robaxin, ® Zanaflex, ®
Baclofen, ®Skelaxin®)
There are literally hundreds of ongoing searches for non-
opioid pain medications. This is due to opioids' diminished
efficacy with continued use, their addictive potential, and
their side effects. One promising line of research focuses on
the brain's glial cells . These nonneuronal nervous system
cells have recently been recognized as playing a role in the
generation of neuropathic pain and in opioid tolerance and
withdrawal. Other promising lines of inquiry involve the
cannabinoid receptors, particularly the CB2 receptors that
also seem to modify pain without any psychoactive effects.
It has been shown that some other direct health interven-
tions in combination with opioid medications when treating
chronic pain lead to the best outcomes. The other interven-
tions, besides a few non-opioid medications, include physical
therapy, acupuncture, electrical nerve stimulation, biofeed-
back, massage, exercise, diet, mindful meditation, hypnotism,
yoga, Pilates, chiropractic therapy, aromatherapy, eye move-
ment desensitization, magnet therapy, music therapy, and a
litany of Asian modalities (e.g., reiki, Ayurveda, and qigong. 31
Acupunctutt
Httbal Mtdidnt aJnic
NETWORK
Pain control comes in many forms: medications,acupuncture,Chinese
herbal medicine, electricalstimulation, and hypnotherapy.
© 2014 CNSProductions,
lnc.

"It is deeplq9ratifqin9to see that patientscan acceptlimita-
tions-meanin9, 'Gosh, I understandthat I can't 9et hi9h
anqmore,that that is not 9oin9to be safe forme, but I can
stillreceivecompassionate pain treatment- and that thereis a
9roupof compassionate phqsiciansthat understandthat I hurt
and that I can't just praqor thinkmq waqthrou9hthisand
this is not just9oin9to aoawaq."'
Andrew Mendenhall, M.D., pain specialist , medical director,
Hazelden Clinics, Beaverton, Oregon
It is important for chronic pain patients to understand and
accept that they will always experience some pain, so the
goal of treating chronic pain is to help patients better
manage it through a variety of modalities and control their
response to it.
Emotional Pain
Controlling emotional pain is just as important as control-
ling physical pain. Opioid users often experience decreased
anxiety, a sense of detachment, drowsiness, and a numbing
of unwanted feelings. This is due to the drug's inhibiting ef-
fect on the locus coeruleus on top of the brainstem and its
influence on the survival pathway. Experiments show that
severe stress can activate natural endorphins to mitigate
emotional pain just as they do for physical pain. 48
'When qou areloadedon heroin, qou can watchqourbestfriend
aet hit bq a car, all qourfriendscould be dqin9,qourdo9 could
comedown with rabies,and qou could9et AIDS,herpes,and
cancerall at onceand qou don't care.You'reseparatedfromit
and blockedoff fromqouremotions."
18-year-old female heroin addict
Unfortunately, the distortion and the magnification of physi-
cal pain that occurs with long-term opioid use (e.g., hyper-
algesia, hyperpathia, and allodynia) also occurs emotionally
with hyperkatifeia, which postulates that extended use of
opioids induces a hypersensitivity to emotional distress,
so even minor emotional stressors can become intolerable
during withdrawal and while in recovery .
Even though all opioids relieve pain , small alterations in the
molecular structure can produce dramatic differences in the
strength of the drug , the duration, and the side effects. For
example, heroin and codeine will relieve pain for four to six
hours, whereas fentanyl barely lasts an hour but is strong
enough to be used as an anesthetic during surgery.
Extendeduse of opioidsinducesa hypersensi-
tivityto emotional distress,so when striving
for abstinence,even minor emotional stressors
can become intolerable(hyperkatifeia).
Reinforcement(reward, pleasure)
In terms of abuse, dependence, and addiction to opioids, the key
is dopamine and its effect on the survival pathway (which
includes the nucleus accumbens and the prefrontal cortex).
When this system is activatednormally,the releaseof endorphins
Downers:Opiates/Opioids and Sedative-Hypnot
ics 4.17
also releases dopamine , which encourages the repetition of
the action until that need is satisfied (e.g., eating or having
sex). Just as important the brain remembers these actions
so that they can be repeated in the future when needed.
These reactions can also be mimicked by the use of external
opiates, which are much more powerful than endorphins.
Of the various opioids, heroin seems to have the strongest
effect on the reward reactions of the survival pathway.
'The last shot is never900d enou9h.You'realwaqslookin9fora
certainshot. You'relookin9forthe sameshot qou had whenqou
firstdid the dru9, whichqou'IIneveraet a9ain."
22-year-old recovering heroin addict
I
"It'slikeputtin9all qourtroublesin one ba9and qou havea
solutionforit and that's heroin.Yourone problemis to worrq
about9ettin9qourheroineverqdaq."
72-year-old recovering heroin addict
When the natura l (endogenous) endorphins and enkepha-
lins produce a reward, triggered by a specific action (positive
reinforcement), various cells in the brain monitor the action
and when the need is filled, the brain sends out a signal to
stop: "don't release any more endorphins"; "that's enough ."
Addiction to powerful psychoactive drugs, including heroin,
can disrupt this "stop" switch, which resides in the pre-
frontal cortex. The brain never receives the signal to stop,
so the activity continues. The more frequently this switch
is overloaded due to heroin or other powerful opioids , the
greater the malfunction. Communication between the "stop"
switch and the "go" switch-via the fasciculus retroflexus
and the lateral habenula-is often damaged by continued
drug use, so even if the brain knows what to do, the signals
can't be communicated to the part of the brain that would
drive the person into action.
Powerful opioids overactivate the "go" switch,
disrupt the "stop" switch, and interrupt
communication between the two. Carried
far enough, this process leads to physical
dependence and addiction.
The same area of the brain that signals pleasure/reward
also signals alleviation of pain, so if people want to either
induce a good feeling/rush/high or alleviate emotional/
mental/physical pain, they sometimes reach for an opioid.
Relief from the pain of withdrawal symptoms is also a
powerful motivator for continued use, as illustrated by
studies conducted on animals at the University of Cambridge
in England , which found that the subjects were more moti-
vated to self-administer heroin to gain relief from with-
drawal symptoms than to simply experience the drug even
when there is no pain. The longer the heroin was used, the
greater the incentive for continued use during withdrawal.' 0
Drug abusers will keep using past the point of pain relief
while searching for an emotional high or because they are
simply unable to stop.
 4. 18 CHAPTER4

"Nomatterwhat I did, I had no control.Once I 9ot that first

dru9and I 9ot hi9h, I immediatelq hatedit. I resrettedit.
Everqthin9 I did... it's like. .. what did I just do to 9et this?
I can't believeit. And thenoncethe hi9hwentawaq,it went
strai9htbackto whatam I 9oin9to do to 9et more,whodo
I haveto robto 9et more."
26-year-old heroin addict

The good news is that the brain does begin to repair itself
once a user enters recovery.49

Cough Suppressionand Diarrhea Control

Besides pain control and pleasure inducement, opioids are
used to suppress coughs and control diarrhea. They sup-

I
press coughs by desensitizing the cough center in the
brainstem that signals an irritation in the respiratory tract.
Codeine- and hydrocodone-based cough medications like
Robitussin® A-C and Hycodan® syrup are widely prescribed,
but Robitussin ®is sometimes abused for the opioid-like high
from the codeine or for the psychedelic effects from the dex-
tromethorphan (cough suppressant). Reactions like respira-
tory suppression, nausea, and vomiting are common. In one
study coroners reported that when opioids in cough
suppressants were involved in overdose deaths, it was most
often in combination with other drugs, particularly alcohol,
benzodiazepines, and antidepressants. 51 Because of the
increased misuse of Robitussin® DM and similar non-
prescription cough medications, these products are kept
behind the counter in many states to restrict and control
their sale.
Opioids control diarrhea by inhibiting gastric secretions
and depressing the activity of intestinal muscles. The pro-
pulsion of food through the digestive system is therefore
slowed. Constipation can become a severe problem in ad-
dicts, those with chronic pain who use
opioids over a long period, and post-
surgery patients.
"I had somekneesur9erqand I wasin the
hospitalfor overa week,takingVicodin®
for pain.At somepointtheq had to
rushme to sur9erqbecauseI was
so impactedbq the Vicodin®and
almostbusteda 9ut, literallq."
58-year-old recovering heroin abuser
Law enforcementas well as treatment personnel can get a strong
indication of drug usefrom the size of pupils. Top:opioids (especially
heroin) constrict pupils. Bottom: methamphetamine, ecstasy,and
cocaine (stimulants) dilate pupils.
Courtesyof the CaliforniaHighwayPatrol
Recently a concoction of cough syrup containing codeine
and promethazine (an antihistamine) mixed with Sprite
and a handful ofJolly Roger Candies has become popular in
the hip-hop music scene and at electronic dance music raves
and parties. It acts like a downer but it also gives a spacey
effect. It is called "purple drank," "sizzurp," "syrup,"
"lean," "purp," and "Texas tea."
PhysicalSide Effects
Opioids, particularly heroin, affect many organs and tissues
in every part of the body, particularly when used to excess.
The heart, lungs, brain, eyes, voice box (larynx), muscles,
cough and nausea centers, reproductive system, digestive sys-
tem, excretory system, and immune system-all are compro-
mised . Some of the major physical side effects of heroin are:
• insensitivity to pain, which can keep a user from treat-
ing a damaging ailment such as an abscess
• lowered blood pressure, pulse, and respiration
• sedation and delayed reactions
Some of the side effects of the stronger opioids are quite
identifiable in the heavier user, particularly with heroin:
• Eyelids droop and the head nods forward.
• Speech becomes slurred and slowed, and the voice is
raspy or hoarse.
• The walking gait and coordination are slowed .

The basic ingredientsof alcohol, codeine, • Pupils become pinpoint and do not react to light.
Cannabis extract, and chloroformwould • The skin dries out and itching increases due to hista-
have stopped any cough in the late 1800s. mine release .
Courtesyof the Library
of Congress,
National
Instituteof Medicine Some of the desired medicinal effects can also have negative
consequences:

• Suppression of the cough center in the brain can hinder
clearance of phlegm in those users with respiratory ail-
ments such as emphysema , pneumonia , and tuberculosis.
• Opioids can trigger the nausea center; some heroin
addicts deem a batch of heroin to be good if it makes
them vomit.
"It hit fromthe feetgoingup to the head. I wasqellingat him
to takethe needleout, and I wason the toiletseat. I meanI
huggedthat toiletbowlfor hours,vomiting."
23-year-old heroin user
• Opioids affect the hormonal system; a woman's period
is delayed, and a man produces less testosterone; sexual
desire is dulled, often to the point of indifference .
'When I'm on heroin,I can't havean orgasm. It's just one of
those things.I can havesex for hours, and it startsto get pain-
ful. Heroinmakesmq wholebodqnumb. I don't wantto move
around,and I don't wantto havesex whenI'm high."
24-year-old dealer and heroin addict
Tolerance,TissueDependence,
and Withdrawal
The desire for pain relief and the experience of pleasure
combined with the development of tolerance, tissue depen-
dence, withdrawal (along with hyperalgesia , hyperpathia,
allodynia , and hyperkatifeia) are the main reasons opioids
are so addictive .
Tolerance
Tolerance occurs when the body tries to protect itself from
heroin (or any other psychoactive drug) by:
• speeding up metabolism, particularly in the liver
• desensitizing the nerve cells to the drug 's effects
• excreting the drug more rapidly through urine , feces,
and sweat
• altering the brain and body chemistry to compensate for
the effects of the drug
"Mqtoleranceto Demerol,®morphine , and thingslikethat was
tremendous.I had to havetonsof the stuff I wentto havea
localsurgerq,and theqwerelike, 'Okaq, how'sthat?' and I was
0
like,'Is thisjust a test or what?"'
35-year-old recovering opioid addict
As the body adjusts, the user must increase dosage to achieve
the same effects. Because tolerance occurs so rapidly with
opioids, users might need 10 times as much (e.g., morphine)
in as little as 10 days. There is almost no limit to the devel-
opment of opioid tolerance. After a year of opioid use, one
terminal cancer patient had five fentanyl patches , was taking
20 Demerol® tablets, and was using continuous morphine
suppositories every day-a level that would have killed a
nontolerant user.
Downers:Opiates/Opioids and Sedative-Hypnoti
cs 4.19
"No matterhow muchI was doingtowardthe end, I wouldn't
get high. I wouldn't get that nod that I waslookingfor. I didn't
get that anqmore, I got well. I got to whereI wouldfeelgood
enoughto be ableto go out and rgureout how to get more."
23-year-old recovering opiate addict
Tissue(physical)Dependence
Tissue dependence is an attempt by the body to protect it-
self and occurs when the body changes due to continued use
of an opioid. It is the tipping point at which cessation of
use causes withdrawal symptoms . Users continue to shoot
or smoke just to feel normal and to avoid or relieve the pain
of withdrawal.
I
"In mostpatientsusuallqtwo weeks'worthof medicationa~era
smalloperationor somethinglikethat willlead to a certainlevel
of phqsicaldependen cq, wheretherewillbe a mildwithdrawal
that happens. If somebodqwasjust beginningto useheroin,
theqmaqstartto experience withdrawalsomewhatsooner."
Andrew Mend enhall , M.D., pain specialist, medical director ,
Hazeld en Clinic s, Beaverton , Oregon
A study conducted by Dr. Eric Nestler and his colleagues at
Yale University showed that chronic administration of mor-
phine to rats actually reduced the size of dopamine-producing
cells (in the ventral tegmental area) by one-fourth. 52 This
implies that when chronic morphine (or heroin) use is
stopped, the body's ability to produce its own dopamine
decreases, resulting in a diminished ability to feel elated or
even normal. This depletion intensifies the desire to use the
drug again and to use more. Researchers also found that tis-
sue dependence developed more rapidly in animals that had
become dependent on a drug that was then withdrawn and
then readministered. This implies that tissue dependence
returns more quickly each time a user relapses.
'The rrst timeit tookseveralmonths, but onceqou'vebeen
phqsicallqdependenton heroin,the nexttimeqou use, it onlq
takesone or two timesand qou'redependentagain."
28-year-old female recoverin g opioid abuser
Tolerance and physical dependence can extend to other
opioids . If a user builds tolerance to and a physical depen-
dence on heroin , he or she will also have a tissue dependence
on and a tolerance to morphine, codeine, and other opioids
(cross-dependence).
Tissuedependence
This cross-dependence is returnsmore quickly
the basis for methadone eachtime a
maintenance treatment , user relapses.
where one opioid (heroin)
is replaced by another, less damaging one (methadone or bu-
prenorphine). Tolerance and physical dependence appear to
be receptor specific, however, so an opioid , such as heroin ,
that works at the mu receptors will not create as much toler-
ance as one that works at the kappa receptors. 53 This process
is called select tolerance.
 4.20 CHAPTER4

Withdrawal
0 ioidWithdrawal
Symptoms
When opioids are used to excess, the changes to the body
Bone,join~andmuscular
painandspasms
and the brain are so extreme that when abstinence is initi-
ated and the body tries to reverse those changes , the conse- Insomnia
andanxiety
quences are equally extreme. Sweating
andrunnynose
• Short-acting opioids (3 to 4 hours), like heroin, mor- Stomach
cramps,
vomiting,
diarrhea,
andanorexia
phine, and hydromorphone (Dilaudid ®), result in more- Highbloodpressure,
rapidpulse,andtachycardia
acute withdrawal symptoms beginning 8 to 12 hours
Dilatedpupilsandtearyeyes
after cessation of chronic use, reaching peak intensity
within 48 hours, and then subsiding over a period of 5 to Hyperreflexes
andmusclecramps
7 days. Fever,
chills,andgooseflesh
• Long-acting opioids such as methadone (24 to 36
hours) activate withdrawal symptoms starting 36 to 72
hours following cessation; symptoms reach peak inten-

I
sity in 4 to 6 days and persist for 14 days or more. 53-54
Protracted withdrawal is also the occasional recurrence of
• Withdrawal patterns from other opioids , such as codeine , withdrawal symptoms brought about by an environmental
oxycodone (OxyContin ® and Percodan ®), and hydroco- trigger (e.g., a particular sight, odor, or neighborhood) that
done (Vicodin®), fall between those two extremes . stimulates an addict 's memory of getting high or being in
withdrawal.
'The ps~chological and the emotionalpain wasso bad
that at one point I felt as though I waspowerlessand that Opioid withdrawal is almost never life
I wantedto commitsuicide."
threatening. Those in withdrawal just
35 -year-old male recovering opioid abuser feel like they want to die.
For powerful opioids the three types of withdrawal are:
Post-acute withdrawal syndrome (PAWS) is the reappear-
• acute withdrawal (detoxification)
ance, on an irregular basis , of emotional and physical with-
• protracted withdrawal drawal symptoms 3 to 6 months, or in some cases up to 18
• post-acute withdrawal months , after abstinence has begun. PAWS symptoms in-
clude insomnia , nightmares , memory and thought problems,
Acute withdrawal occurs when tissue dependence has
anxiety, coordination difficulties, and a feeling of being back
developed after chronic use and the person suddenly stops
in active withdrawal. These symptoms are not triggered by
using. The user's physiology has changed enough to trigger
environmental cues and seem to come out of nowhere.
this rebound effect as the body tries to return to normal too
quickly instead of tapering use .
"/ don't likepost-acute withdrawals~ndromeat all. It is b~ far
m~ leastfavoritepart aboutgoingthroughrecover~because
'Your musclesare likewrenching;~ourentiredigestivetract is
it's like. .. all of a suddenm~ handswillbe clamm~or just even
goingcraz~.Stomachcramps-but not just stomachcramps, internal/~I'll feel likesomethingis off"
alsodiarrhea.Ever~thingthat cango wrongwith ~ourintestinal
21 -year-old male recov ering opioid addict
tract happens. Your legs,~oukickconstant/~ ; that's wh~ I think
the~call it 'kicking.'Your legswilljerkand kickuncontrollabl~.
This condition can be compared with a post-traumatic stress
Youhaveinsomnia.You vomit,havesweats,and what else,oh
disorder phenomenon , where a recovering user is fine for a
~eah,the craziness,delirium."
few days, wakes up sick one day, and the next day is fine. A
27 -year-old female heroin user
few weeks pass, and the same thing happens.
One reason for the hyperactivity of withdrawal is the sudden Unlike acute withdrawal from alcohol or sedative-hypnotics,
release of the excess norepinephrine that is produced but not acute heroin withdrawal is almost never life-threatening.
released because opioids inhibit the release of these neu- Opioid withdrawal is uncomfortable and painfu l and creates
rotransmitters in the locus coeruleus. 32 such high anxiety that the fear of withdrawal becomes more
of a motivator for continued use than does the desire to re-
Protracted withdrawal (extended withdrawal symptoms)
peat the rush.
lasts for weeks or months once abstinence has begun.
Initially, symptoms such as mild increases in blood pressure,
"I haveat timeswishedI wasdead. That's how severeit would
body temperature, respiration, and pupil size occur from
be.I'veseenpeoplein jail tr~ to hang themselves.I'veseen
week 4 to week 10. In a later phase , there is a decrease in
peoplein jailshoot theirown urineto tr~ and get the heroinout
blood pressure, body temperature , and respiration along
of the urinethat's left in there."
with a general feeling of unease. These symptoms fluctuate
72-year -old recov ering heroin addict
but improve incrementally with continued abstinence .

AdditionalComplicationsCaused
by Opioids
Neonatal Effects
"Mq littlebrotherand I wereboth bornaddictedto heroin.
I spentthe firstthreemonthsof mq lifecomin9off of heroin
in the hospital."
23-year-old female recovering opioid addict
Most opioids, especially heroin and morphine, can quickly
cross the placental barrier between the fetus and the mother,
delivering large doses of the drug to the developing fetus.
Pregnant heroin users have a greater risk of miscarriage , pla-
cental separation , premature labor, breech birth , stillbirth,
and eclampsia (increased blood pressure and convulsions) .
An addicted mother will give birth to an addicted baby
with acute tissue dependence. Although the birth defects
that are common due to alcohol and amphetamine abuse are
rarely seen in opioid babies, severe neonatal withdrawal
symptoms appear six to eight hours after birth. These
include low birth weight, a high-pitched cry, irritability,
tremors , exaggerated reflexes, diarrhea , rapid breathing,
sweating, and vomiting along with sneezing, yawning, and
hiccupping. " Symptoms can last five to eight weeks and ,
unlike adults, infants in opioid withdrawal can die. 56
'The two infantsthat I had that wereheroinaffected-heroin
addictedat birth- weremanaaedon morphinefor 3 months
and then continuedto do withdrawal{oranother3 to 6 months
beforethe chemicalswereout of theirbodies. Whiletheq're90-
in9throu9hwithdrawal,theqare not developin9 . Theq are not
rollin9over;theqarenot sittin9;theqarenot plaqin9with toqs."
36-year-old foster mother of children born to drug-u sing mothers
This infant is going through opioid withdrawal (prescription
painkillers) at a medical center. The symptoms are controlledby
administering a Jewdrops of methadone. The infant is then
gradually tapered from the methadone.
© 20 11 New YorkTimes,Damon Winters
Downers:Opiates/Opioids and Sedative-Hypnot
ics 4.21
The amount of prenatal care received by an opioid addict is
crucial to the health of her infant; the more care she re-
ceives, the fewer the neonatal health problems. The use of
methadone or buprenorphine to stabilize the fetal environ-
ment in an opioid-dependent pregnant woman has been suc-
cessful, but these drugs don't prevent the baby from being
physically dependent on the opiates and subject to with-
drawal symptoms requiring intensive medical management
after detoxification. Some pregnant users have used naltrex-
one to help with detoxification and to temper any return to
opioid use. Addicted infants must be medically managed in
a restful, comforting environment. The opiate paregoric
aids in decreasing seizure activity, increasing sucking coordi-
nation , and decreasing the incidence of explosive stools.
Benzodiazepines , especially Ativan,® are commonly used to
I
decrease opioid withdrawal symptoms in newborns .
Infantsborn to addictedmothers
will go into withdrawaland can die
unlesstreated.
Overdose
An opioid overdose causes the blood pressure to drop and
prevents the heart from beating strongly enough to circulate
blood ; breathing slows, and lungs labor and fill with fluid.
The victim's lips and sometimes entire body turn blue from
lack of oxygen in the blood. The person overdosed on opi-
oids can exhibit pinpoint pupils , gasping or rattling respira-
tions , cardiac arrhythmia , and convulsions.
"I'veseen mq sister90 out liketwiceand I had to reviveheronce,
and that wasthe most terrifqin9momentof mq entirelife, like
seein9heron the bed, prettqmuch dead, and havin9to shake
her,and beat her, and pickherup, and dropher untilshe like
cameto 'causeI didn't knowCPR[cardiopulmonarq resuscita-
tion]. And she didn't rememberanqthin9of it. When she woke
up, she said, 'Whq the hellareqouscreamin9?You're9oin9to
freakout our parents.'She had no idea."
26-year-old heroin addi ct
Of 1.627 million drug-related emergency departm ent men-
tions in 2011 , there were 258,482 that involved heroin com-
pared with 505,224 for cocaine, 159,840 for amphetamine
and methamphetamine , and 724,306 involving alcohol alone
or in combination with another drug. In addition , there were
more than 556,551 cases involving opioid prescription
drugs such as morphine, oxycodone (OxyContin ®), hydro-
codone (Vicodin®), methadone, and others. 2 It is estimated
that each year 15,000 people die from opioid overdoses
alone or in combination with other depressants , especially
alcohol. This is almost four times as many deaths as in
1999. 17 Severe respiratory depression is the major cause of
overdose death. The user passes out and unless quickly
revived slips into a coma, stops breathing, and dies. In about
50% of the deaths attributed to opioid overdose, a benzo-
diazepine was found in the system during the toxicol-
ogy screen ."
 4.22 CHAPTER4
I
The medical examinerfound heroin, cocaine,benzodiazepines,and
amphetamine in the body of Philip Seymour Hoffman after he was
discovereddead in his New York apartment with a syringe still in his
arm, on Super Bowl Sunday, February 5, 2014. Beforehis recent
relapsehe had been in recoveryfrom heroin addictionfor 23 years.
© 2014 New YorkPost
Overdoses are common in opioid addicts: about half of all
heroin users experience a clinically significant overdose at
some point in their use. 58 In one study 57% of the overdoses
were accidental, while 43% were deliberate.
"Youknow,peoplewho do heroinaren'tworriedaboutdqing
becauselikeif threepeopledie froma newbatchofheroin,
everqbodqwantsto knowwheretheqaregettingthat heroinso
theqcan go get somebecauseit's the best,and theq figuretheq
willjust do a littleless."
41 -year -old recovering heroin addict
Providing aid for a heroin overdose vicum first involves
establishing an airway, checking heartbeat, preventing
aspiration, and then administering a shot of an opioid
antagonist-naloxone (Narcan ®)-to block and reverse the
life-threatening effects. Unfortunately for the addict, the
Narcan ® also obliterates the high and precipitates severe
withdrawal effects.
"Whenwe revivedthisguq who had herointracksall overhis
armsand had ODed, wegavehim a Narcan®shot and he
literallqpoppedup within10 seconds,and his firstreaction
wasto curseus 'causewe had screwedup his highand he was
in pain frominstantwithdrawal.We also had to keepan eqe
on him and probablqinjecthim againbecausethe overdose
couldeasilqreturn.We had temporarilqstoppedthe sqmptoms,
but the drugwasstill in his bodq."
San Francisco emergency medica l technician
In about 50% of opioid overdosedeaths,
a benzodiazepinesuch as Xanax® is found
in the system.
Dirty and Shared Needles
Of the quarter million treatment admissions for heroin use,
58% were injection drug users. Most had been using for an
average of 14 years before entering treatment. Injection as a
method of use is more common with heroin than with any
other psychoactive drug . This excessive use of the injection
method for opioids causes high rates of illness and death due
to dirty or shared needles . Needles deliver a large amount of
the drug into the bloodstream at one time, but users can also
unknowingly inject adulterants, infectious bacteria, and
viruses such as hepatitis C, HIV (human immunodeficiency
virus), endocarditis, malaria, syphilis, flesh-eating disease,
and gangrene.
HepatitisC and HIV
Various studies have shown that 50% to 90% of all needle-
using heroin addicts carry hepatitis C (a severe liver dis-
ease) . Even those who used less than one year had a positive
rate of 71.4% . Once infected 20% to 40% will develop liver
disease and 4% to 16% will develop liver cancer." Since the
hepatitis C virus (HCV) was identified in 1988, the number
of cases of HCV caused by transfusion has dropped dramati-
cally, but IV drug use transmission remains high. IV users
have created a well of infection to be spread to their partners
and fellow users .
"I watchedsomebodqwho refusedto washthe sqringeout
a~er I had it, and I told him I had AIDS, I'm positive,
I havethe disease.And he said, 'I reallqdon't care.'
Didn't washit out, and qou couldsee whenhe pulledback
and the outfit wasclearand it had bloodin it and he shot
it up. I mean, I hopethe man'salive."
29-year-old recovering heroin addict with AIDS
Addicts will use diabetic syringes, eyedroppers,veterinary needles,
and anything else that's handy to inject heroin or other opioids into
veins, under the shin, or intravenously.
© 201O CNSProductions, lnc.
 Downers:Opiates/Opioidsand Sedative-Hypnotics 4.23

More than half of all IV drug users in the United States are
carriers of the human immunodeficiency virus that causes
the autoimmune deficiency syndrome (AIDS). The incidence
of HIV varies radically from city to city. It is estimated that:
• 17% of all U.S. HIV/AIDS cases were the result of trans-
mission to an IV drug user by a contaminated needle
(about three-fourths are male)
• 3% were the result of sexual transmission from IV drug
users to heterosexual or homosexual partners
• 70% of children infected with HIV had mothers who
were either IV drug users or had sexual contact with IV
drug users
• 10% were transmitted by blood transfusions before the
blood supply was made safe60

50% to 90% of needle-using heroin

addicts carry the hepatitis C virus, and
half carry the HIVvirus.

Since the beginning of the AIDS epidemic, almost 60 million

people worldwide have been diagnosed with HIV and
25 million have died of HIV-related diseases. In 2011 about
34 million people were living with HIV (3.3 million of that
number were children under 15). There were 2.5 million
new infections (down 22% over the past 10 years) and
1. 7 million deaths. Two-thirds of those living with HIV are in
sub-Saharan Africa. 61
In the United States, an estimated 455,636 people have been
diagnosed with AIDS and I. 1 million are living with HIV
(this includes both diagnosed and undiagnosed cases of
AIDS). Since the epidemic began in the 1980s through 2011,
about 636,000 Americans have died from AIDS.60
In China the IV use of opioids accounts for 51% of HIV
cases. 62 To counter this statistic, Mainland China promoted
needle-exchange programs, which reduced the number of
junkies sharing needles from 62.8% in 2004 to 13. 7% in
2006. 62
Abscessesand Other Infections
AIDS, HlV, and hepatitis C caused by lV drug use are a pri-
mary concern to those in the treatment community, but there
are dozens of other problems caused by IV drug use. Excess
needle use continually traumatizes the blood vessels, often
causing them to become unusable for injection (due to fi-
brosis and scarring), which is why injection drug users
switch to locations other than the antecubital fossa opposite
the elbow. Uncommon injection sites include the wrist, be-
tween the toes, the neck, and even the dorsal vein of the
penis.
Septic abscesses and ulcerations caused by soft-tissue infec-
tions are common among IV drug users because most heroin
abusers shoot up four to six times a day, often with a con-
taminated needle. The most common infectious organisms
are Staphylococcus aureus and beta-hemolytic Streptococci.
The immunosuppressive effects of the drugs themselves add
to the severity of these infections. 63
This is someof the damage that can be causedby infected needles.
The abscesseshave ravagedthe arms of this IV heroinaddict
I
Courtesyof the CaliforniaHigh-.vayPatrol
Other signs of IV drug use are:
• lesion s, "t racks," or "rails" -scars on the skin caused by
constant inflammation at the injection site
• hyperpigmentation (discoloration)
• sterile abscesses caused by irritation
• cellulitis (deep inflammation of soft or connecti ve tissue)
caused by bacteria or by irritation from repeated use or
adulterants
'The~ [abscesses]can be lifethreatenin9;f ~oulet them90 to a
point, but I've also lost all m~ veins. I've hit nerves;I've hit ar-
If
teries. ~ou should shoot into an arter~,it's extreme/~painful.
Havin9to wear lon9-sleevedshirts to work is like an inconvenient
thin9aboutshootin9up."
40 -year-old recovering heroin addict
One of the worst infections is necrotizing fasciitis, an infec-
tion that destroys fascia and subcutaneous tissue but is not
immediately visible on the skin surface. Bacteria such as
Clostridium perfringens and variant strains of Streptococcus
and Staphylococcus cause this condition, also known as
"flesh-eating disease." Large sections of infected tissue must
be cut away to prevent the disease from spreading. Other
reported infections include wound botulism, cutaneous an-
thrax , toxic shock syndrome, and Staphylococcal scalded
skin syndrome.
Endocarditis, an infection of the h eart valves, is often found
in IV drug users. Research points to a variety of organisms
(including those involved in abscesses) that are dislodged
from the injection site and settle in heart valves.
 4.24 CHAPTER 4
'With endocarditis, infection9ets to the heart valves.If
antibioticsdon't worl the~tr~ sur9erf In m~dau9hter's
case, the~ repairedone heart valveand replacedone with a
pi9valve.A weeklaterthe~had to 90 backin and put in a
pacemaker. M~ daua/'1ter started usin9 heroinwhen she was
24; she9ot sic( whenshe was25 and died whenshe was27."
Mother of an IV hero in user
Cotton fever is caused by endotoxins that thrive in cotton
and is another illness frequently contracted by IV drug users.
Cotton fever is also a term used by addicts to describe any
short-term bacterial infection or pyrogenic reaction with
symptoms that include fever, chills, tremors, aches, and
pains.
I
Dilution and Adulteration
One reason why an overdose occurs is because street heroin
varies radically in purity from 0% to 90% pure, so if a user
is expecting 3% heroin and gets 30%, the results could be
fatal.
Diluting an expensive drug like heroin with a cheap substi-
tute such as starch, sugar (dextrose or lactose), aspirin,
Ajax, ® quinine, caffeine, or talcum powder is extremely
common. Many dangerous impurities enter the bloodstream
by injection with the diluted heroin. Harmful bacteria and
viruses also found in many heroin samples are introduced to
the body by injecting them with the drug. Stronger opioids
$8,000 MarketingScheme
Colombia
$55,000
Boston/New
York
-
Heroin mill
$250,000
- $55,000
$195,000Profit
Retailsales
25,000g\assine x 65 Kg
bagsx$l0=
$250,000 $12,675,750
Raw opium sells for a few hundred dollars per kilogram (kg) in
Colombia. When refined to heroin, the price goes up to $8,000. On the
East Coast of the United States, the price rises to $55 ,000. After it is
adulterated and divided into 25 ,000 glassine bags or balloons that sell
for $10 each ("dime bags"), with 40 to 50 milligrams (mg) in each
bag, the gross income rises to $250,000.
DEA 2009
like fentanyl continue to cause overdose deaths in the United
States when sold as heroin on the street. All of these issues
emphasize the unreliability and the dangers of illicit heroin.
These impurities can enter the bloodstream along with any
bacteria lodged in a piece of dirty cotton used to strain the
heroin solution.
According to the U.S. Drug Enforcement Administration,
heroin purity for retail-level sale is 10% to 70% compared
with 1% to 10% just 30 years ago. Currently, the estimated
average purity of heroin at the retail level varies from about
31% in South American heroin to 16.8% in Mexican to
12.3% in heroin from Southwest Asia (down from 20.9% a
year ago). 64
Cost
Contrary to the image promoted by television and film that
portrays heroin addicts as derelicts, criminals, and people
who have a mental illness, the majority of heroin users
(79%) are gainfully employed. 65 Because tolerance builds
quickly, the high cost of a heroin habit leads a great many
users to illegal activities to pay for the drug. The average cost
of heroin is $172 per gram, according to the United Nations. 28
The cost of a heroin habit ranges from $20 to $200 per day,
depending on the level of use. It is estimated that Americans
spend about $12 billion a year on heroin (compared with
$42 billion on cocaine).
'When we were real/~strun9 out, we werespendin9$150 to
$200 a da~to feelnormal.It'sone thin9to spendthat (ind of
mone~andaet loaded, but when~ou'respendin9that (ind of
mane~to just function as a human bein9, it's irritatin9."
32-year-old recovering heroin addic t
The overwhelming need to support an opioid habit makes
antisocial behaviors, such as robbery, and eventual involve-
ment with the legal system almost inevitable. It is estimated
that 60% of the cost of supporting a habit is acquired by
consensual crime, including prostitution and drug dealing,
and supplemented by welfare payments or occasional em-
ployment. Most of the remaining 40% comes from shoplift-
ing and burglary. In an experiment in the late 1980s in San
Jose, California, when it was still legal to do so, the police
placed every heroin user they could find into treatment. As a
result, burglaries in the San Jose area dropped by 60%.
The cost of healthcare associated with addiction is consider-
able. The lifetime cost to treat an HIV-positive IV drug user
is about $600,000. This is close to the lifetime cost for heart
disease and a few other chronic conditions. 66
PolydrugAbuse
"A~er45 ~earsof treatin9morethan350,000 clientsfor
addiction, I rarel~run into someone who abusesa sin9le
dru9.The~ma~havea favoritedru9, but the diseaseis
addiction and often an~ dru.9in a mini-crisiswill do."
Darryl Inaba , Pharm .D., former director of the Haight -Ashbury Clinic ;
current medical director of the Addictions Recovery Center, Medford, OR

• Opioids can have additive and synergistic effects when
used with most depressant drugs, especia lly alcohol and
benzodiazepines. These opioid/downer combinations
increase the potential for respiratory depression, leth-
argy, possible overdose, and even death.
• A user might take heroin in the morning to stop with-
drawal symptoms and calm down; later some speed
for energy in the afternoon; and finally another shot of
heroin in the evening.
• Cocaine or amphetamine with heroin is a common poly-
drug combination. This upper/downer combination,
called a speedball, can enhance the euphoric and pain-
killing effects of both drugs but can also be dangerous
because each drug masks the toxic effects of the other.
• Legitimate methadone users use other drugs to get a
better high because straight methadone doesn't have a
strong rush. Many methadone users take clonazepam
(Klonopin ®) because the combination feels somewhat
like a heroin high.
• OxyContin ® is often mixed with other drugs to simulate
a heroin-like high. Some dealers spike poor-quality mari-
juana with heroin to give it an extra kick and sell it as
high-quality pot.
• To counter the depressant effects of heroin, some ad-
dicts use uppers to help them stay alert. Users become so
wired from cocaine or methamphetamine that they use
alcohol or heroin to come down.
Some heroin addicts will stop using the drug for several
weeks, switching to a cheaper high to give the body a chance
to lower its tolerance and tissue dependence. They might
switch to alcohol, benzodiazepines, or marijuana in the in-
terim and then cycle on and off heroin for the next few
months. This practice reduces the cost of their addiction
because once tolerance has decreased, smaller amounts of
heroin deliver the same high until tolerance rebuilds.
From Experimentationto Addiction
People experiment with alcohol, marijuana, and tobacco at a
much younger age than they do with heroin. The mean age
of first heroin use was 22.1 years in 2011 compared with
20.1 for first cocaine use, 17.5 for marijuana, 17.2 for to-
bacco, and 17.1 for alcohol. 67 Many start experimenting as
young as 10, 11, and 12 years old. It can take as much as a
year of sporadic heroin use for someone to develop a daily
habit, although users with a predisposition to opioid addic-
tion can jump to daily use after just a week or two.
"I'dwakeup in the mornin9and beforeI'd90 to work(whenI
wasworkin9) , I'd haveto do a hit of dopejust to function./"d
haveto do a hit of dopejust to aet out of bed. I'd haveto do a
hit of dopeto90 to the bathroom . It wasn'ta matterof 9ettin9
hi9h an~more;it was a matter of 9ettin9 functional."
38-year-o ld male recovering heroin abuser
Downers:Opiates/Opioidsand Sedative-Hypnotics 4.25
Once an opioid user passes from experimentation to abuse
or addiction, treatment becomes a physiological as well
as a psychological process. Physically, an addict must be
detoxified from the drug, often with medications such
as methadone (a long-lasting opioid) or buprenorphine
(a powerful opiate agonist at low doses and an antagonist at
high doses). In addition, cravings must be controlled to
maintain abstinence. Psychologically, addicts must learn a
new way to live that guards them from the emotional and
env ironm ental cues that often lead to relapse.
"Opiateaddictionis fromhell,I mean, ~ouknow..
it's fromhell.It real/~is. Youknow, it's a thie(
It's a promisethief- It's a dream robber."
45 -year-old female recovering opiate abuser
I
The number of people admitted to treatment for heroin use
has remained fairly constant over the past 10 years (256,256
in 20 10), although the number of those entering treatment
for prescription opioid use has gone up almost six-fold
(157,171 in 2010). The majority (70%) of the 256,256
entering treatment were heroin injectors. First-time admis-
sions, however, involved more smokers, snorters, and sniff-
ers than injectors. 24
"/ wouldwait to shoot up becauseI foundout if I let the
withdrawals~mptoms9row, and then use, the reliefwas as
900d as one of the earlierrushes I used to 9et from m~ dope.
A~era while~ou'renot just killin9~ourpain,~oustartto
kill~ourfeelin9s
, an~feelin9s~oumi9hthavere9ardless
of
whether~ou'rehaYin9pain."
36 -year-old recovering heroin abuser
A comprehensive study of 582 heroin-addicted criminal of-
fenders spanning 33 years revealed lives characterized by re-
peated cycles of drug abuse and abstinence interspersed with
health and social problems. More than half died prematurely
(e.g., overdose, accidental poisoning, homicide, suicide, ac-
cident, liver disease, and other causes); and of the 242 re-
maining, 40% had used heroin in the past year. The death
rate for this group was many times higher than the rate for
men of the same age range in the general population.
The Vietnam Experience
Dr. Lee N. Robins, a psychiatrist at Harvard, and others stud-
ied the use of heroin by U.S. sold iers from 1967 to the end of
the Vietnam War in 1973. They tested several groups of Gis,
first while still stationed in Vietnam and then after they
returned to the United States. Almost half the Gis experi-
mented with opium or heroin; 20% were addicted at one
time and reported withdrawal symptoms. Because heroin
was so readily available, experimentation was easy even for
those who were too young to drink, so the usual progression
from alcohol, cigarettes, and marijuana to heroin or cocaine
was reversed. According to Robins, the most startling part of
the study was that only 5% of those who had become
addicted in Vietnam relapsed within 10 months after
returning to the States, and only 12% relapsed even briefly
with in three years. Most of the returning Gis never went
 4.26 CHAPTER4

military culture. Today the Department of Defense is ac-

knowledging the need for treatment by allotting more
money for mental health and drug treatment and protect-
ing the careers of those who voluntarily seek help and
counseling.

Specific Opioids
Morphine (lnfumorph," Kadian,"
Roxanol," MS Cantin®)
When Friedrich SertO.rner isolated morphine in 1805, physi-
cians embraced this truly effective painkiller and its sales
soared. Profits from this revolutionary new medicine estab-
lished a number of drug companies. It remains the standard

I
by which effective pain relief is measured. It wasn't until
During the Vietnam War in the late 1960s and the early 1970s, many 1952 that researchers were able to fully synthesize morphine.
Gis learned how to use heroin, but people forget that a percentage of
the indigenous population of any drug-growing country has an Morphine is normally processed from opium into white
addiction problem. This is a methadone clinic in Hai Phong, Vietnam. crystal hypodermic tablets, capsules, suppositories, oral
0 Chau Doan. Getty Images. solutions, skin patches, and injectable solutions. This anal-
gesic may be swallowed or eaten; absorbed under the tongue,
rectally by suppository, dennally through patches; or injected
into a vein, a muscle, or under the skin. Different routes of
through treatment. 69 This study suggests that even though administration produce different effects. For example, three
tissue dependence caused by drug use is powerful, other to six times more morphine must be taken orally to achieve
factors, especially pre-existing sensitivity determined by the same effects produced by injecting.
heredity and environment, have a great influence, as well. The liver is the principal site of metabolism. Along with other
tissues, it converts morphine into metabolites that easily
The Iraqi/Afghani Experience
cross the blood-brain barrier and have the potential to be
The stress of war in Iraq and Afghanistan after years of com- more potent than the morphine itself. 8 Some morphine is
bat plus the easy availability of drugs-particularly heroin, excreted quickly in urine, while some remains in measurable
hydrocodone (Vicodin ®), and oxycodone (OxyContin ®)- amounts in plasma for four to six hours and can be detected
led to increases in experimentation, abuse, and addiction. in urine for several days.
Other factors that lead to drug abuse in the military are the
prolonged periods of inactivity and boredom as well as the Morphine and other opioids suppress the immune system,
combat need to either stay alert or stand down. For support which lowers a person's ability to fight off infections. Patients
troops, boredom is the biggest issue. A 2007 survey found being treated for bums or certain cancers and those whose
that 7.1 % of veterans met the criteria for substance use
disorders. The percentage for active-duty personnel is
somewhat lower. 70 About 16,000 U.S. Army personnel re-
ceived alcohoVdrug counseling in 2009, but it is believed
that tens of thousands more are too fearful of repercussions
to step forward.
The number of active-duty personnel seeking treatment for
alcohol abuse has gone up 50% since 1998, while those seek-
ing treannent for drug abuse has risen much less, possibly due
to the added stigma of being dependent on drugs. 71 Increased
urine drug testing may also be a large factor. When the num-
ber of combat personnel who developed post-traumatic stress
disorder or other mental illnesses during their tour is com-
bined with the greater number of suicides, the number
actually in treatment is just the tip of the iceberg.
In the military, readiness trumps confidentiality, so for years
treatment was not a priority. Commanders were notified if Morphine is the standard for severe physical pain. The problems occur
one of their soldiers came in for drug treatment, and that when it is used over long stretches of time or for emotional pain.
usually stalled or killed the GI's career. The exception was 0 2010 HiaPercy/Phonic. Permission by SuperStock.
alcohol because it has traditionally been so much a part of

immune systems are already compromised are particularly
vulnerable. 72
New research conducted at the Naval Health Research Center
in San Diego concluded that the immediate use of morphine
to treat 700 troops wounded in Iraq reduced their potential
for developing post-traumatic stress syndrome by half. 73
Codeine (3-methylmorphine)
"For me codeineis just weak heroin. It doesn't do much
for me. Codeine just stops the pain and stops qour nose
from runnin9. It just 9ets qou able to functionenou9h
in order to 90 9et some heroin."
42-year-old male recovering heroin user
Codeine is extracted directly from opium or refined from
morphine. Also known as methylmorphine, it is about one-
fifth as strong as morphine and is generally used for the relief
of moderate pain. Codeine was once the most widely pre-
scribed and abused prescription opioid in the United States
and abroad, but today hydrocodone (Norco, ®Vicodin ®) and
oxycodone (OxyContin ®) have claimed that dubious honor.
Codeine alone is a Schedule II drug and when mixed with
other drugs and used for analgesia it is a Schedule III drug.
The most common drugs mixed with codeine are aspirin and
acetaminophen because of synergistic analgesia (the drugs
increase each other's strength). Codeine is also commonly
used to control severe coughs (Robitussin ® A-C and
Cheracol ®). It is a Schedule V drug in cough syrups and is
still sold over the counter in some states. Some addicts drink
large amounts of codeine-based cough syrup to relieve
heroin withdrawa l symptoms. One of the side effects that
codeine shares with many other opioids is that it triggers
nausea. The half-life of codeine is about 3 hours, and the
drug is detectable in the blood for up to 24 hours and in the
urine for up to 72 hours. If physical dependence develops,
withdrawal symptoms can begin in a few hours and peak
within 36 to 72 hours.
The use of cough syrups containing codeine and prometha-
zine have become very popular, especially in the rave and
electronic dance music party scene.
Heroin (diacetylmorphine)
Although most heroin is used illegally, it still is used medi-
cally in some countries (not the United States) for a variety
of situations, including acute pain, severe physical trauma,
heart attack, post-surgery pain, and chronic pain such as
end-stage cancer and other terminal, painful illnesses.
Medically, it is usually injected: under the skin (subcutane-
ous), into a muscle (intramuscular), in the space around the
spinal cord (intrathecal), or into a vein (intravenous). Use of
diacetylmorphine is outlawed in the United States.
In some countries heroin is used to treat the erratic habits of
long-term chronic IV heroin users. This is similar to metha-
done maintenance, but it is more controversial perhaps be-
cause heroin gives a stronger high and rush than does meth-
adone and it is injected while methadone is oral. Methadone
Downers: Opiates/Opioids and Sedative-Hypnotics 4.27
is used in the United States, the United Kingdom, Germany,
Switzerland, Denmark, and the Netherlands. In 2009
Germany passed a law allowing prescription diacetylmor-
phine to be a standard treatment for addicts.
One reason why addicts prefer heroin over methadone is
because heroin is fat soluble and crosses the blood-brain
barrier more rapidly than morphine, making the rush and
the subsequent euphoria come on more quickly and power-
fully. The intensity makes it more addicting.
Historically, heroin was involved in the majority of over-
doses, but methadone is closing in on that dubious distinc-
tion because it has become so widely prescribed for pain
control, not just maintenance to treat addiction. In 2012 in
the United States, there were more overdose deaths due to
I
prescription methadone than to street heroin.
Hydrocodone(Vicodin,® Hycodan,®
Tussend,
® Norco,® Lortab®)
More than 131 million prescriptions were written for hy-
drocodone in 2010, up from 108 million just three years
earlier. 1 One survey of prescription opioid addicts showed
that most began their use through legitimate prescriptions
for real ailments, but when the dependency escalated most
got their drugs from friends, theft, forgery, and street dealers
who had access to legitimate supplies. 74
More than 131 million prescriptions for
hydrocodone (Vicodin ®) and 30 million
for oxycodone (OxyContin ®) are written
each year in the United States.
Hydrocodone is the most widely prescribed opioid and has
many of the same actions as codeine but produces less nau-
sea. It is also used in cough preparations called antHussives
(e.g., Hycomine ®syrup). Characteristic of other opioids, hy-
drocodone causes respiratory depression, can mask illness,
and is dangerous when used simultaneously with other de-
pressants. There have been reports that abuse of hydroco-
done with acetaminophen (more than 20 pills per day for at
least two months) can precipitate a sudden hearing loss .75
The acetaminophen it is combined with can also harm the
liver as the dosage escalates with addiction.
"I injuredm~selfand I wasan h~drocodone . ~ouknow. I'd take
one, nexthourand a half I'd be realsleep~and li9htheaded .
be dilllj. It'slikebein9drunk.I developeda smalladdiction
to it, ~ouknow. It wasan eas~ escape;pop a pill, drinksome
water, drown mq fearsawaq, drown the pain awaq, and feel
900d for a while."'
24 -year-old weightlifter
About 600 deaths are reported each year due to hydrocodone
overdose, although more occur when it is used with other
depressants. 2 In 2009 a U.S. Food and Drug Administration
(FDA) panel recommended that hydrocodone in combina-
tion with acetaminophen should not be sold in drugstores
because of the toxic effect of the acetaminophen on the liver.
 4.28 CHAPTER4

Oxycodone(OxyContin,® Percodan,® Percocet®)

Oxycodone, a semisynthetic derivative of codeine, is used
for the relief of moderate to severe pain . Oxycodone in
standard form (Percodan ® and Percocet ®) is usually taken
orally, often in combination with aspirin or acetaminophen.
By this route it usually takes about 30 minutes for the effects
to appear , which then last four to six hours. Its pain-relieving
effects are much stronger than those of codeine but weaker
than those of morphine . When OxyContin ,®a time-release
higher-dose version, was formulated in 1995 by Purdue
Pharma, the abuse potential drastically increased once opi-
oid abusers discovered that the pill could be chewed , crushed
OxvCONTIN"<E
IOXYCODONE
HCI
CONTROL
LED
·RELEASE
l TABLET
S
and injected, or crushed and sniffed , thus destroying the
time-release effect and delivering a much higher blood level New 15mg, 30mg , and 60mg tablet strengths
• Flulbltitytommetothl-app«>JlfMteqllhdc>K
of oxycodone. Heroin and other opioid abusers describe the Helpi~theni..wnbffoftableulindp,~requt,edwhendtm~

I
high as similar to that of heroin .
In 2012 Purdue Pharma's sales of OxyContin ® was
$2.4 billion, about 30% of the total painkiller market in the
United States. That same year there were also about 175,229
emergency room visits attributed to oxycodone by itself
or in combination with other drugs. This is a three-fold
increase since 2005 .2
Because the introduction of this powerful analgesic occurred
at the same time that the medical community was placing
more emphasis on compassionate pain treatment, this long-
acting and time-release medication gained favor due to bet-
ter compliance rates, better long-term control of pain, and
fewer side effects when compared with short-acting narcot-
ics (when used as directed).
Within a year of the introduction of OxyContin, ®reports of
increased illicit use began to surface . The drug, which is also
called "ocs, " "oxy," "o'cotton ," and "hillbilly heroin, " origi-
nally came in 10, 20, 40 , 80 , and 160 mg tablets. Production
of the large tablets, known as "blue bombers " and "o'coffins "
was suspended by the manufacturer due to the high rate of
overdose . Street prices average about $1 per milligram or
$10 for the small est-dose tablets. Purdue Pharma was fined
$634.5 million in 2007 for misleading doctors and the public
about the risks of addiction caused by the misuse of the
time-release formulation .
Diversion of legitimate supplies increased as pharmacy rob-
beries increased . Some ethical physicians who wanted to
treat pain more humanely were easily duped into writing
prescriptions . Other, unethical physicians and pharmacists
lined their pockets by writing prescriptions for bogus
patients (100 of the 40 mg tablets could bring in $4,000).
Patients with valid prescriptions contributed to the diversion
by selling their medication to others.
Responding to the potential for abuse, in 2010 Purdue
Pharma replaced the first version of OxyContin ® with one
that was allegedly more tamp er resistant. In respons e
OxyContin ® abusers turned to a similar opioid, oxymor-
phone, sold by Endo Pharmaceuticals in higher doses in the
same abusable time-release formula as the original
OxyContin .® This was Opana ER,® whose sales originally
soared but began to drop when the manufacturer also had to
• Rt.dbltltywhtncon~, fn:imotti.roplolds to0.yCon1'"9T•blffl
This 80 mg tablet of OxyContin®is currently the
largestdose available. A pill this size could go for
$40 to $80 on the street vs. $6 at a pharmacy.
The larger 160 mg tablets were taken off the
market because of abuse.
Courtesyof the U.S.Drug EnforcementAdministration
add the same safety features as Purdue Pharma 's version. In
an effort to limit generic versions of the original OxyContin ®
formulation, the FDA forbade the manufacture of any new
abusable opioids based on the original, very abusable for-
mulation . This guaranteed continued high profits to Purdue
Pharma for its version of the drug . Street chemists, how-
ever, have found a way around the new safety features by
freezing the drug to strip th em away. The battle continues.
Methadone (Dolophine®)
One-third of all prescription painkiller overdose deaths in-
volve methadone , a figure six times greater than it was 10
years ago. The explosion of methadone overdos es is due to
the current practice of doctors prescribing the drug for
pain, often to cut states ' Medicare/Medicaid costs because
methadone is so much cheaper than OxyContin ,® the other
primary drug for intractable pain. In 2011 approximately
76,000 people visited an emergency room because of meth-
adone (up from 32,000 in 2004). 2 The drug remains contro-
versial even though it has been around for more than 75
years.
When the United States and its allies set up an embargo on
exporting morphine to Germany, German laboratories devel-
oped methadone , a synthetic opioid , somewhat weaker than
heroin but longer lasting, to supplement their limited supply
of painkillers .14 Methadone made its way to the United States
in 1947. It is a legally authorized opioid used to treat heroin
addiction through the practice known as methadone mainte-
nance. Under this harm-reduction program, started in New
York in 1965, clinics dispense methadone daily to heroin and
opioid addicts to lower their craving for opioids . On a few
occasions (e.g., weekends or when the methadone user will
be out of town) a take-home dose is dispensed. In 2011 there
 Oner<"-'Onlorth<incre><einthenumb<rold<ath<from
m<1hadon,i>tho1it,low,thebody'smet2boli!iffl,oothere
isabu ild upoFth<drugwhrniti,Wl<nevery4to6hour<
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lationofmethmonedini«mdtigh1controloonth,,upp ly
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:~t:::-:::""~~~d:-~:~•o~!•~~=:.;
ond • lpnzolam(XEw< " ),toint<n<ifyth,highmdremind
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• ::~~~::«• morte-inlrn« high> rnd low• than
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opioid withdraw :11, the prefrrr«l protocolio townn th<
• Heroini>ill,gal,andchronicu«l<ad,to•dy,lunctionol
p~mt moth,r in th, thin:! trim<>l<r; but !I th, wom,m•
libtyl<
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controllingtheb:lby'swithdrawai,ymptom, i,prefenb le to
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rahuoociat«lwithfinanc ing • habi1ha< l,dto•oub,;12n- t~e ";,~ of ne~ l, in;«t:n, ~v::!i"." · •nd pb.c.enul >qnn ·
tialdecrnS<incrimeHwdluthetI2It•mi .. ionofHIV,
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that "th"n twomonth' · ru1m,nt 'n't"1 ' n,•pero • DeportmentofHealth•ndHumanServices,•mongoth<r<, to
oognitiveperformane<improvedintheu<a•ofverbal l<am - mH<methmonelrteatmrntmorteconvrn·,n1•ndtob'g 't
ing and memory . ,i,uospo.Wl l memo ry, and J"y<homotor in to th< moimuam of hcalthcu,, imt<>.d of limiting m:ov -
,pttd. " Uk, • ll opioido . methadone hn painkilling and de- <ring addicto to ncc:riving tI<C
a tment only >t m<thadone din -
pr,ssant dferu that • rteu«ful in din ica! ,itu.otion,. lto uW - i«.Thedrugwou ldbe0>oaib.bl,throughcertifiedphy,;icians
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 4.30 CHAPTER4
have failed to embrace these proposals for fear that making
methadone more widely available will lead to negative out-
comes down the road. There is also continuing controversy
in the treatment community about the overall efficacy of
methadone maintenance and other drug replacement (harm-
reduction) therapies.
Buprenorphine(Suboxone,® Buprenex,®
Subutex,® Butrans,® Zubsolv®)
Buprenorphine is a semisynthetic powerful opioid agonist
at low doses and an opioid antagonist at high doses. In low
doses it is used as an analgesic alternative to morphine be-
cause it is 50 times stronger than heroin. At high doses it
blocks the opioid receptors by hyperpolarizing or overacti-
vating them. This is called an inverse agonistic effect.
I
Buprenorphine continues to block the effects of morphine,
heroin, and other opioids for about 30 hours after use .82 lt is
approved as an alternative to methadone for detoxification,
as a transition away from methadone maintenance, and for
buprenorphine replacement therapy.
More and more physicians are dispensing buprenorphine
in an office setting as replacement therapy for patients who
have an opioid addiction. Treatment professionals favor its
use because it has a high degree of safety, a long duration of
JAMES SCHALLER,M.D.
SUBOXONE
TAKEBACKYOUR LIFE
FROM PAIN MEDICATIONS!
This publication by James Schaller,M.D., describeshow to use
Suboxone®for opiate detox and treatment in a physician'.soffice rather
than at a drug clinic. The physician must go through training and be
certified to prescribethis drug.
Courtesyof Dr.JamesSchallerand ReckittBenckiser Group
action, flexible dosing, and milder withdrawal effects. 83 The
downside is that it is much more expensive than methadone.
The exact length of time needed for detoxification from her-
oin and other opioids with buprenorphine varies, with the
average lasting 3 to 21 days. There is even a 1-day detoxifica-
tion protocol. For detoxification it is used at low doses as
an opioid agonist, replacing riskier drugs of addiction like
heroin . If it is used for longer-term maintenance, it is pre-
scribed to be taken once a day. If the goal is to wean the
addict from the use of all opioids, the dose is initially in-
creased until it blocks withdrawal and craving and is then
tapered off, usually over 10 to 14 days.
There is abuse potential when the drug is used in low doses
as an agonist, so the manufacturer (Reckitt Benckiser, a
British pharmaceutical company) combined buprenorphine
with naloxone (Narcan, ® an opioid antagonist) to block the
opioid agonist effects of the drug if a user crushes the tablet
to inject it. 84 Two drugs, Subutex ®and Suboxone, ®were ap-
proved in 2002 for the treatment of patients with opioid
dependence. Subutex ®contains only buprenorphine, whereas
Suboxone® combines buprenorphine and naloxone to limit
abuse (sales of Suboxone ®were $1.5 billion last year) and is
by far the most widely used of the two. One recent addition
is Butrans, ® a transdermal delivery system, prescribed for
pain rather than for opioid withdrawal. Zubsolv® is the most
recent form used to treat addiction. It contains lower doses
of both buprenorphine and naloxone.
More and more physiciansare dispensing
buprenorphinein an officesettingas
replacementtherapyfor patientswho have an
opioid addiction.They need to be certifiedby
the DEAto do this.
An important provision of the FDA approval allowed quali-
fied physicians to administer buprenorphine in their offices
rather than making it available only at a drug treatment
clinic . This change was made to accommodate the many
addicts who do not have easy access to methadone clinics or
other treatment facilities. Making this safe drug more widely
available increases treatment options for heroin addicts.
Addicts receiving buprenorphine treatment are still required
to be simultaneously enrolled in counseling and clinical
treatment services for their addiction.
With a number of years of experience to draw from, the
reviews of buprenorphine are mixed, particularly from the
addicts' perspective . Buprenorphine doesn't relieve every
withdrawal symptom, so clients have slightly unrealistic
expectations about the drug's effectiveness. Other medica-
tions are often combined with it for those symptoms not
relieved by buprenorphine.
Fentanyl(Sublimaze,® Actiq®)
Even in its milder therapeutic formulation, fentanyl, intro-
duced in 1968, is the most powerful of the opioids-50 to
100 times as strong as morphine on a weight-for-weight
basis. Structurally, this synthetic phenylpiperidine derivative
 Downers:Opiates/Opioids and Sedative-Hypnot
ics 4.l 1

is related to meperidine (Demero l®). It can be delivered in- NO EXIT © Andy Singer
travenous ly during and after surgery for severe pain. It is
also available in a skin patch to give steady relief to pa-
tients with intractable pain, in a lollipop to manage postop-
erative pain in children, and as an oral-transmucosal prepa- THIS MEDICATION'S SIDE EFFECTS MAY
rat ion on a plastic stic k (Actiq ®) which disso lves slowly in INCLUDE MEMORY LOSS,DIZZINESS,NAUSEA
the mouth. Due to its strength and availability, fentanyl is AND FEELINGS OF BEING HIT BY A TRUCK .
favored as a drug of abuse by some surgical assistants, anes-
thesiologists, and other medica l personnel.
The street versions of fentany l (alpha, 3-methyl) and me-
peridine (MPPP), manufactured in illegal laboratories, are
extremely potent, often more so than the drugs they imitate.
Sold as "China white," these drugs bear witness to a growing
sophistication of street chem ists, who now can bypass the
traditional smuggling and trafficking routes of heroin.

I
Because these designer drugs are made without controls on
purity and dosage, they represent a tremendous health threat
to the opioid-abusing community . There have been numer-
ous instances of overdose deaths caused by ultra potent street
fentany l sold as normal-potency heroin. In one series of
cases tied to a fentany l factory in Mexico, more than 1,000
addicts died as a resu lt of us ing th is version of the drug. 85

"WhenI first 9ot out here011 the West Coast, I foundout that
it [Chinawhite]wasn'twhitedopeat all-it wasfentan~l.
And it wasn'tevenpharmaceutical fentan~l;it wasbathtub
fentan~l,and peopleweredf119011 it."
© 2008 Andy Singer. Courtesyof Cagyle cartoons.
Dealer and heroin user

Hydromorphone(Dilaudid,® Hydrostat,®
Palladone®)
Hydromorphone, synthesized in 1924 and released as
Dilaudid,® is a short-acting (four to five hours) semisynthetic
opioid that can be taken orally or injected . Hydromorphone
is refined from morphine through a process that makes it
five to eight times more potent gram-for-gram than mor-
phine, and it is used as an alternative to morp hine for the
treatment of moderate to severe pain. Because it is more po-
tent than morphine, it has a higher abuse potential. Illegally
dive rted Dilaudid ® became attractive to cocaine users as an
ingredient for the drug comb inat ion known as a "speedball"
(hydromorphone and cocaine or methamphetamine). Street
names for the drug include "dillies," and "drugstore heroin."
The price of a 4 mg tablet of Dilaudid ® sold on the street
ranges from $5 to $10.
Virtually all the street supplies are diverted from legitimate
prescriptions. Though it is quite potent, only a few deaths
from overdose are reported each year. The onset of effects is
so rapid and has such a short duration of action that hydro-
morphone is harder to use for a sustained opioid high. Most
of the continuous abuse of hydromorphone occurs in a
medical setting where the drug is readily available.
Meperidine (Demerol,® Pethidine,® Mepergan®)
A synthetic phenylpiperidine derivative developed in the
1930s, this short-acting opioid is a widely used analgesic for
moderate to severe pain, though it is only one-sixth the
strength of morphine. It is often used for pre-anesthesia and
postoperative situations. Meperidine is usually injected but
can also be taken orally. Users either crush the pills to make
them soluble and inject the solution, or crush them and snort
them for the rush. This drug can be neurotoxic in large doses .
The effect of Demerol® on the brain causes as much sedation
and euphoria as morphine but less constipation and cough
suppression. Because it is eliminated by the kidneys, patients
with impaired kidneys should avoid the drug. Though less
potent by weight than morph ine, it is the opio id most often
abused by medica l professiona ls.
If improperly made, street Demerol ® can contain the chem-
ical MPTP, which destroys the dopamine-producing brain
cells that control voluntary muscu lar movement. The subse-
quent loss of contro l causes the degenerative nerve condi-
tion Parkinson's disease . This degeneration causes a con-
dition called "frozen addict" because the addict loses the
ability to move for the rest of h is or her life.
Pentazocine(Talwin® NX, Fortwin,®Talacen®)
Talwin® NX, prescribed for chronic or acute pain, comes in
tablets (combined with naloxone) or as an injectable liquid .
It has a fraction of the potency of morphine and acts as a
weak opioid antagonist as well as an opioid agonis t. This
drug was frequently combined and injected with pyribenza-
mine, an antihistam ine drug ("Ts and blues") for the heroin-
like high. Increased vigilance and reformu lation of Talwin®
(including the addition of na loxone, a more powerful opioid
 4.32 CHAPTER4
antagonist) by its manufacturer have almost put a stop to
this practice, although some people still abuse Talwin® NX
orally by itself. There are no current emergency department
reports of pentazocine overdoses.
Propoxyphene(Darvon,® Darvocet®)
In 2010 Eli Lilly and Company removed Darvon ® and
Darvocet® from the market in the United States and Europe
due to a risk of producing fatal heart arrhythmias. Darvon®
had been used for relief from mild to moderate pain since
1957. Propoxyphene had also been occasionally used as
an alternative to methadone maintenance and for heroin
detoxification, especially for younger addicts. It has only
one-half to two-thirds the potency of codeine .
LMM (levomethadyl acetate, Orlaam®)
I
LAAM (from its alternative chemical name, levacetylmeth-
adol) is another long-acting opioid approved for heroin re-
placement therapy. It prevents withdrawal symptoms and
lasts 2 to 3 days compared with 1 to 2 days for methadone.
This reduced clinic visits for the drug to every other day or 3
days a week and eliminated the need for take-home doses,
thereby reducing the potential for street trade. The half-life
of LAAM is 48 hours, and the half-life of its active metabo-
lites is 96 hours. In the early 2000s, a number of cardiac ar-
rhythmias were documented in patients treated with LAAM.
Roxanne Pharmaceuticals voluntarily ceased production of
the medication in 2003, but it is still referenced in current
research.
Naloxone (Narcan,® Nalone,® Narcanti®)
Naloxone is an opioid antagonist. It blocks the effects of
heroin, hydrocodone, and other exogenous opioids as well
as the endorphins and enkephalins, the body's own endoge-
nous opioids. Naloxone is effective in treating heroin or
opioid drug overdose . When a victim of an opioid overdose
is injected with the drug, opioid effects (e.g., respiratory de-
pression, low blood pressure, and sedation) are immediately
halted or reversed and the person snaps back to conscious-
ness within a matter of seconds (or within two minutes). 3
Naloxone is short acting, however, and when it wears off,
the patient can fall back into a coma because heroin or an-
other opioid is still in the patient's system and dangerous
toxic effects can resume. Often naloxone must be injected
repeatedly until the heroin is completely metabolized.
Naloxone itself will not cause significant effects except in
those who are physically addicted to opiates, in which case it
will cause major withdrawal symptoms.
"/ just rememberfinallqfindinga veinand thenwakingup witha
plastictubein mq nose,gettinghit in the chestbqa paramedic.
Then everqthing wentfromblackto lightand theq'restanding
overme and I wasreallqpissedoff at them forkillingmq buzz.
And theq'relike,'Wejustsavedqourlife,'and I said, 'MaqbeI
didn'twantqouto. Youjust wasted$20. "'
20-year-old male recovering heroin addict
Recently, there has been a move to make naloxone more
readily available as a nonprescription drug, even distribut-
ing it to addicts themselves, claiming that it would reduce
opioid overdoses by 50%. Opponents claim that it would
only encourage increasingly dangerous drug use, while pro-
ponents say that the risks would be minimal compared with
the alternative, which is often death. 86
Naltrexone(Revia,® Depade,® Vivitrol,®Trexan®)
Another opioid antagonist, naltrexone is used to help pre-
vent relapse and break the cycle of opioid addiction. It was
the first FDA-approved medication to treat a drug craving.
The effectiveness of this drug gave scientific validation to the
premise that drug craving is an actual biologic manifesta-
tion and not merely manipulation by addicts to excuse
their relapse into chemical dependency
Taking naltrexone daily effectively blocks the euphoric
effects of heroin and every other opioid. Some clients take
it daily for three months or longer; others use it only when
the cravings for the euphoric effect get too strong. Naltrexone
is also used regularly to reduce cravings for alcohol and
cocaine in support of detoxification and abstinence. 87 ,88 ,89
There are time-release injectable versions of the drug (e.g.,
Vivitrol ®) as well as injectable implants. These injectable
products have been developed to increase medication com-
pliance and help prevent relapse .90 The initial injectable ver-
sion contained an oil that released the naltrexone over a pe-
riod of 30 days. The new formulation is a pellet that is in-
jected into a muscle and then releases the drug over a period
of 90 days.
Naltrexone is not addicting in itself; it simply blocks an opi-
oid's effects. If a person who is still physically (tissue) depen-
dent on opioids or still using takes naltrexone, it triggers
severe withdrawal symptoms. Side effects are usually mild
but can include nausea, irritability, headache, fatigue, and
dizziness." Naltrexone is proven effective in smoking-
cessation programs, particularly among female smokers. 92
There are a number of research projects studying the use of
low-dose naltrexone to treat certain immunological diseases.
One theory of how this mechanism could work assumes that
the temporary partial blockage of endorphin/enkephalin ef-
fects with low doses leads to a greater than normal produc-
tion of the body's own endogenous opioids, which provide
multiple healthy effects to the body, especially boosting the
immune system. 93 Researchers are testing low-dose naltrex-
one on hundreds of conditions such as fibromyalgia,
Crohn's disease, endometriosis, multiple sclerosis, and
lupus. Low-dose naltrexone is postulated to promote stress
resilience, social bonding, and emotional well-being when
reducing problems of autism and depression. Rigorous test-
ing is needed; but although naltrexone is cheap, rigorous
testing is expensive.
Clonidine (Catapres®)
This non-opioid, originally prescribed for the treatment of
hypertension, is often used to diminish opioid withdrawal
symptoms such as nausea, anxiety, and diarrhea and, in
some cases, to alleviate opioid craving. Clonidine shortens
withdrawal time from almost a month to a couple of weeks
 Downers:Opiates/ 0pioids and Sedative-Hypnot
ics 4.33

This mural by the Dope

Project,on the walls of
ClarionAlley in San
Francisco,advocates the
use ofNar can,®an opioid

I
antagonist, in order to
reverse the effe cts of an
opioid overdose. The project
works with local artists to
create public art that
supports community goals.
Photography by David Okamoto,
© 2014 CNS Productions, Inc.

because it acts on norepinephrine receptors to control their Kratom

overactivity, which is one of the main causes of severe opioid
The Kratom tree is native to Southeast Asia and grows to
withdrawal symptoms. When used in combination with nal-
50 feet tall. The leaves are used (in tea, by chewing, and as
trexone, severe withdrawal symptoms dissipate in about five
an extract) in low doses as a stimulant and in high doses
days in a process called rapid opioid detoxification.
for diarrhea control and as a sedative, a painkiller, a treat-
Butorphanol(Stadol®) and Tramadol(Ultram®) ment for opiate addiction , and a recreational drug. More
than 25 alkaloids have been identified in the leaves. The
These newer synthetic opioid analgesics were developed to
principal active ingredient, 7-hydroxymitragynine , is more
be less abusable and addictive than existing opioids.
powerful than morphine. It acts on the opioid mu and kappa
Although butorphanol successfully treated pain , it was
receptors. The major drawback of this drug is its ability to
abused as much as the older opioids and is a Schedule IV
induce an opioid-like dependence with a significant with-
drug. Since its release in a nasal spray form, abuse and over-
drawal syndrome when used at high doses on a daily and
dose deaths have increased . As of 2013 tramadol is not clas-
chronic basis .94A
sified as a controlled substance nationally (but is at a state
level in a few states) even though it has an opioid-like over-
dose liability and there is evidence of abuse . Both butorpha-
nol and tramadol have less addiction and overdose potential
than the more powerfu l opioids like meperidine and mor-
phine , but they are capable of producing the same type of The three main groups of sedative-hypnotics are benzodiaz-
addiction attribut ed to other opioids . Both drugs are being epines, barbiturates, and various nonbenzodiazepine, non-
evaluated as potential treatments for other addictions . barbiturate sedative-hypnotics, especially the Z-hypnotics.

UltrarapidOpioid Detoxification The effects of sedative-hypnotics are similar to those of

alcohol (e.g ., lowered inhibitions, physical depression ,
Ultrarapid opioid detoxification is a medically supervised
sedation, and muscular relaxation); and, like alcohol ,
technique that lessens the duration and the intensity of
sedative-hypnotic drugs can cause memory loss, tolerance ,
acute withdrawal symptoms by administering naltrexone
tissue dependence , withdrawa l symptoms, and addiction .
orally or naloxone intravenous ly while the patient is heavily
The obvious difference between the two classes of depres-
sedated or even under genera l anesthesia . There is much
sants is their potency. On a gram-by-gram basis , sedative-
controversy about this technique, and complications can be
hypnotics are much more potent than alcohol.
fatal if mistakes are made . Some treatment professionals be-
lieve that even though the physical withdrawa l is treated, the Sedatives are calming drugs, e.g., alprazolam (Xanax®) ,
psychological addiction continues and will eventually cause diazepam (Valium®) , clonazepam (Klonopin ®), and mepro-
a relapse. 94 bamate (Miltown ®) . They are also called minor tranquilizers .
 4.34 CHAPTER4

A number of benzodiazepines act on the neurotransmitters

GABA, serotonin, and dopamine to help control anxiety and
restlessness. Sedatives are also capable of causing muscle
relaxation, body heat loss, lowered inhibitions, reduced
intensity of physical sensations, and reduced muscle coordi-
nation in speech, movement, and manual dexterity. They are
also used to help with alcohol or heroin detoxification and to
control seizures.

The effectsof sedative-hypnoticsare similar

to those of alcohol-lowered inhibitionsand
physicaldepression.

Hypnotics are sleep inducers, i.e., short-acting barbiturates

and benzodiazepines such as Halcion ® that work on the

I
brain and the brainstem . They also depress most bodily
functions, including breathing and muscular coordination.
Some sedatives are used as hypnotics and some hypnotics
are used as sedatives, so it is sometimes difficult to separate
the two. Z-hypnotics
Sedativesare calming such as Ambien® and
drugs.Hypnoticsare Lunesta® are also com-
sleep inducers. monly prescribed for
insomnia.
Almost all sedative-hypnotics are available in pill, capsule,
or tablet form, although some, such as diazepam (Valium®)
and lorazepam (Ativan®), are used intravenously when im-
mediate treatment of seizure and panic attack is necessary
History
Calming and sleep-inducing drugs have been around for
millennia. Ancient cultures used natural plant derivatives
(especially opium) or products of fermentation processes
that were probably first discovered by accident or through
experimentation. As a result of the increasing sophistication
of chemical processes, virtually all the sedative-hypnotics of
the past 100 years are synthetic and were developed in the
laboratory.
The United States has had recurring periods of sedative-
hypnotic abuse, each linked to the release of a new drug or
family of drugs. Barbiturates were abused in the 1930s and
1940s, Miltown ® in the 1950s, benzodiazepine from the
1970s to the present, and for the past decade, Z-hypnotics
such as Ambien, ® Lunesta,® and Sonata.® All sedative-hyp-
notic drugs have been abused to one degree or another de-
spite continued assurances that "this one is not addictive."
At the beginning of the twentieth century, bromides, chloral
hydrate, and paraldehyde were commonly used. Opiates
were often used to induce sleep in infants.
Though chemically quite different, all sedative-hypnotics
depress the central nervous system.
• Bromides, used as sedatives or anticonvulsants, were
first introduced in the 1850s and were often sold over
The main ingredientof Dr Franklin Miles'.spatent medicine tonic was
bromide, a sedative. This ad from the 1920s promised relieffrom
nervous ailments such as sleeplessnessand nervousness.Chronic
bromideintoxication was once common.
Courtesyof the Libraryof Congress
the counter; they had a long half-life, so prolonged or
unsupervised use could build up toxic doses in the body
• Chloral hydrate was sold at many drugstores in 1869;
it was used as both a sedative and a hypnotic to relieve
tension and pain and to help treat alcoholics' insomnia.
It was often prescribed for women to treat delirium tre-
mens and to help pregnant women cope. 95 It was the
original "Mickey," slipped into a drink to knock out and
shanghai sailors . It is still sometimes used to treat sleep
problems (Noctec ®) because it has a higher margin of
safety than barbiturates.
• Paraldehyde, developed in 1882, was used to control
the symptoms of alcohol withdrawal. Despite its offen-
sive odor and tendency to become addictive, it is still
occasionally used to treat alcohol withdrawal. It is one of
the safest sedatives . It can be injected or taken orally or
rectally.96
• Barbiturates were first developed at the end of the
nineteenth century and slowly grew in popularity; they
peaked in the 1930s and 1940s. Phenobarbital, secobar-
bital, and pentobarbital were among the hundreds of
compounds synthesized from barbituric acid. An aware-
ness of the toxic potential of barbiturates, due to a low
margin of safety, a low degree of selectivity, and a high
dependence and addictive potential, caused apprehen-
sion and encouraged researchers to look for new classes
of sedative-hypnotics.
• Meprobamate (Miltown,® Equanil, ® Meprospan ®) was
developed in the late 1940s and 1950s. Known as "moth-
er's little helper," this long-acting sedative replaced many
long-acting barbiturates, including phenobarbital. Its
popularity peaked from 1955 to 1961, after which ben-
zodiazepines took center stage.

"Men just aren'tthe same todaq, I hearev'rqmothersaq.
Theqjust don't appreciatethat qou9et tired.
Theq'reso hard to satisfq.Youcan tranquilizeqourmind,
so 90 nunnin9for the shelterof a mother'slittle helper
and to help qou throu9hthe ni9ht,
help to minimizeqourpli9ht."
Mick Jagger and Keith Richards (Rolling Stones),
"Mother's Little Helper,"© 1965
• Glutethimide (Dori den®) was used as a barbiturate sub-
stitute, but it had many of the same disadvantages with-
out enough advantages. It was also weaker than pheno-
barbital and subject to abuse , especially when combined
with codeine ("loads," "sets," and "setups ") to potentiate
the effects of both drugs. It is no longer manufactured in
the United States.
• Benzodiazepines were first discovered in 1954 (Librium®)
and then rediscovered in 1957 at Hoffmann-La Roche
Laboratories in a deliberate search for a safer class of
sedative-hypnotics. When Librium ® (chlordiazepoxide)
and Valium® (diazepam) were synthesized and marketed
in 1960 and 1963, respectively, they quickly became im-
mensely popular because they were less toxic than barbi-
turates , meprobamate, and glutethimide, although many
of the sites of action in the CNS were similar to those of
barbiturates. Over the years more than 3,000 compounds
were developed , but only 20 or so were marketed and
released. 97 Today benzodiazepines still dominate the
market for sedative-hypno tics. Though they are less
toxic than other sedatives, benzodiazepines can be very
addictive and have dangerous withdrawal symptoms .
• Other sedative-hypnotics, especially Z-hypnotics, are
unde r development in an attempt to improve this class of
drugs while tempering their addictive propert ies. Drugs
such as Lunesta,® BuSpar,® Rozerem,"' Ambien,® and
Lyrica® are advertised as safer and less addictive than
other sedative-hypnotics. The only two drugs that rigor-
ous research has validated as non-dependence produc-
ing are BuSpar"' and Rozerem.®
Classification
More prescriptions were written for sedative-hypnotics in
the 1960s, 1970s, and 1980s than are written today due to
the use of psychiatric medications for depression, which
has significantly decreased the sedative-hypnotics' market
share in favor of tricyclic antidepressants and the newer
selective serotonin reuptake inhibitor (SSRI) antidepres-
sants, such as Celexa® (citalopram), Zoloft® (sertraline),
Prozac® (fluoxetine) , Lexapro® (escitalopram) , and Paxil®
(paroxetine). At least 200 million prescriptions for anti-
depressants were written in 2011.
Downers:Opiates/Opioidsand Sedative-Hypnot
ics 4.35
Use, Misuse,Abuse,and Addiction
In 1993 the average number of prescriptions per capita per
year in the United States was seven; in 2012 it was almost 13.
Almost half of all Americans take at least one prescription
drug every day.98 In the twentieth and twenty-first centu-
ries, society's atti tude toward the use of sedative-hypnotics
and psychiatric medications swung like a pendu lum. The
liberal use of barbiturates in the 1930s and 1940s, along with
the vision of a drug-controlled society depicted in Aldous
Huxley's futuristic novel Brave New World,led to a search for
non-addictiv e alternatives. But the widespread use of
Miltown®in the fifties, which eventually led to the vernacu-
lar "better living through chemistry " in the sixties, seemed
to confirm Huxley's fears. Subsequently, benzodiazepines
I
were hailed as miracle drugs and prescribed in huge num-
bers (100 million prescriptions per year in the United States
by 1975), and fear of becoming a drug-dependent society
resurfaced (88.7 million prescriptions in 2012). 1 About one-
third of opioid overdoses (many ending in fatalities) also
involve benzodiazepines. The recent increase in psychiatric
medications such as antidep ressants (164 million prescrip-
tions) has lessened the popu larity of sedative-hypnotics. It
should be noted though that many of these antid epressants
are actually used for their sedative effects.
Differences of opinion created controversy in the medical
and treatment community between those who want the
freedom to prescribe benzodiazepines and other sedative-
hypnotics when they believe it is appropriate, and those who
believe that overuse of prescription drugs must be brought
under control.
When used properly, sedative-hypnotics can be beneficial
therapeutic adjuncts for the treatment of a variety of psy-
chological and physical conditions. When misused they
can cause undesirable side effects, dependence , abuse,
addiction , and even death.
'You don't thinkthat pill is9oin9 to makeqou90 a~er more
and morepills likea fixof heroin. And then it becomes a habit.
/t becomesas hideousas anq illicitdnu9habit. /t can become
moredan9erousactuallq."
43 -year-old recovering benzodiazepine abuser
Sedative-hypnotic as well as opioid misuse , abuse , and ad-
diction can occur when patients overuse the drugs or com-
bine them with other psychoactive drugs to magnify the
effects. They obtain these extra drugs through a friend di-
rectly, by stealing drugs from other people 's medicine cabi-
nets, or by diverting them from legal sources through
forged prescriptions, black market purchase , or theft .99
Over the years in popular and scientific literature and mov-
ies, sedative-hypnotics have been associated with both ac-
cidental and intentional drug overdoses. The image of an
empty prescription vial is a visual cliche indicating a suicide
attemp t or the need for a stomach pump.
 4.36 CHAPTER4

Sedative-Hyi>notics
NAME TRADE
NAMES STREET
NAMES NAME TRADE
NAMES STREET
NAMES
BENZODIAZEPINESVarious
Benzos Tranx,
BDZs, downers, Equalparts Tuina
l® Rainbows,tuies,
randy,chillpills,totem secoba
rbitaland doubletrouble
poles amobarbital
Very-Long-Acting Butalbital Esgic,
®Fiorina
l®
Flurazepam Dalmane,
®Dalmadorm
® Hexoba
rbital Sombulex®
Halazepam Paxipam
® Pentobarbital Nembutal
® Yellows,
yellowjackets,
nebbies
Ketazolam Anxon
®
Secobarbital Secona
l® Reds,
reddevils,F-405
Medazepam Nobrium
®
Very-Short-Acting
Pinazepam Damar
®
Methohexita
l Brevita
l®
Prazepam Centrax,
®Lysanxia
®
Thiamyla
l sodium Surital
®
Quazepam Doral®

I
sodium Pentothal
Thiopental ® Truthserum
Intermediate-Acting
Bromazepam Lexotani
l,®Somalium,
® NONBENZODIAZEPINE,
NONBARBITURATE
SEDATIVE-HYPNOTICS
Bromam ®
Bromides
Chlordiazepoxide Librium,
®Libritabs,
® Libs
Limbitrol,®Tropium,
® Buspirone BuSpa
r®
Risolid
® Chloralhydrate Noctec,
®Somnos
® Jellybeans,Mickeys,
Clonazepam Klonopin,
®Rivot
ril® Klonnies,
klons, Knockoutdrops
Klondike
bars Eszopiclone Lunest
a®
Clorazepate Tranxene
® Ethchlorvynol Placidyl
® Greenweenies
Diazepam Valium,®Apozepam,
® Vais,valleygirl, blues Flumazeni
l (benzo- Anexate,
®Mazicon,
®
Vival® antagonist) Romazicon
®
Short-Acting GHB(gamma Xyrem
® Grievous bodily harm,
Alprazolam Xanax,
®Xanor,
®Tafil,
® Xannies,bars,x-boxes, hydroxybutyrate) liquidE,fantasy,Georgia
Alprox
® coffins,
Z-bar,bricks (alsocalled homeboy
sodiumoxybate)
Lorazepam Ativan,
®Temesta,
®
Tavor,
®Lorabenz
® GBL (gammabutyl BlueNitro,® Revivaran~
® (GBLisa chemiraland
lactone) lnsom-X,®Revivaran
t® biologicprecursor
to GHB)
Loprazo
lam Dormonoct® G,Gamma G,®GH
Midazolam Versed,
®Domicum,
® Revita
lizer,®Remforce
®
Hypnovel
® Glutethimide Doriden
® Goofba
lls,goofers
Oxazepam Sera
x® (obsolete)

Temazepam Restori
l® Glutethimide
and Doriden,
®codeine Loads,
sets,setups,
hits,
codeine C&C,foursanddoors
Tetrazepam Mylostan
®
Meprobamate Equinil,
®Miltown,® Mother'slittlehelper
Very-Short-Acting Meprospan,
®
Estazolam Pro-Som
® Meprotabs,
® Deprol
®

Triazolam Halcion,
®Rilamir® Methaprylon Noluda
r® Noodlelars

Banned
intheUnitedStates Methaqualone Quaalude,®Soper,
®
(onlyillegalforms) Somnafac,®Pares!,
®
Flunit
razepam Rohypnol,®Flunipam,
® Ruffies,roofies,roachies Optimil®
Flusrand
®
Paraldehyde Para
l®
BARB
ITURATES Various Barbs,
downers,
barbies Pregabalin Lyrira
®
Long-Acting Quetiapine Seroquel
® SuzieQ Quell,Q squirrel
Phenobarbital Lumina
l® Phenos Ramelteon Rozerem
®
Mephobarbital Mebaral
® Zaleplon Sonata,
®Stamoc
®
Intermediate-Acting Zolpidem Ambien,
®Zoldem, A-minus,
zombies
Nytamel
®
Amobarbital Amytal
® Blueheaven,
blues
Zopiclone lmovane,
®Rhovane,
®
Aprobarbital Nurate
®
Simovane
®
Butabarbita
l Barbased,
®Butiso
l®
Talbutal Lotusate
®

Depressant
Effectsof Increasing
Amounts
of Sedative-Hypnotics
or Alcohol
Norma
l aging $80 each, in 2012. More than 94 million of those pre-
Anxietyrelief
Increasing
amountsof depressants
(sedat
ive-hyp
noticsor alcohol)
This chart shows that, like with alcohol,increasingdoses of sedative-
hypnotics can lead the user to severeimpainnent. The developmentof
toleranceslows the process,whereasthe use of another depressant,
particularly alcohol,acceleratesthe process.
© 2014 CNSProductions, lnc.
In the Annual Emergency Room Data Survey, physicians list
the drugs that cause medica l prob lems severe enough to make
peop le seek medical attention. 2 Table 4-4 lists the drugs
reported most often. Overall there were almost 2.5 million
visits to emergency rooms in 2011 for psychoactive drug
misuse and abuse problems, such as overdose, dependence,
withdrawal syndrome, and drug interactions. About half of
those are for illicit drugs or misuse of prescription drugs,
and most visits involved multiple drug ingestions.
Studies of sedative-hypnotic drug misuse and overdose con-
ducted by the Nationa l Institute on Drug Abuse reveal other
factors that contribute to misuse, abuse, or overdose.
• Because sedatives impair memory, awareness, and judg-
ment, individuals forget how many they have taken to
help them get to sleep or to relieve stress; and while wait-
ing for the full dose of the drug to take effect, they con-
tinue to take more of the drug and accidentally reach a
toxic state. This is known as drug automatism .
• Ignorance of additive and synergistic effects caused by
combining these drugs with alcohol, opiates, or other
sedatives is widespread .
• Selective tolerance to some effects of the drug but not
to its toxic effects results in a narrow window of safe-
ty, where the amount needed to produce a high comes
closer to the letha l dose of the drug.
• Adolescent attitudes of invulnerability promote risk-
taking behavior with respect to the amount of drug
ingested when used illicitly.
• A misperception exists that prescription drugs are
either safer or not as potent, dangerous, or addictive
as street drugs. 100
Downers: Opiates/Opioids and Sedative-Hypnotics 4 .37
Driven by an aging popu lation, the availability of more ge-
neric drugs, and the Medicare Part D prescription benefit,
U.S. pharmacies filled close to 4 billion prescriptions, aver-
scriptions were for benzodiazepine sedative-hypnotics .
Their use in other countries is also widespread.
Benzodiazepines
Benzodiazepines are by far the most widely used sedative-
hypnotics in the United States . This class of drugs was de-
veloped in the 1950s as an alternative to barbiturates .
Because benzodiazepines have a fairly large margin of safety
compared with other sedatives, many healthcare profession-
als initially overlooked their peculiarities: the length of time
I
they stay in body tissues, their ability to induce physical de-
pendence at low levels of use, and the severity of withdrawa l
from the drug . For these reasons almost all recommenda-
tions for benzodiazepine use today emphasize short-term
use and only for specific conditions.
Benzodiazepines were developed
as safe alternatives to barbiturates.
They are the most widely used
sedative-hypnotics in the United States.
The most widely used benzodiazepines are alprazolam
(Xanax®), lorazepam (Ativan ®), clonazepam (Klonopin®),
diazepam (Valium®), and temazepam (Restoril®).
Medical Use of Benzodiazepines
Medically, benzodiazepines are used to :
• provide short-term treatment for anxiety and panic
disorders
• control anxiety and apprehension in surgical patients
and diminish traumatic memories of the procedure
• treat sleep problems
• control musculoskeletal spasms
-
NOC S97i,2-oo57• 1
tollt>ltt8
,0:0004,4JCl6Ul
alprazolamXR E)
mandlo,l'IIIMM tll:i&oUI KLONOPIN
(clonazepam)
r.v
0.5 mg I,
Most benzodiazepineshave come off patent, so the vast majority of
prescriptionsarefor the genericversions of the drug. Alprazolam is
Xanax,®clonazepamis Klonopin,®and diazepam is Valium.®
© 2011 CNSProductions,Inc.
 4.38 CHAPTER
4

Benzodiazepines alone can be abused, but they are most of-

Mentions
of DrugProblems
in
ten abused in conjunction with other drugs. Methamphe-
U.S.Emergency
Rooms tamine and cocaine abusers often take a benzodiazepine to
DRUG NUMBER
OFDRUG MENTIONS come down from excess stimulation. This combination is
2004 2008 2011 connected to spasms of the coronary arteries that can dam-
Alcohol 674,914 656,892 724,306 age the heart. 102 Heroin addicts frequently take a benzodiaz-
epine to boost the high or when their drug of choice is un-
Cocaine 475,425 482,198 505,224
available, and benzodiazepines are prescribed to alcoholics
Marijuana 281,629 374,475 455,658 to prevent convulsions and other life-threatening with-
Heroin 214,432 200,166 258,482 drawal symptoms. According to various studies, up to 41 %
Methamphetamines 132,526 66,308 102,961 of alcoholics, 73% of heroin addicts, and 94% of methadone
users also used or abused benzodiazepines. 103 -104
Amphetamines 34,085 34,924 70,831
Ketamine nfa 329 1,550
Benzodiazepinesare most often abused
PCP 31,342 37,266 75,539 in conjunctionwith other drugs,usually

I
GHB 1,789 1,441 2,406 alcoholor opioids.
MOMA(ecstasy) 10,220 17,765 22,498
LSD 2,346 3,287 1,550 "If I threwdown10Valium,® I didn't reallqfeel that much.
Otherhallucinogens 3,150 6,028 8,043 It wasn'tliketakin9butalbitalor otherbarbiturates whereqou
Inhalants 9,525 7,115 10,032 9et a realrush. I wouldhaveto takean awfullot to feel
Benzodiazepines 170,471 330,235 425,616
anqthin9.It relievedcertainanxieties;it alleviateddepression.
You tell the doctor,'I'm anxiousor depressed.'And all theq
Aspirin,
ibuprofen,
NSAIDs 102,076 138,446 662,400 willsaq is 'Okaq,takesomeXanax.®"'
Opioids(painkillers) 264,759 593,956 662,400 48-year-old female recovering benzodiazepine abuser
Antidepressants 81,889 99,057 108,388
Othersedative-hypnotics 38,409 72,756 87,803 Neurochemistryand GABA
Ambien
" 13,903 33,715 37,225 Benzodiazepines exert their sedative effects in the brain by
Antipsychotics 41,950 53,388 76,197 increasing the effects of a naturally occurring neurotransmit-
Barbiturates
ter called GABA(gamma amino butyric acid) in the cerebel-
12,919 10,808 19,902'
lum, cerebral cortex, and limbic system. 104 A GABA is recog-

nized as the most important inhibitory neurotransmitter,

• elevate the seizure threshold (anticonvulsant) to
control seizures
• control acute alcohol withdrawal symptoms (e.g.,
severe agitation, tremors, impending acute delirium
tremens, and hallucinosis).
'The enclosedspaceof the MRI [ma9neticresonanceima9in9]
machinetheq were9oin9to slip me into reallqtri99eredone of
mq claustrophobic panicattacks,so we couldn'tpnish.I was
qellin9,'Get me out of here,'alon9withsomenastqthreats.The
next timetheq9aveme someValium,®and thou9hI stillfelt
nervous,it did calmme enou9hso I could havethe scan done."
SO-year-old female with no drug dependency problem
NonmedicalUse of Benzodiazepines
Because the desirable emotional and physical effects of ben-
zodiazepines are very similar to those of alcohol, people
take them for the same reasons: to numb emotions, relieve
anxiety, induce a mild euphoria, and lower inhibitions. A
double-blind study on non-drug addicts compared the ef-
fects of low-dose diazepam injections and alcohol injections.
The subjects found the highs from each drug to be similar,
but higher-dose diazepam produced more physical impair-
ment. 101Most benzodiazepine abusers are over 30, white,
well educated, and female.
so when a drug like alprazolam (Xanax®) greatly increases
the actions of GABA, it subsequently inhibits anxiety-
producing thoughts. 34 Other neurotransmitters, such as
serotonin and dopamine, are also increased.
Most benzodiazepines are prodrugs, which means they
must undergo chemical conversion by metabolic processes
before becoming an active or stronger pharmacological
agent. The liver converts a certain percentage of a drug , such
as diazepam (Valium"), to a psychoactive metabolite (e.g.,
nordiazepam). The metabolites can be as active or more ac-
tive than the original drug itself. Nordiazepam can be fur-
ther converted to temazepam and oxazepam .105 These two
active metabolites are also manufactured separately by phar-
maceutical companies as Restoril®and Serax.®The metabo-
lites, along with the original drug, are very fat-soluble (lipo-
philic) and therefore remain in the body for a long time. 106
Specific benzodiazepines are promoted and prescribed to
treat specific conditions even though they have similar
effects:
• Short-term alprazolam (Xanax®) is used to immediately
relieve the symptoms of generalized anxiety disorder, panic
disorder, and depression resulting from anxiety (many
patients are prescribed alprazolam just for depression).
• Triazolam (Halcion ") is used for short-term (seven to 10
days) treatment of insomnia .
 Downers:Opiates/ 0pioids and Sedative-Hypnot
ics 4.39

dence and addiction when these drugs are taken daily for a
year or more . In addition , the drug 's ability to control anxiety
and other undesirab le mental effects can result in a psycho-
logical dependence .

Withdrawal
After high-dose continuous use for one to three months or
lower-dose use for at least one to two years, withdrawal
symptoms can be severe . It can take a dependent benzod iaz-
epine user several months to taper off the drug and allow
the body chemistry and functions to return to normal. If
tape ring isn 't carefully monitored , withdrawal seizures can
occur , sometimes with fatal results. 107

"Benzo detox in the mornin9is verqfri9htenin9becauseqour

U.S.manufacturers of pharmaceuticalshave legallyreleased dozens
of tons of pharmaceuticalsinto U.S.waterways.Traces havebeen
found in the drinkingwat er suppliesof 51 millionAmericans.Utilities
say the waterwaysaresafe, and the dilutionof the drugsmakes them
harmless_ll'
© 2009 Tom Meyer.Reprinted by permission.All rights reserved.
I
mind is just tellin9 qour bodq that 'we are not connected.' It
took maqbe 10 daqs beforethe manic depressivestate the of
to of
detox finallqstarted show li9ht at the end the tunnel."
34 -year -old recovering b enzod iazepine abuse r
Evenlow-dosebenzodiazepineuse can lead to
tissuedependenceand addictionwhen taken
dailyfor a year.

• Diazepam (Valium®) is used to treat anxiety, to gain relief Withdrawal symptoms are caused by:
from musculoskeletal spasms caused by inflammation • recurrence of the symptoms originally treated with the
of the muscles and joints , and to control seizures such benzodiazepine
as those that occur duri ng severe alcoho l or barbiturate
withdrawal. • magnification of the original symptoms
• false withdrawa l caused by the user's exaggerating the
• Intrave n ous Valium®is used as a sedat ive before surgery
recurrence of symptoms
Tolerance, Tissue Dependence, • true withdrawa l when a user becomes physically depen-
dent and stops using
and Withdrawal
Tolerance
Tolerance to benzod iazepines develops as the liver becomes
Benzodiazepine
Withdrawal
vs.
more efficient in processing the drug. Age-dependent re- Short-Acting
Barbiturate
Withdrawal
verse tolerance also occurs with these drugs, meaning
younger people can tolerate higher doses of benzodiaze-
pines than can older people . The effect of a dose on a Typical short-acting
50-year-old first-time user can be two to four times stronger barbituratewithdrawal
than the same dose on a 20-year-old. Many diagnoses of
dementia are actually due to overuse of benzodiazepines and
other drug interactions .

"/ was unhappq and I wanted the easq waq out.

I went back to the same psqchiatristand 9ot a prescription
ofXanax.® It started out at 0.25 m9, and I ended up
doin9 between8 and 10 m9 a daq." 16 24 32 40 48 56 64
43 -year-old recovering benzodiazepine abuser Daysofabstinence

TissueDependence
Physical addiction to a benzodiazepine can develop if a pa- The delayin the occurrenc
e of withdrawalsymptomscanbe
tient takes 10 to 20 times the prescribed dose daily for a dangerousto benzodiazepineabuserswho abruptlystop using.
couple of months or takes a normal dose for a year or more. Symptomscan comeandgo in cyclesseparated by two to 10 days.
Because many benzodiazepines are deactivated over a period © 2014 CNS Productions, Inc.
of several days, even low-dose use can lead to tissue depen-
 4.40 CHAPTER4
The half-lives of benzodiazepines are long lasting, depend-
ing on the specific drug, so with true withdrawal the onset
of symptoms is delayed-24 hours for short-acting and up
to 5 days for long-acting benzodiazepines. The symptoms
can last 7 to 20 days for short-acting and up to 28 days or
longer for long-acting benzodiazepines . 108
Because many of the symptoms of true withdrawal are similar
to those of an anxiety or depressive disorder, it is hard to judge
the level of dependence from an underlying mood disorder.
First a craving for the drug occurs . This is the tissue-
dependent brain 's attempt to avoid the onset of withdrawal
symptoms. The craving is followed by headaches , tremors ,
muscle twitches, nausea and vomiting, anxiety, restlessness,
yawning , tachycardia, cramping, hypertension, inability to
focus, sleep disturbances, and dizziness. There are reports of
I
people experiencing a temporary loss of vision, hearing, smell,
or other sensory impairments (and occasionally hallucina-
tions) while in withdrawal. 108 The symptoms continue and
peak in the first through third weeks. Symptoms occasionally
include multiple seizures and convulsions that can be fatal.
"I stoppedtakin9them, and on the thirdda4 I rememberI was
sweatin9.I chan9edthe sheetson the bed. I tooka shower.
I wasfair/4relaxedand I wentintoa convulsion.I don't
rememberwhat happened.All I can rememberis wakin9up
and all m4 frontteethwereknockedout. I endedup 9oin9
throu9habout80 convulsions."
Recovering benzo abuser
The persistence of benzodiazepines (Figure 4- 7) in the body
from low- or regular-dose use taken over a long period of
time results in prolonged withdrawal symptoms and in
symptoms that erratically come and go in cycles separated
by two to 10 days . These symptoms are sometimes bizarre ,
sometimes life threatening, and always complicated by the
cyclical nature of benzodiazepine withdrawal. Short-acting
barbiturates, on the other hand, follow a fairly predictable
course , where the symptoms come and then disappear for-
ever. Called protracted withdrawal, the symptoms ofbenzo-
diazepine withdrawal may persist for several months after
use of the drug has been terminated.
Overdose
In 2011 more than 425 ,000 emergency room visits (some
fatal) were due to complications caused by benzodiaze-
pines, up from 170,000 just seven years earlier. 2 Actual
overdoses and suicides dropped even with the increased use
of benzodiazepines and the decreased use of barbiturates be-
cause benzodiazepines have a much greater therapeuticindex
(the lethal dose of a drug as compared with its therapeutic
effective dose). The therapeutic index of barbiturates is 10 to
1 compared with benzodiazepines ' therapeutic index of 700
to 1. A fatality can occur if an individual who has not devel-
oped tolerance takes 10 times the therapeutic dose of a bar-
biturate or 700 times the therapeutic dose of a benzodiaze-
pine. The margin of safety diminishes significantly if an
individual takes benzodiazepines with alcohol, other ben-
zodiazepines, phenothiazines, monoamine oxidase (MAO)
inhibitors, barbiturates, opioids, or antidepressants. 3
Symptoms of overdose include drowsiness, loss of con-
sciousness, depressed breathing, coma, and death if left
untreated; however , it might take 50 to 100 pills to cause a
serious overdose. Street versions of the drug , often misrep-
resented and sold as Quaaludes, ®are so strong that only 5 or
10 pills can cause severe reactions.
Memory Impairment
Benzodiazepines impair the ability to learn new information;
they disrupt the transfer of information from short- to long-
term memory and slow the ability to shift attention from one
thing to another. 106 •109 The amnesic effect of benzodiazepines
(medically known as anterograde amnesia), commonly
called a drug "blackout" or "brownout, " helps patients forget
traumatic surgical and medical procedures. Benzodiazepines
have been used by sexual predators to cause victims to
forget they were sexually assaulted.
'The4 tookadvanta9ewhenI passedout at a part4and I was
sleepin9on a couchand I wokeup and the4 weredoin9stuff
to me that the4shouldn'thave. And I remember runnin9into
the bathroomand throwin9up and then sleepin9on the noor
that ni9ht. I'm carefulnowabout m4 surroundin9s. If it's a safe
placewhereI knowI can havea few beersand havefun with
m4 friends, I'll do it; but I'm a littlebit war4of whereI drinkor
whateverjust becauseof that experience. "
20 -year-old woman
Until it was banned in the United States, the drug most as-
sociated with date rape was the benzodiazepine Rohypnol ®
(flunitrazepam) . Like other benzodiazepines, Rohypnol ®
causes relaxation and sedation. Rohypnol ® (or another very-
short-acting benzodiazepine) is dropped into an alcoholic
beverage, causing the victim to become incapacitated and
disrupting the victim's memory. This illicit use began in
Europe in the 1970s but didn't occur in the United States
until the 1990s. The manufacturer, Roche Pharmaceuticals,
added a blue dye to the tablet to make it detectable when
dropped into a drink. A few years later, GHB, originally pre-
scribed as a sedative, became the new date-rape drug. In
1996 the FDA banned all imports of Rohypnol, ® even for
personal use. In 1996 laws were enacted to add 20 more
years to the sentence of anyone convicted of using Rohypnol ,®
GHB, or any other drug to sexually assault someone or com-
mit violence.
Barbiturates
Three iconic stars of the twentieth century met their tragic
ends with excess barbiturates in their systems . Dozens of
other celebrities died during the 1960s and 1970s with excess
barbiturates in their systems, as well. And whether the deaths
were deliberate , accidental, or synergistic with alcohol and
other drugs, the dangers of barbiturates were well known.
Though barbituric acid was first synthesized in 1863, it
remained a chemical curiosity until 1903, when the mole-
cule was modified to create barbital (Verona! ®). The chemi-
cal modification made it possible for the drug to enter the

. AT 42
Singe!!~!
nervous system and induce sedat ion. It was originally be-
lieved to be free of the addictive propens ities of opiates and
opioids . Phenobarbital came along in 1913, and since then
about 50 of the 2,000 other barbiturates created have been
marketed. In the time it took for extensive clinica l experi-
ence to be recorded and studied, the dangers of overdose,
severe withdrawal symptoms, dependence, and addiction
had become common. In the decades since their peak abuse
in the 1940s through the 1970s, licit and illicit use of barbi-
turates declined dramatically due to increased scrutiny of
production and prescribing practices but primarily due to
the development of benzodiazepines.
Effects
• The long-acting barbiturates, such as phenobarbital, last
12 to 24 hours and are used mostly as daytime sedatives
or to contro l epileptic seizures, particula rly in young
people.
• The intermediate-acting barbiturates, such as butabar-
bital (Butiso l®), are used as longer-acting sedatives and
last 6 to 12 hours .
• The short-acting compounds, including butalbital (e.g.,
Esgic,®Axocet®) and, in the past, Seconal® ("reds") and
Nembutal ® ("yellows"), last 3 to 6 hours and are used to
induce sleep. Initially, they can cause pleasant feelings
along with the sedation, so they are more likely to be
abused.
• The very short-acting barbiturates, such as thiopental
(Pentothal ®), are used for anesthesia because they cause
immediate unconsciousness. The high potency of these
barbiturates makes them extremely dangerous when
abused.
Both benzodiazepines and barbiturates affect GABA, putting
a brake on inhibitions, anxiety, and restlessness. Because
they can induce a feeling of disinhibitory euphoria, barbi-
turates produce an initial stimulatory effect but eventually
become sedating. Even more than with many sedative-
hypnotics, the effects of barbiturates are very similar to
those of alcohol. Excessive or long-term use can lead to
changes in personality and emotional stability, including
mood swings, depression, irritability, and boisterous behav-
ior .110The effects often depend on the mood of the user and
Downers:Opiates/Opioids and Sedative-Hypnot
ics 4.41
ersHeortA
Judy Garland, Marilyn Monroe,and
Elvis Presley all had barbiturates
:---!!!!!!_
.
in their systems when they died.
,..,.., ,.,..,'
Barbiturate overdosesoften involved
B.rico..;,,~ alcohol as well. The role that
Doi
Insanity
barbituratesplayed in overdoses
-- ..._..ense was the reasonfor the switch to
R'POrtCa,i benzodiazepinesin the 1960s and
Pit!,At..1.;;. 1970s.
~-.
AslBta,;.1 © New YorkDaily News
I
where the drug is taken . An agitated barbiturate user in a
crowded room might become combative, whereas a tired
barbiturate user in a quiet setting might go to sleep.
Tolerance,TissueDependence,and Withdrawal
Tolerance to barbiturates develops in a variety of ways. The
most dramatic tolerance-dispositional tolerance (metabolic
tolerance)-resu lts from the physiologic conversion of liver
cells to more-efficient cells that metabolize or destroy
barbiturates more quickly. The other process, pharmaco-
dynamic tolerance, causes affected nerve cells and tissues to
become less sensitive . Tissue dependence (physical addic-
tion) to barbiturates develops after eight to 10 times the
normal dose is taken daily for 30 days or more .
Within six to eight hours after stopping use of short-acting
barbiturates, users begin to experience withdrawal symp-
toms such as anxiety, agitation, loss of appetite, nausea,
vomiting, increased heart rate, excessive sweating, abdom-
inal cramps, and tremulousness. The symptoms peak on
the second or third day. The heavier the use, the more severe
the symptoms. Withdrawal symptoms resulting from heavy
tissue dependence are dangerous and can cause convulsions
within 12 hours and for up to one week
Other Sedative-Hypnotics
Pregabalin(Lyrica®)
Pregabalin is FDA approved to treat seizures as well as nerve
pain from shingles or diabetes . It modu lates calcium ion in-
flux in hyperexcited neurons, which results in a decrease in
the release of neurotransmitters. Lyrica® has been used for
the treatment of generalized anxiety disorder (off label)
and is approved for such uses in Europe . In 2009 the FDA
required the manufacturer to add language to the warning
label on Lyrica,® addressing the product's risk for suicida l
behavior and ideation. Like other sedatives, it can cause diz-
ziness, drowsiness, lethargy, and memory prob lems that are
exaggerated when taken with narcotics, sedatives, or alco-
hol. Euphoria has also been associated with its use, and it
has a mild potential for abuse and dependence . Pregabalin
is classed as a Schedule V drug.
 4.42 CHAPTER4

Ramelteon(Rozerem®) and about the same as flurazepam (Dalmane®) and oxazepam

(Serax®). 112 Tissue dependence and withdrawal have also
This medication represents a new approach to treating
been reported with the use of Z-hypnotics. Withdrawal ef-
insomnia . The mechanism of action of ramelteon is its ability
fects peak within 24 to 36 hours and include tremors ,
to directly activate the brain's melatonin receptors. Melatonin
cramps , insomnia , anxiety, confusion, limb rigidity, halluci-
is the body's natural neurotransmitter that helps maintain the
nations , and seizures .
circadian rhythm responsible for normal sleep/wake cycles.
Ramelteon is usually recommended for short-term treatment Buspirone(BuSpar®)
of sleep disorders---one or two days up to one or two weeks.
Buspirone is a sedative-hypnotic medication mostly used to
Adverse effects include dizziness and excessive sleepiness.
treat generalized anxiety disorder; it is not pharmacologi-
Abuse and dependence are not associated with its use, and it
cally or chemically related to other sedative-hypnotics. This
is not a controlled substance . Ramelteon® and alcohol have
anxiolytic, or antianxiety, medication is also used in com-
synergistic toxic effects and should not be used together. m
bination with SSRI antidepressant medications to treat de-
Zaleplon (Sonata®), Zopiclone(lmovane®), pression. The way buspirone works to reduce anxiety and
augment the effects of SSRI drugs is unknown . Research
Zolpidem (Ambien®), and Eszopiclone
shows that it has a high affinity for serotonin receptors and a

I
(Lunesta®) moderate affinity for dopamine D2 receptors in the brain .
Zaleplon , Zopiclone , and Zolpidem are known as the
Unlike the other sedative-hypnotics , buspirone does not ap-
Z-hypnotics because they have similar actions and their
pear to have any direct effects on the GABAneurotransmitter
chemical names began with the letter z. Eszopiclone
system, and it lacks the ability to produce abuse or addic-
(Lunesta ®) is also considered a Z-hypnotic because it has the
tion. These characteristics make buspirone a more appropri-
same mechanism of action and effects as others designated
ate treatment for anxiety when there is a concern about the
Z-hypnotics.
patient's risk of addiction or relapse . It does not suppress
The Z-hypnotics are short-acting, with one- to four-hour withdrawal seizures and should not be used to detoxify alco-
half-lives, and are thought to have a lower risk of addiction hol or sedative-hypnotic dependence unless used with
than most benzodiazepines. They work by activating the another anti-seizure medication.
benzodiazepine receptor to enhance the effect of GABA in
Although buspirone has been demonstrated to effectively
the brain. Excess use can cause nausea, diarrhea , headaches,
reduce panic and anxiety, and ramelteon (Rozerem®) dem-
dizziness, and drowsiness the following day.3
onstrates an ability to induce sleep, it takes several weeks
Zolpidem (Ambien®) was responsible for 37 ,225 emergency before a patient feels the full effects of the drug. Because
room visits in 2011. Like benzodiazepines, the Z-hypnotics many patients don't experience the typical downer buzz
can cause memory, performance, and learning impairment. when they initially take buspirone and ramelteon, they
In 2007 the FDA began requiring Ambien ,® Rozerem,® believe them to be ineffective .
Lunesta, ® and 10 other sleep-aids to carry warnings noting
the small risk of "complex behavior impairments such as
driving, preparing food, or even gambling in an almost hyp-
notic or sleep-walking state." They can also increase the risk
of depression . The other drugs include Dalmane ,® Doral,®
Halcion ,® Placidyl,® ProSom,® Restoril,® Seconal,® Sonata,®
and Carbrital. ®113
PHARMACY
.•.AcTUALLY
,lHe.
Eszopiclone (Lunesta®) is a hypnotic agent prescribed for
rl II ~j[!.SARE
QLlife
insomnia. Like other insomnia medications, it affects GABA
SMALL.o.
and the benzodiazepine receptor complex that augments the ..Bl)TWe.
NEEDED
effects of GABA. Lunesta® can cause a severe allergic reac- 1H~R00MTO
tion. If it is taken longer than a few weeks at a high dose, LISTALL11-lE
dependence can develop. There is an additive effect when it 5\DEEFFECTS.
is taken with opioids or other sedatives. Though Jess severe
than with benzodiazepines and barbiturates , significant with-
drawal symptoms , including stomach and muscle cramps,
vomiting, sweating, and shakiness , can result if dependence
has developed. Relative to other sedative-hypnotics , eszopi-
clone is less prone to abuse than diazepam but more than
oxazepam . It is as toxic in overdose as the benzodiazepines. 112
The Z-hypnotics have a high therapeutic index and rarely
cause overdose deaths except when taken in combination
with other depressants. The liability for abuse and addic- © 2000 Ziggyand Friends, Inc.Reprinted by permissionAmericanUniversal
Uclick.
tion of Z-hypnotics is less than that of diazepam (Valium®)

Ethchlorvynol(Placidyl®) and ChloralHydrate
(Noctec,® Somnos,®Aquachloral®)
Two of the older sedative-hypnotics in continuous use are
Placidyl® (called "green weenies " on the street) and chloral
hydrate. Both are volatile liquids at room temperature and
are therefore enclosed in a suppository or gelatin capsule for
ease of administration . Ethchlorvynol is actually a chemical
ether, one of the first hypnotic drugs discovered. Chloral
hydrate has the same effects and liabilities as alcohol and
is actually three molecules of ethanol that have been fused
together. If taken with Antabuse ,® an adverse reaction can
occur. Both are controlled substances and are often ignored
because they are not abused as frequently as the newer seda-
tive drugs, but both have a long history of toxic overdoses
and patterns of addictive use . The autopsy of celebrity Anna
Nicole Smith, who died from an accidental drug overdose in
2007, listed Noctec®among the 15 medications found in her
body. Ativan,® Klonopin, ® methadone, Robaxin,® Soma,®
Topamax,® Valium,® and Benadryl® were the other psycho-
active drugs identified during the autopsy. 114
GHB (gamma hydroxybutyrate
or
sodium oxybate)
GHB is a strong, rapidly acting CNS depressant. This
slightly salty-tasting white powder, which is taken orally,
was initially available in health-food stores or by mail order
and was described as a nutrient rather than a sedative. GHB
was used as a sleep inducer in the 1960s and 1970s. By the
1990s GHB had become popular among bodybuilders
because it changed the ratio of muscle to fat. It also induces
effects similar to alcohol (sedation and disinhibition),
ecstasy (empathy and sensory enhancement), and even
heroin-like intoxication (euphoria). In recent years it has
gained popularity as a club drug.
GHB has been called "liquid ecstasy," "scoop," "Georgia
home boy," "easy lay," and "grievous bodily harm ." By the
1990s the FDA determined that the health risks warranted
taking GHB off the market. In 2000 it was added to the
Controlled Substances Act of 1970. Street chemists have
rushed in to fill the void.
"I remember likefor the prsthour I just felt reallqwoozq
and thenall of a sudden,I like-it startedto buildand
aboutan hourlaterlikeI couldn'tmove. I felt likemq head
was9onnadetachfrommq bodqand I justcouldn'tmove
mqarmsand I just staqeclthat waqforaboutfourhours
I thinkit was,maqbelon9er."
19-year-old club drug user
Despite the abuse of GHB, studies found it to be safe and ef-
fective for the treatment of narcolepsy, and in 2002 it was
approved as the prescription drug Xyrem.® Paradoxically,
narcolepsy is an illness characterized by the inability to stay
awake. GHB is undetectable when dissolved into commercial
mineral water, so it frequently surfaces at rave events and
music festivals. A dose costs $5 to $10 on the street, and the
effects last three to six hours.
Downers:Opiates/Opioids and Sedative-Hypnot
ics 4.43
• A 1 gm dose delivers a feeling of relaxation.
• With a 2 gm dose , relaxation increases while heart rate
and respiration fall. Balance, coordination , and circula-
tion are disrupted (2.5 gm or a level teaspoon is the typi-
cal amount).
• With a 2 to 4 gm dose , coordination and speech become
impaired.
Depending on the susceptibility of the user, side effects in-
clude nausea and vomiting (which are immediate signs of an
impending overdose), depression, delusions, hallucinations,
seizures, amnesia, respiratory depression, and coma with a
greatly reduced heart rate. m
In 2011 the number of emergency room visits for GHB fell
sharply from six years earlier, to 2,406, compared with ec-
I
stasy, which has increased to 22,498. 2 Most of the incidents
involved naive users who became anxious that the first dose
wasn't working so they continued to use until they felt some-
thing; at that point they had taken too much.
Because GHB causes mild euphoria and lowers inhibitions, it
has been used by sexual predators to lower a victim's de-
fenses. These effects, along with its ability to induce coma
and amnesia, caused GHB to be added to the list of date-rape
drugs .116 GHB's use spurred the passage of the Drug-Induced
Rape Prevention and Punishment Act of 1996, which in-
creased federal penalties for the use of any controlled sub-
stance while committing acts of sexual assault or violence .
GHB and its precursor chemicals are now classified as
Schedule I illegal substances, but its medication form Xyrem®
is listed as a Schedule III drug.
GBL(gamma butyrolactoneor 2(3H]-furanone
dihydro)and BD (1,3 butanediol)
The increased legal scrutiny of GHB resulted in the abuse of
GBL and BD. GBL and BD are prodrugs (they are metabo-
lized to GHB in the body). They are ingredients in liquid
paint strippers and are available through chemical suppliers
in the United States and on the Internet. GBL and BD were
quickly formulated into mint-flavored elixirs and are sold at
raves under the trade names Blue Nitro ,® Revivarant,®
Gamma G,® Remforce,® and Insom-X.® Some abusers have
even swallowed diluted paint stripper or "huffed" the hard-
ware store products containing GBL. GBL and BD are now
Schedule I illegal substances.
Methaqualone(Quaalude,® Mandrax®)
Methaqualone was developed in India in 1955 as a safe bar-
biturate substitute and was originally marketed in Japan and
Europe. In 1965 it was the most commonly prescribed seda-
tive-hypnotic in England. It was popular because of its over-
all sedative effect and the prolonged period of mild euphoria
caused by the suppression of inhibitions . This disinhibitory
effect is similar to that caused by alcohol and can last 60 to
90 minutes; the sedating effects last six to 10 hours. Larger
doses can bring about depression, irritating behavior, poor
reflexes, slurred speech , and reduced respiration and heart
rate. Tolerance to methaqualone develops quickly.
 4.44 CHAPTER4
Quaalude ®was once widely used as a sleep aid, but its heavy
nonmedical abuse led to the product's withdrawal from the
legitimate U.S. market. In 1984 it was reclassified as a
Schedule I drug, which led to a tremendous increase in il-
licit production; street versions were sold as bootleg "ludes"
but looked identical to the original prescription drug. In the
1970s and 1980s, Mandrax ® (methaqualone and an antihis-
tamine) was very popular in Europe. The antihistamine ex-
aggerated the effects of the methaqualone. Mandrax ®is still
widely used in South Africa.
Quetiapine(Seroquel®)
Seroquel® was approved to treat schizophrenia and bipolar
disorders. It is thought to block a number of brain receptors,
resulting in benzodiazepine-like sedative effects. This has
I
led to a growing abuse of the medication in recent years .
Drug Interactions
Pharmacologic research confirms that more than 150 pre-
scription and OTC medications interact negatively with
alcohol. This does not include those that interact negatively
with one another independent of alcohol. Drug interactions
are a serious problem because one in six Americans takes
three or more prescription drugs each day Those over 65
take 25% of all prescription medications, often seven or
more every day This group is more sensitive to the effects of
drugs because as we age the efficiency of organs changes,
particularly that of the liver.
Synergism
Drug synergy occurs when two or more drugs interact in a
way that magnifies their effects or side effects, especially if
both are depressant drugs. Polydrug combinations can cause
a much greater reaction than simply the sum of the effects.
One of the reasons for this synergistic effect lies in the chem-
istry of the liver. For example, if alcohol and alprazolam
(Xanax®) are taken together, the complications are greater
than if they were taken independently The liver metabolizes
the alcohol, which allows the sedative-hypnotic to pass
through the body at full strength . Alcohol also dissolves
the alprazolam more readily than stomach fluid, which
causes more alprazolam to be
More than 150 absorbed rapidly into the
prescriptionand body. The benzodiazepine
OTCmedications exerts depressant effects on
interactnegatively different parts of the brain
with alcohol. than those affected by alco-
hol. So, a greater amount of
the brain is sedated when both drugs are taken together. The
risk of exaggerated respiratory depression and blackouts is
heightened when alcohol and another depressant are taken
together.
"I took m~ little medicationwith me one ni9ht, drinkin9in
the bar. I pla~edsome pool and that's all I remember.
This was on a Sunda~. When I woke up, it was Wednesda~."
Recovering polydrug abuser
According to the Centers for Disease Control and Prevention,
synergistic effects are responsible for about 19,000 deaths
per year, 229,564 people are treated in emergency depart-
ments because of adverse reactions to alcohol and illicit
drugs, and 143,783 are treated for illicit drugs in combina-
tion with pharmaceuticals. 2
Cross-Tolerance
and Cross-Dependence
Cross-tolerance is the development of tolerance to other
drugs resulting from the continued exposure and develop-
ment of tolerance to the initial drug . For example, someone
who develops a tolerance to a high dose of Xanax® is also
tolerant to another benzodiazepine like Klonopin ® and to a
lesser extent can withstand higher doses of anesthetics,
opiates, alcohol, and even blood-thinning medication. One
explanation for cross-tolerance is that many drugs are metab-
olized, or broken down, by the same body enzymes, so if a
user continues to take a barbiturate, the liver will create more
enzymes to effectively metabolize the drug; those enzymes
also metabolize other drugs such as benzodiazepines, so the
user becomes more tolerant to those drugs as well.
Cross-dependence occurs when an individual becomes ad-
dicted to or tissue dependent on one drug and this causes
the person to become addicted to another drug . This is
caused by the biochemical and cellular changes created by
abuse of the first drug . A heroin addict's altered body chem-
istry makes it more likely that he or she will be addicted to
another opiate/opioid (e .g., hydrocodone, oxycodone,
meperidine, morphine, or methadone). Cross-dependence
most often occurs with different drugs in the same chemical
family A heavy butalbital user is also tissue dependent on
phenobarbital. Cross-dependence involving opiates/opioids
and alcohol, cocaine and alcohol, and benzodiazepines and
alcohol has also been documented.
Prescription
Drugsand the
PharmaceuticalIndustry
In 2012 America 's health tab was $2.7 trillion, about 17.9%
of the U.S. gross national product and rising . That works out
to $8,608 per person. Of that Americans spent almost 12%
or close to $340 billion on prescription drugs, up from
$132 billion in 2000 .1 Worldwide prescription drug expendi-
tures are approaching $1 trillion. U.S. healthcare expen-
ditures are expected to rise to $4 trillion by 2020, pushing
prescription drug expenditures over $0.5 trillion. 1 Legal
psychoactive drugs, including psychiatric medications,
account for approximately 10% to 12% of all prescriptions
in the United States . Americans also spent more than
$40 billion on OTC drugs such as laxatives, digestion and
cold medications, and vitamins.
There is also a significant increase in the use of prescription
medications for children. Antidepressants and drugs for
ADHD and therapeutic medication are responsible for this
change. Today the FDA requires more black box warnings
and cautions on the use of drugs for children.

NO EXIT © Andy Singer
J FOR £VER'r' PROBLEM,
PILLS, PILLS, PILLS,
THERE RRE PRESCRIPTIONS,
PILLS,PILLS, PILLS,
.. , OR EXPENSIVE,
/VONPRESCRtPTION,
PHl'IRMflCEUTICflLS
,&/P/LL TOBE STRONG,
A PILL TO OIE,
,q PILL TO H/:WE SEX,
A PILL TO GET HIGH,
PILLS TO BE SMART,
PILLS TO LOSE WEIGHT,
f'/ PILL TO SLEEP,
,&/NO PILLS TO STRY
.AWRKE, ,,
( REPEAT fiEFRFIIN)
c:,2008 Andy Singer. Courtesy of cagyle cartoons.
Research/Developmentand Marketing
The industry justifies the high cost of prescription drugs by
citing the expense of developing a new medication, which
often takes hundreds of millions or even billions of dollars to
bring to market. In 2012 the pharmaceutical industry esti-
mated that $48.5 billion was spent on research and develop-
ment. 117Because only about one in 20 researched drugs
makes it in the marketplace, it is estimated that it costs
$5 billion for each successful drug. Considering that the
most prescribed drugs bring in $2 billion to $7 billion per
year, the costs involved in research and development deliver
a high return. The National Science Foundation , using dif-
ferent calculation methods , estimated the cost for a single
drug at half that amount. Drug patents are good for 17 years
(including testing time), so companies must recoup their
research-and-development and startup production costs in a
short period of time . The availability of a generic version,
once the patent runs out, further diminishes the return on a
drug company's initial investment.
The pharmaceutical industry was unsuccessful in lobbying
to extend the life of a patent beyond 17 years, but it has tried
a number of other tactics to preserve profits. Generics were
kept off the market for years because the FDA did not have a
streamlined approval process for the drugs , but lobbyists for
the consumer fought for changes , and the approval process
became easier. Other strategies drug companies use to pro-
tect profits on prescription drugs includ e:
• manufacturing their own generics
Downers:Opiates/Opioids and Sedative-Hypnot
ics 4.45
• using legal challenges to delay the introduction of
generics
• making slight changes to a drug's formula or introduc-
ing a time-release version to get another patent
• expanding their direct-to-consumer (DTC) advertising
• employing "detail men and women" to personally con-
tact physicians
• relentlessly battling a consumer's ability to purchase
medications online from foreign sources, particularly
Canada, by questioning the quality and the authenticity of
the product (consumers claim that they are being denied
,
access to more-affordable versions of the drugs they need)
In his book Generation Rx, Greg Critser worries that we are
becoming a prescription drug-dependent society . He be-
I
lieves that the increase in prescription drug use comes from
more-sophisticated marketing by the drug companies. An
astonishing $24 billion was spent by the pharmaceutical
industry on marketing to physicians. Another $3.1 billion
was spent advertising directly to consumers (OTC) , up
from $2 million in 1980 .2 •98 •98A For every dollar spent on
advertising , sales increased by a median of $2.20. But those
figures are dwarfed by the $24 billion spent on marketing
(and free samples) to physicians.
Direct-to-consumer advertising on TV and in print is osten-
sibly designed to create an awareness of a disease rather than
to sell drugs directly. Patients see a commercial and ask their
doctor for the medication they saw advertised. Almost every
other country bans OTC advertising for prescription drugs.
Of the 1,035 new drugs approved by the FDA between
1989 and 2000 , more than half showed "no significant clin-
ical improvement" over older, less expensive drugs.98 Drug
companies have successfully used professional promotions
and consumer advertising to sell patented drugs that cost
dozens of times more than generics to deliver hefty rewards
to their bottom line.
In contrast to the $340 billion spent on illegal diversion of
prescription drugs in the United States, about:
• $70 to $75 billion was spent on illegal drugs such as
heroin, cocaine , and marijuana
• $70 to $80 billion was spent on tobacco
• $150 to $160 billion was spent on alcohol
These figures do not include the healthcare costs associated
with abusing psychoactive drugs. Assuming overall health-
care costs are more than $2.5 trillion, the cost of treating the
medical consequences of abuse (e.g., emphysema , heart dis-
ease, hepatitis C, HIV infections, and cirrhosis) could easily
approach $1 trillion, about 40% of all healthcare costs.
The most cost-effective method to lower these numbers is to
implement prevention programs and encourage lifestyle
changes . Even though these have proven to be successful ,
prevention is too often perceived as unnecessary and there is
little profit to be gained. When free enterprise is at odds
with unprofitable public policy, inaction, heavy political
contributions in opposition, and delaying tactics are often
the result, usually to the detriment of the general public.
4.46 CHAPTER4
GeneralClassification
• Major depressants (downers): opiates/opioids, sedative-
hypnotics, and alcohol (see Chapter 5).
• Minor depressants (downers): skeletal muscle relax-
ants, antihistamines, and over-the-counter downers.
PrescriptionDrug Epidemic
• America is in the midst of a prescription drug abuse
epidemic, mainly opioid painkillers and benzo-
diazepines.
• Sales of and deaths from prescription painkillers have
gone up four- to five-fold since 1999.
• Diversion oflegitimate prescriptions is the main route
for acquiring prescript ion drugs.
• Tens of thousands of Americans die each year from
overdoses, and several million are injured from
adverse drug reactions.
• Besides allcohol and tobacco, the number one cause of
preventable deaths in America is abuse of prescription
drugs .
• About 60% of illegal prescription drugs are acquired
from friends or relatives.
Opiates/Opioids
In this review the term opioids represents both opiates and
opioids.
Introduction
• The United States consumes 80% of the world's
supply of prescription opiate painkillers .
• Opioids can control pain , but they can also cause
addiction and overdoses, includin g many fatalities.
Classification
• Opiates are natural or semisynthetic derivatives of the
opium poppy (e.g., opium, morphine , codeine, heroin ,
hydrocodone, and oxycodone).
• Opioids are synthetic versions of opiates (e.g., fentanyl,
buprenorphine, and methadone).
• Opioid antagonists include naloxone and naltrexone.
Historyof Methods of Use
• Over the centuries, opium refinement methods and
laboratory discoveries evolved along with different
routes of administration (ingesting, smoking, injecting,
snorting, and skin absorption), which contributed to
an increase in the intensity of effects and consequently
the abuse and overdose potential.
• Patent medicin es containing opioids and other psy-
choactive drugs were heavily abused in the late 1800s
and the early 1900s.
Twentiethand Twenty-FirstCenturies
• Historically, most drug laws were made for political
and taxation reasons, not medical considerations .
• There are 5 million to 10 million heroin addicts world-
wide and even more prescription-opioid addicts.
• Most opium is grown in Afghanistan, but most U.S.
heroin comes from Mexico (black tar heroin) and
Colombia (white heroin).
Effectsof Opioids
• Most opioids control pain and often induce euphoria.
The drugs also suppress coughs and control diarrhea.
• Opioids mimic and manipulate naturally occurring
pain-suppressing neurotransmitters, mainly endor-
phins and enkephalins.
TherapeuticPain Controlvs. Hyperalgesia
• Physicians sometimes underprescribe, for fear of
addicting the patient, or overprescribe, leading the
patient into dependence .
• Extended opioid use increases sensitivity to pain , both
physical and emotional , through processes called hy-
peralgesia, hyperpathia , allodynia, and hyperkatifeia .
• Nerve cells are sensitized, emotions become mag-
nified, and people hurt where they never felt pain
before.
• Physicians should be aware of their patients ' risk fac-
tors for addiction .
• Side effects of opioids include depressed respiration
and hean rate , constipation, and slurred speech ; these
side effects worsen as use and dosage increase due to
the development of tolerance , tissue dependence , and
withdrawal symptoms, which are not life-threatening
but make the user feel like dying.
AdditionalComplicationsCausedby Opioids
• Additional complications include dangerous fetal
effects, sexually transmitted diseases, abscesses , and
complications from polydrug use .
• Problems involving the drugs themselves and meth-
ods of use include overdoses, drug contaminations ,
infections (HIV/AIDSand hepatitis C), and dangerous
polydrug interactions.

From Experimentationto Addiction
• Most opioid addicts entering treatment shoot heroin.
Treatment includes physical detoxification and psy-
chological processes.
• Opioid and drug use increases in wartime, necessitat-
ing the availability of treatment for returning military
personnel.
SpecificOpioids
• Morphine is used for the relief of severe pain. Other
opioids include codeine, hydrocodone, oxycodone,
methadone, buprenorphine , fentanyl , and other opi-
oid analgesics.
• The opioid antagonists naloxone and naltrexone are
used for treatment.
• Kratom chemicals are non-opioids but have opioid-
like effects and cause opioid-like addiction.
Sedative-Hypnotics
• Sedatives are calming drugs while hypnotics are sleep-
inducing drugs (both are downers) . Their effects are
similar to those of alcohol (e.g., lowered inhibitions
and physical depression).
• Benzodiazepines, such as alprazolam (Xanax®) and
clonazepam (Klonopin ®), are the most frequently
prescribed sedative-hypnotics .
• Barbiturates and the Z-hypnotics are other main classes
of sedative-hypnotics.
History
• Calming and sleep-inducing drugs have always been
desired.
• Sedative-hypnotics range from bromides and chlo-
ral hydrate to barbiturates, benzodiazepines , and the
Z-hypnotics.
Classification
• Benzodiazepines have been the most common
sedative-hypnotics but in the last dozen years, the
Z-hypnotics such as Ambien® and Sonata® or other
newer ones like Lyrica® and Lunesta® are being
prescribed.
Use, Misuse,Abuse,and Addiction
• Attitudes toward sedative-hypnotics include both avid
acceptance and a wariness of their addictive potential.
• Misuse and abuse occur due to a variety of reasons.
Benzodiazepines
• Benzodiazepines are the most widely used sedative-
hypnotics. They were developed as safe alternatives
to barbiturates, but in spite of a higher margin of
Downers:Opiates/Opioidsand Sedative-Hypnot
ics 4.47
safety, tolerance , withdrawal symptoms, overdose ,
and addiction still occur.
• Benzodiazepines are used to provide short-term
treatment for anxiety and panic disorders, to treat
sleep problems , and to help control musculoskeletal
spasms, seizures, and other beneficial effects.
• These drugs can also cause tissue dependence, slurred
speech, muscular disruption, and memory impair-
ment.
• They should be used short-term for specific conditions
rather than as long-term medications. Withdrawal can
be dangerous and even life-threatening.
Barbiturates
• Since 1900 more than 2,500 barbiturate compounds
have been developed (e.g., Seconal® and phenobarbi-
tal) ; they were often abused and widely used (until
the introduction of benzodiazepines).
• Their effects are very similar to those of alcohol.
Other Sedative-Hypnotics
• Ambien,® Lunesta,® Lyrica,® Rozerem,® Sonata,® and
GHB, among others , are prescribed for anxiety and
other conditions and are sometimes abused for their
psychic effects.
• GHB can be easily disguised in alcohol ; and because
of its ability to cause amnesia, it has been abused as a
date-rape drug .
Drug Interactions
• Using two or more downers at one time (especially
alcohol with a benzodiazepine) can lead to overdose ,
respiratory depression, and death.
• Cross-tolerance and cross-dependence also develop.
PrescriptionDrugsand the
PharmaceuticalIndustry
• Worldwide expenditures for prescription drugs will
reach $1 trillion by 2014 and $350 billion in the
United States.
• Of the 3.8 billion prescriptions written each year in
the United States, approximately 250 million are for
psychoactive drugs , mostly downers.
• Americans spend $15 billion to $40 billion each year
on over-the-counter medications. Some of the most
common are antihistamines, sleep-aids , nond epres-
sant analgesics, and anti-inflammatory drugs.
In every country where alcohol
is consumed,problems with
overuseand alcoholism exist.
Alcohol is consumedsocially,
as an accompanimentto
meals, to alter a mood, and to
become inebriated. This
Hmong woman stands in a
market in Dong Van, Vietnam,
supporting her drunken
husband and waitingfor him
to wake up.
® 2002 Chau Doan/Getty Images
 Downers:Alcohol
Thischapteronth,thirdmajordowne r (bnidesopioids•nd.,W,tive -hypnotics)
looksotthechemistryof• loohol•nditsdfecton t h<body\hal thandth < hr.,l n \
n eurochtmistry . ~u.,• lroho l i,oneolth<o ld<>t>ndmootwid«praddown -
• <n,th<WOTld's!iOCi<tiesh>,.,hadth < moslap<rirncewiththisdrugandh.ov,lad
1oodju,;1toitsimpactsonh<lllth,crim<, a OOdom<>ticvioknc:<c
Th< low,ri ngofinh ibitions,thelo .. olphy,ica l and<mo tiona l contro l, them•in
on thelh,er,thedamag<to t hefetu,;o f •drinkingpnegn.,.n1womE1 - 1lcon1n<t
withi,.l>rndicia l ,f!ectsolne lieving,tr<>,,h<lpingthehunin lowd=,as •
d" .,, :tant, a OOasamed'um' ,,.fo1 fc"r,a;

Introduction

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/tn,nt , mpt,lii,wtob/,,,tootslonff/,,tt,r,..,,,tolJ.·

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 5.2 CHAPTER5
'The~ sa~ some of m~ stars drink whiske~.But I have found that
the ones who drinkmilkshakesdon't win man~ ball9ames."
Casey Stengel, manager, New York Yankees
These historical quotes illustrate how alcohol and drinking
have been romanticized and praised throughout history,
most often by men. The quotes attributed to women (which
are hard to find) present a very different view of alcohol.
"Alcoholis pe1ectl~consistentin its effects upon a man.
Drunkennessis merel~an exaBBeration.A foolishman drunk
becomesmaudlin;a bloo~ man, vicious;a coarseman, vu~ar."
Willa Cather, novelist , 1873-1947
"Alcoholis barren.The wordsa man speaksin the ni9ht of
drunkennessfade like the darknessitself at the comin9of daf"
MargueriteDuras, Frenchnovelist and film director, 1914-1996
Views aside, last month in the United States almost as many
I
women had a drink as did men (64 million vs. 71 million).
Internationally, significantly more men drink than do women;
most heavy drinkers are men .1
Worldwide
• 2 billion people consume alcohol.
• Most countries, except Islamic countries, allow alco-
holic beverages.
• Alcohol consumption in China and India has doubled
in recent years.
• Russia has the highest rate of consumption. Russian
men consume the equivalent of six to seven bottles of
vodka per capita per year.2
The Consequences Worldwide
• 76 million people suffer from an alcohol consumption
disorder.
• 2.25 million die annually due to the direct effects of
alcohol (4% of all deaths) .
• Approximately 10% of all diseases and injuries are a
direct result of alcohol abuse .
• 75% of the homeless in Japan are alcoholics. 2
In the United States Last Month
• About 135 million Americans (52% of those 12 or older)
had at least one drink; 17 million are considered heavy
drinkers (five or more drinks in one sitting at least five
times in the past mont h) .
• About 60% of the 11 million students at four-year col-
leges had at least one drink, and more than 40% were
binge drinkers.
• Approximately 5.1% of eighth-grade students, 15.6% of
tenth-grade students, and 23.7% of twelfth-grade students
consumed five drinks at one sitting in the past two weeks.
• $162 billion was spent on alcohol at bars , restaurants ,
and in retail stores .
• Champagne toasts were made to 7,500 newlyweds.
In the United States Last Year
• About 80,000 Americans died as a direct result of alcohol
consumption and approximately 50,000 due to alcohol-
involved car crashes, accidents, violence, and suicides.
• 25% to 30% of hospital admissions were directly or
indirectly due to medical complications from alcohol.
• About half of all murder victims an d half of all per-
petrators had been drinking alcohol just prior to the
crime.
• More than half of all rapes involved alcohol.
• About half of American adults had a close family member
who is a practicing or a recovering alcoholic.
• Some 2.7 million crime victims reported that the of-
fender had been drinking alcohol prior to committing
the crime.
• Alcohol abuse and addiction cost businesses, the judicial
system, medical facilities, and the U.S. government more
than $224 billion, or $720 for every man, woman, and
child. 1•2 •3 •4 ·'· 6 •7•8 •9 •10
History
Alcohol is the oldest and most widely used psychoactive
drug in the world. It has been around since airborne yeast
spores fermented fruits and plants into alcohol about 1.5 bil-
lion years ago. Animals became drunk on alcohol long before
humans did. Even today monkeys, giraffes, and elephants
that eat the fermented fruit of the South African marula tree
after it has fallen to the ground get as staggeringly drunk as
the most inebriated college freshman." ·12
Hundreds of thousands of years ago our ancestors probably
discovered alcohol in much the same way. Perhaps they
sampled a bunch of grapes or a batch of plums that was
left in the sun, allowing the fruit sugar to ferment into
alcohol. Perhaps some wild fermented honey was found,
diluted with water, and tasted. This early alcoholic beverage
would later be called "mead. " Initially, peop le were most
likely drawn to the mood-altering effects rather than to
the taste. Curiosity led to further experimentation as
thirsty farmers discovered that the starch in potatoes , rice,
com, and grains could also be fermented into alcohol
(beer or wine). Over time the value of alcohol as an anti-
septic and a medicine was discovered along with a dozen
other uses.
The desire for ready access to the pleasurable effects as well as
the health benefits of beer and wine led to the cultivation of
the raw ingredients for alcohol. Some historians believe that
about 10,000 years ago the first settlements were created to
ensure a regular supply of grain for bread and beer, grapes
for the table and wine, and poppies for opium.13
The early use of alcohol is documented in most civilized
societies through myths, religions, songs, hieroglyphs,
sacred writings, and commercial sales recorded on clay tab-
lets. The Babylonian Epic of Gilgameshproclaims that wine
 Downers: Alcohol 5.3

The Drunkenness of Noah by

Giovanni Bellini shows Noah lying
drunken. His sons try to cover his
nakedness.
© JamesTissot, Jewish Museum of New
York.Reprintedby permission SuperStock.

grapes were given to the eart h as a memorial to fallen gods.

The Bible contains more than 150 references to wine, some
positive, some negative.

"Godgive~ouof the dewof the sk~,of the fatnessof the earth,

and plent~of grainand newwine."
many peop le did not cons ider it a drug, although that atti-
tude has almost disappeared over the past 50 years.

Genesis 2 7 :28
"Noahwasthe firsttillerof the soil. He planteda vine~ard;
and he drankof the wine,and becamedrunl and la~
uncovered in his tent.... Shem andJaphethtooka garment,
laidit uponboth theirshoulders,and walkedbackwardand
coveredthe nakednessof theirfather;theirfaceswereturned
awa~,and the~did not seetheirfather'snakedness."
Genesis 9:18-29
"Alcoholis a drug,period."
Heard often at Alcoholics Anonymous meetings
I
• Whether it is used for desirable reasons or as the focus
of prohibition forces, alcohol remains the object of both
desire and vilification, depending on the moral attitude,
social acceptability, and the politics of the prevailing
government.

nie Legal Drug

Historically, the acceptability of alcohol has been intertwined
with cultura l, social, and financial imperatives. It has been
used as a reward for those building the pyramids of Egypt, as
a food (grain-rich beer) for peasants, as a solvent for opium
in the cure-all known as laudanum, as a sacramental for reli-
gious ceremonies, as a water substitute for contaminated
wells, as a social lubricant for all classes, as a tranquilizer
for the anxious, and as a source of tax revenue for the ruling
classes or the government.

The firstsettlementswere createdto ensure

a regularsupplyof grainfor bread and beer,
grapesfor the table and wine, and poppies
for opium.
Because beer, wine, and liquor were legal and widely avail-
able in most societies (except in Islamic count ries) and
because alcohol was promoted by custom and advertising,
Arjen Robbenof the Bayem Munich'ssoccer team celebrateshis team's
win of the German Cup in Berlin. A country'suse of beer,wine, and
distilled liquors depends on the country'sculture, the availability of
certain kinds of beverages,and the specific occasion.Fans drink
alcohol at sporting events and winners celebrate.
© 20 13 Christo! Stache/GettyImages
 5.4 CHAPTER 5

• Almost every country has had periods in its history

during which alcohol use was restricted or banned.
Those prohibitions were often reduced or rescinded.
• Starting around 4000 B.C., Egyptians considered beer
and wine necessities of life, a gift from the gods.
• The Chinese Canon of History, written about 650 B.C.,
recognized that complete prohibition was almost
impossible because men loved their beer. 13
• In India, Hindu texts describe the beneficial uses of al-
coholic beverages and the consequences of abuse. Many
Buddhist sects prohibited alcohol in 500 B.C., continu-
ing to this day.
• Even though ancient Greeks worshiped Dionysus, the god
of revelry and orgies, mead (an alcoholic beverage made
from honey) and wine (originally made from grapes) were
a part of everyday life, but drunkenness was not common
because of a cultural emphasis on temperance.
• In sub-Saharan Africa, banning alcohol was never con-
sidered because home-brewed beers had great nutritional
and economic value.

I
• The Gin Epidemic in England in the 1700s was the
result of poverty, unrestricted use, and industrialization
coupled with the higher concentration of distilled alco-
hol-all of which led to abuse and, for many, addiction.
The unrestricted sale of gin (20 million gallons per year
in England) led to illness, public inebriation, absen-
teeism from factory work, and death. The government
recognized the public health hazard of promoting gin,
prompting Parliament to place severe restrictions on its
manufacture and increasing the tax on every bottle. 14
A flapperin 1926 defiesProhibitionin the UnitedStateswith her
• In colonial America alcohol was part of everyday life. silver flash.
The Pilgrims of Plymouth Colony regarded it as an
Courtesyof the Library of Congress
"essential victual"; the founding fathers used the culti-
vation, manufacture, sale, and taxation of whiskey and
rum to partially finance the American Revolution and the
slave trade.
ported by the concept of recovery from alcohol abuse and
• The alcoholic excesses of the 1700s and 1800s in
addiction through personal spiritual change. 15 ·16 ·17
America (almost two bottles per week per capita) led to
calls for temperance in the 1840s by such groups as the Official prohibition of alcohol by the U.S. government (the
Washington Temperance Society. Those efforts moved Eighteenth Amendment and the Volstead Act) was put into
tens of thousands of drinkers to temperance and even action in 1920, but flouting the law was widespread. The
abstinence, but severe relapse was common; and for criminalization of the manufacturing and distribution sys-
those with a drinking problem, even one drink was too tem, and pressure brought by those who wanted to drink,
much. 14 This shifted the goals of the Washingtonians, the including the Wet Party , led to the repeal of Prohibition
Women's Christian Temperance Union, and other groups 13 years later. 14
to advocate abstinence rather than just temperance.
One reason why many restrictions, including Prohibition,
were overturned is the value of alcohol as a major source of
'We, the undersi9ned,reco9nizin9the evils drunkenness of excise taxes. Currently, the federal government collects
and resolvedto check its alarmin9increase, with consequent
$13.50 per gallon from distilleries (about $7.594 billion in
povert~, miser~and crimeamon9 our people, hereb~solemnl~
2011), and state governments collect an average of $3.75 per
pled9eourselves that we willnot9et drunkmorethanfour
gallon up to $12.50 per gallon. If the tax rate had kept up
timesa qear,viz.. FourthofJulq,MusterDaq, ChristmasDaq,
with inflation, the federal government would collect three
and Sheep-Shearin9."
times as much alcohol revenue, or around $23 billion.
Massachusetts temperance societies , 1820, quoted in
The Great Quotations, George Seldes, 1983 Because alcohol has played a central economic and social
role in the United States since colonial times, contemporary
The Oxford Group, active in the 1920s and 1930s, spawned society 's view of a heavy drinker is more forgiving than its
Alcoholics Anonymous, which believed in abstinence sup- view of a cocaine, heroin, LSD, or marijuana user. As states

that have legalized marijuana (Colorado and Washington)
figure out how to collect more taxes on the drug, other
states will probably become more forgiving in their
attitude.
The Chemistryof Alcohol
There are hundreds of alcohols. Some are made naturally
through fermentation, whereas those that are used industri-
ally are synthesized . Some of the more familiar alcohols
include:
• ethyl alcohol (ethanol, or grain alcohol), the primary
psychoactive component in all alcoholic beverages; it is
still evolving as an alternative fuel to replace gasoline
in automobiles
• methyl alcohol (methanol, or wood alcohol), a toxic in-
dustria l solvent
• isopropyl alcohol (propanol, or rubbing alcohol), used
in shaving lotion, shellac, antifreeze, antiseptics, and
lacquer
• butyl alcohol (butanol) , used in many industrial processes
Ethyl alcohol is the least toxic of the alcohols. Few people
drink pure ethyl alcohol because it is very strong and fiery
tasting. By convention, any beverage with alcohol content
greater than 2% is considered an alcoholic beverage.
Alcoholic beverages also contain trace amounts of other
types of alcohol, such as amyl, butyl, and propyl alcohol that
result from the production process and storage (e.g., in
wooden barrels). Other components produced during fer-
mentation , known as congeners, contribute to the distinc-
tive tastes, aromas, and colors of the various alcoholic bev-
erages. Congeners include acids, aldehydes, esters, ketones,
phenols , and tannins. Beer and vodka have a relatively low
concentration of congeners, whereas aged whiskeys and
brandy have a high concentration. Congeners are often
Chemistryof Fermentation
r~
-
'(>QO
GB eum +
Ethylalcohol Carbondioxide
Sugar
fromfruit, berries, psychoactive bubblesin beer
vegeta
bles,or grain component and champagne
Yeastfeeds on sugar and excretesalcohol and carbon dioxide.
Cl 20 13 CNSProductions, Inc.
Downers:Alcohol 5.5
blamed for the severity of hangovers and other toxic reac-
tions to drinking , but the main culprit is ethyl alcohol.
Ethylalcoholor grainalcohol
is the primarycomponentin
all alcoholic beverages
The anaerobic conversion of sugar to carbon dioxide and
alcohol by yeast is called fermentation. It occurs when air-
borne yeast feeds on the sugars in honey or on any watery
mishmash of overripe fruit, berries, vegetables, or grain.
The process results in ethyl alcohol and carbon dioxide
(Figure 5-1).
Typesof AlcoholicBeverages
The principal categories of alcoholic beverages are beer,
wine, and distilled spirits .
I
• Beer is produced from fermented grain.
• Wine is produced from fermented fruit.
• Distilled spirits have varying concentrations of alcohol
and are made from fermented grains, tubers (e.g., pota-
toes) , vegetables, and other plants. Spirits can also be
distilled from wine or other fermented beverages .
Examples of fermented plant matter are Mexican tequila
made from the agave cactus, Russian kvass made from cereal
or bread, central Asian kumiss made from mare's milk ,
Japanese sake made from rice, and dandelion or garlic wine.
The actual consumption of beer vs. wine vs. distilled spirits
depends on the culture of a country. Germans drink six times
more beer per capita than they do wine; the French drink
eight times more wine per capita than do Americans.
Beer
Beer brewing and bread making began about 8000 B.C. in
Neolithic times. The raw ingredients (usually grain) were
grown in cultivated fields. Some of the first written records
mentioning beer were found in Mesopotamian ruins dating
from 5400 to 3500 B.C. The Mesopotamians taught the
Greeks how to brew beer, and the Europeans learned it from
the Greeks.
Beer is produced by first allowing cereal grains, usually bar-
ley, to sprout in water, causing an enzyme called amylase to
be released . The amylase helps convert the starches in
crushed barley malt into sugar. This crushed malt is boiled
into a liquid mash, which is then filtered, mixed with hops
(an aromatic herb first used around A.D. 1000 to 1500) and
yeast, and then allowed to ferment.
The major styles of beer include ale, stout, porter, malt
liquor, pilsner, lager, and bock. The differences have to do
with the type of grain used, the fermentation time, and
whether they are top-fermenting beers (those that rise in the
vat) or bottom-fermenting beers. Top-fermenting beers are
more flavorful and include ales, stouts, porters, and wheat
beers. Bottom-fermenting beers include the most popular
 5.6 CHAPTER5
Most bars offer dozens of choicesof beers,from national brands to
locally producedmicrobrews.
I
© 2013 CNSProductions,
Inc.
pale lagers (e.g., Budweiser® and Coors®). Traditional home-
brewed beers are dark and full of sediment, minerals, vita-
mins (especially B vitamins), and amino acids and thus have
appreciable food value, unlike modem commercial beers
that are highly filtered.
The alcohol content of most lager beers is 4% to 5%; ales,
5% to 6%; ice beers, 5% to 7%; and malt liquors, 6% to 9%;
light beers contain only 3.4% to 4.2% alcohol.
Wine
In some early cultures, beer was the alcoholic beverage of
the common people and wine was the drink of priests and
nobles. Vineyards were difficult to establish and cultivate, so
wine was scarce and reserved for the upper classes. In Egypt,
however, pharaohs were entombed with beer in their pyra-
mids to sustain them on their afterlife journeys and to offer
as a gift to the gods. Ancient Greek and Roman cultures
seem to have preferred wine, the ruling classes keeping the
best vintages for themselves. These cultures also cultivated
vineyards in many of their colonies. After the fall of the
Roman Empire, monasteries in Germany, France, Austria,
and Italy continued to cultivate grapes and even hybridized
new species.
Wines are usually made from grapes, though some are fer-
mented from berries, other fruits (e.g., peaches, pears, and
plums), or starchy grains (e.g., sake rice wine). Generally,
grapes with a high sugar content are preferred. A disease-
resistant hybrid of Vitas vinifera grafted onto several
American species was heavily planted worldwide particu-
larly in the temperate climates of France, Italy, Spain,
Argentina, California, and New York. Wine had a short shelf
life until the 1860s, when Louis Pasteur discovered that
heating it would halt microbial activity and keep the wine
from turning into vinegar (pasteurization).
This vineyard is near Yountvillein the Napa Valley of California, the
most famous wine-growingregionin the United States. Though
serious viniculture started in the 1960s, it was not until 1976 at an
international wine exposition that California wines werefinally
recognizedas world-class.Since then other states, including Oregon
and Washington,have developedvineyards comparableto those of
California and Europe.
© 2013 CNSProduct
ions,Inc.
Wine grapes are crushed to extract their juices. Either the
grapes contain their own yeast, or yeast is added and fermen-
tation begins. The kind of wine produced depends on the
variety and the ripeness of the grapes, the quality of the soil,
the climate, the weather, and the balance between acidity
and sugar. White wines typically are aged from six to 12
months, red wines from two to four years.
New World wines (from the Americas, Australia, and New
Zealand) have an alcohol content between 12% and 14%.
European, or Old World, wines contain 8% to 12%. At
higher levels the concentration of alcohol becomes toxic to
the fermenting yeast, thus halting the conversion of sugar
into alcohol. Recently, new fermentation techniques and
more-resistant yeasts have allowed alcohol concentrations to
reach 16% and higher.
Before the development of new fermentation techniques,
wines with an alcohol content higher than 14% were classi-
fied as fortified wines because they had pure alcohol or
brandy added during or after fermentation; their final alco-
hol content is 17% to 21 %. Wine coolers contain wine
diluted with juice and contain an average of 6% alcohol.
Hard cider is made from fermented apples, so it should tech-
nically be classified as a wine; most cider has an alcohol con-
tent between 7% and 13%.
DistilledSpirits(liquor)
Outside Asia, drinks with greater than 14% alcohol were not
available until around A.O. 800, when the Arabs discovered
distillation. Distillation is the process of separating liquid
through evaporation and condensation. A liquid can be
 Downers
: Alcohol 5.7

Consumption of Beer,Wine,andDistilled byCountry

Liquor
2
litersofi>ure
alcohol
i>erca1>ita)
___ _

COUNTRY BEER WINE LIQUOR BOOnEG OTHER TOTAL

Russia 3.65 0.10 6.88 4.73 0.34 15.76
SouthKorea 2.14 0.06 9.57 3.00 0.04 14.80
Ireland 7.04 2.75 2.51 1.00 1.51 14.41
France 2.31 8.41 2.62 0.35 0.17 13.66
UnitedKingdom 4.93 3.53 2.91 1.70 0.67 13.37
Germany 6.22 3.15 2.30 1.00 0.00 12.81
Italy 1.73 6.38 0.42 2.35 0.00 10.68
Canada 4.10 1.50 2.10 2.00 0.00 9.77
The highest rates of drinking are
UnitedStates 4.47 1.36 2.65 1.00 0.00 9.44 found in eastern Europe, Russia, and
Mexico 3.96 0.02 1.09 3.40 0.03 8.42 otherJanner members of the Soviet
Union. Islamic countries do not allow
Japan 1.72 0.29 3.37 0.20 2.61 8.03
alcohol. The United States, Mexico,
Cameroon 2.05 0.05 0.00 2.60 2.60 7.57 and Canada have similar rates of
Peru 2.16 0.32 0.61 4.00 0.00 6.90 consumptionand preferencesfor beer
Drinkers in South Korea and Russia

I
SaudiArabia 0.00 0.00 0.05 0.20 0.00 0.25 prefer hard liquor
Afghanistan 0.00 0.00 0.00 0.02 0.00 0.02 World Health Organization,2014

separated from solid particles or from another liquid with a
different boiling point. This process eventually led to the
production of distilled spirits such as brandy, rum, whiskey,
gin, and vodka.
Brandy is distilled from wine, rum from sugarcane or
molasses, whiskey and gin from grains, and vodka from
potatoes . Distilled spirits are produced from many other
plants, including figs and dates in the Middle East and agave
plants in Mexico (to make mescal and tequila).
The advent of distillation and the abundance of higher-proof
beverages made it easier to get drunk. Initially, distilled alco-
hol was used primarily for medical purposes. The desire for
excise tax revenues fueled an increase in the distillation
and the sale of potent spirits and led to an explosion of
alcoholism .
Alcoholism was a major social problem in colonial America
due to increased manufacture of corn whiskey and rum.
Grains and other sugar-producing plants were reduced in
volume into more-potent, exportable, and higher-priced
commodities. Rum was so popular that the second publicly
funded building in New Amsterdam (New York) was a rum
distillery built on Staten Island in 1664.
Average alcohol content:
beer 4-7%
wine 12-16%
liquors and whiskies 40-55%
Other Alcoholic Beverages
In addition to beer, wine, and hard liquors, a number of
other alcoholic beverages have been created to offer a variety
of tastes and to increase sales. Infused drinks that combine
alcohol with the taste of herbs and vegetables are available,
as are high-potency drinks that encourage young people to
drink more and allow them to get drunk more quickly (a
common goal of many young people), which are far more
popular.
Boilermakers (hard liquor and beer), ''.JagerBombs" (a shot
of Jiigermeister ® dropped into a mug of beer and chuga-
lugged), and "flamers" such as a "flaming Dr. Pepper" (ama-
retto and 151-proof rum lit, dropped into a beer, and then
chugged; tastes like a Dr. Pepper ®) are extremely popular in
certain circles. Dropping liquor into beer results in an effer-
vescence of the two liquids in the stomach that masks the
strong nasty taste of the drink and may increase its absorp-
tion, resulting in a quicker and more powerful effect. This is
also accomplished by adding a small amount of soda (e.g.,
7-Up®) to a shot of liquor (e.g., bourbon) in a sturdy glass
then covering it with one's palm and slamming it on the
table. One then chugalugs the bubbly drink. This is called
"slamming" or "popping."
Jell-0 ® shots, made with one part alcohol, two parts water,
and flavoredJell-O ®mix, are a party favorite . Depending on
the mixer, 1 to 4 cubes are the equivalent of one standard
drink. A "brass monkey" combines 10 oz. of orange juice
with 30 oz. of malt liquor in a 40 oz. bottle.
AlcoholicEnergyDrinks
When alcohol is added to an energy drink, either premixed
by the distiller or by a bartender, a form of speedball is cre-
ated (combining an upper and a downer). Twenty-three
ounces of an alcohol-laced energy drink contains almost as
much alcohol as a six-pack of beer, but the inebriating
effects are masked by the caffeine, creating a false sense of
sobriety, which increases the drinker's risk of a traffic
 5.8 CHAPTER5

In response to threats of FDA action and outright bans in a

number of states, the makers of products like Four Loko, ®
WINE Sparks,® and Bud Extra® removed the caffeine. To promote
Unfortified
(red,white) 12%-16% the idea of energy drinks as mixers, many bars created energy
Fortified
(sherry,port) 17%-22% drink cocktail sections in their establishments, where drinks
like "Red Bull Wings" (Red Bull®and vodka) are served .
Champagne 12%
Vermouth 18%
Winecooler 6%
Hardcider 7%-13%

BEER
Lager(e.g.,Budwe
iser,®Coors
®) 4%-5% Absorptionand Distribution
Pilsner 3%-6%
Porter 4%-6% Alcohol is absorbed into the bloodstream, partially metabo-
Ale 5%-6% lized by the liver (first-pass metabolism), and then quickly
IPA(Indiapaleale) 6%-7%
distributed throughout the body. The absorption of alcohol
into the bloodstream takes place at various sites along the
Maltliquor 6%-9%
gastrointestinal tract, including the stomach (mostly in

I
Stout 5%-100/o men), the small intestine, and the colon . Because alcohol
Icebeer 5%--6% molecules are small and soluble in both water and fat, most
Lightbeer 3.4o/o-4.2% alcohol enters the capillaries in the walls of the small intes-
tine through passive diffusion (movement from an area of
Low-alcohol
beer 1.5%
higher concentration of alcohol to an area of lower concen-
Nonalcoholic
beer(e.g.,O'Doul's) Oo/o--0.5% tration), moving easily to any organ or tissue. If the drinker
is pregnant, the alcohol will cross the placental barrier into
MALTBEVERAGES the fetal circulatory system. Once alcohol crosses the blood-
brain barrier, psychoactive effects begin.
Hardlemonade,
Bawdi®Silver,Smirnoff
®Ice 5%-6%
How quickly the effects are felt is determined by the rate of
absorption. Absorption is influenced by an individual's
LIQUORS
ANDWHISKEYS
weight and body fat, body chemistry, and factors such as
German
Schnapps 20%-40o/o emotional state (e .g., fear, stress, fatigue, or anger), health
Whiskey,
Scotch,
vodka,brandy,rum 40o/o-55% status, and the temperature of the environment .
Gin 40%-50o/o
Bourbon 51%-79o/o
Overproof
rum
Tequila,
cognac,
Drambuie
®
75%
40o/o Nii@@+ + Alcoholdehydrogenase

Amaretto,
®Kahlua
Absinthe
® 26%
55-90o/o
f§@HM + Acetaldehyde
dehydrogenase

Eve
rclear® 95%
Jagermeister
® 35%
Liqueurs 17%-26%
Metabolismof Alcohol Carbondioxide
pluswaterandenergy
Varioussources

accident, agitated behavior, and a host of other alcohol-

related consequences. 19
The promotion of and the advertising for premixed flavored
energy drink/alcoholic beverages (6% alcohol) in colorful
12-, 16-, and 24-ounce cans (the equivalent of one or
two beers) are aimed at young people . In 2010 the U.S.
Food and Drug Administration (FDA), alarmed by several
deaths attributed to the product, warned that the caffeine
that was added to these alcoholic beverages was an "unsafe
food additive."
Metabolismis accomplishedin severalstages involving oxidation.First
the enzyme alcoholdehydrogenase(ADH),found in the stomach and the
liver,acts on the ethyl alcohol (C,H,OH)toform acetaldehyde(CH,CHO),
a highly toxic substance.Acetaldehydeis then quickly alteredby a
secondenzyme, acetaldehyde dehydrogenase(ALDH), which oxidizes it
into aceticacid (CH,OOH).Acetic acid is further oxidized to carbon
dioxide (CO,)and water (Hp).
© 2013 CNSProductions, Inc.

Other factors that speed absorption in both men and women
include:
• increasing the quantity consumed or the drinking rate
• drinking on an empty stomach
• using high alcohol concentrations, such as Everclear®
(95% ABV) in drinks
• using carbonated drinks, such as Champagne, sparkling
wines, soft drinks, and tonic as mixers
• warming the alcohol (e.g., hot toddies and hot sake)
Factors that slow absorption include:
• eating before or while drinking (especially meat, milk,
cheese, and fatty foods)
• diluting drinks with ice, water, or juice
Absorption of alcohol is greatly sped up if the alcohol is
inhaled instead of drunk, in a technique called "vaping."
This method has recently become popular, just as vaping
marijuana or vaping nicotine in e-cigarettes has come into
vogue. Electronic alcohol vaporizing devices like the
Vaportini® are purchased online or in "head shops." The
machine converts liquid alcohol into vapor so that it can be
inhaled, resulting in more-immediate and more-powerful
effects. Some merely pour liquor over dry ice in a vacuum
flask such as a Thermos ® and inhale the vapors through a
straw for the same effect.
Women register higher blood alcohol concentrations
(BACs) than men from the same amount of alcohol because
they absorb 30% more alcohol into the bloodstream than do
men of the same weight; women feel its psychoactive effects
faster and more intensely 20-21Women react differently as the
result of three other factors:
• Women have a lower percentage of body water than do
men of comparable size, so there is less water to dilute
the alcohol.
• Women have less of the alcohol dehydrogenase enzyme
in their stomach , which is necessary to break down al-
cohol, so less alcohol is metabolized before entering the
bloodstream .
The Vaportini'"vaporizes alcohol so it can be inhaled. The average
price of the kit is $45.00.
Courtesyof Vaportini Inc.
Downers:Alcohol 5.9
• Changes in gonadal hormone levels during menstruation
affect the rate of alcohol metabolism. Women absorb
more alcohol during their premenstrual period than at
other times. 22-' 3
Women registerhigher blood-alcohol
concentrations(BACs)than men do from
the same amount of alcohol,so they suffer
greater physicaldamagethan do men
for the same amount of alcohol.
For these reasons chronic alcohol use causes greater physi-
cal damage to women than to men- female alcoholics have
death rates 50% to 100% higher than those of male alcohol-
ics .8.24.25
A recent German study put the death rate for alco-
hol-dependent women at 4.6 times that for the general pop-
ulation ; it is 1.9 times greater for alcohol-dependent men. 26
Metabolism
I
The body treats alcohol as a toxin or poison, so elimination
begins as soon as it is ingested . Approximately 2% to 10% of
the alcohol is eliminated directly without being metabolized
(a small amount is exhaled, while additional amounts are
excreted through sweat, saliva, and urine). The remaining
90% to 98% of alcohol is neutralized through metabolism
(mainly oxidation) by the liver and then by excretion
through the kidneys and the lungs. 27
Alcohol is metabolized in the liver, first by alcohol dehydro-
genase (ADH) into acetaldehyde, which is very toxic to the
body and especially to the liver. Then the acetaldehyde is
metabolized by acetaldehyde dehydrogenase (ALDH) into
acetic acid, which is finally oxidized into carbon dioxide
(CO,) and water (H,O) (Figure 5-2). The varying availabil-
ity and the metabolic efficiency of ADH and ALDH, due in
part to hereditary factors, account for some of the variation
in people's reactions to alcohol. 28·29·30
For example , there is speculation that the high rate of alco-
holism and cirrhosis of the liver in many Native Americans
is due to disruptions in the ALDH and ADH systems as well
as a tradition of binge-drinking pattems. 30 Asians have a
shortage of ALDH2, which normally breaks down acetalde-
hyde , so after just a few drinks, flushing occurs caused by
the dilation of capillaries . This reaction is found in about
50% of the Asian population.
"We9et drunkand we havefun. We havea 900d time. That's
what we'reabout.And I'm health~.I'm in bettershapethan
an~of~ou9u~s,wellma~benot on the inside.M~ stomach's
kindofmessedup a littlebit. I can'tdrinkliquorthat9ood."
25-y ear-old male alco hol abuser
BloodAlcoholConcentration(BAC)
Although alcohol is absorbed at different rates, metabolism
occurs at a relatively specific continuous rate . About 1 oz. of
pure alcohol (1.5 drinks) is eliminated from the body every
three hours, so it is easy to estimate the amount of alcohol
 5.10 CHAPTER5
circulating through the body and the brain to determine how
long it will take for a given amount to be metabolized and
eliminated . Heredity does play a role in each person's bio-
chemical makeup and can have a strong effect on metabolism
and elimination . The actual reaction and level of impairment
varies widely and depends on a person's drinking history,
behavioral tolerance, mood, age, and a dozen other factors.
The only sure way to avoid a driving-under-the-influence
(DUI) arrest is to have no alcohol if one is going to drive .
Physical impairment increases as BAC rises. From the
moment of ingestion, it takes 15 to 20 minutes for alcohol to
travel via the intestines to the brain and begin to cause
impairment . It takes 30 to 90 minutes after ingestion to
reach maximum blood alcohol concentration .22
Alcohol is metabolized at a
steadyrate for most people,
one ounce everythree hours.
I
The BAC table (Table 5-3) is a measure of the concentration of
alcohol in an average drinker's blood. (Other versions ofBAC
tables show slightly lower levels, but the differences are mini-
mal.) Every state defines legal intoxication as 0.08 regardless
of the driver's ability to function. Many states have stricter
limits or zero tolerance for drivers under 21 years old. For
truck drivers the legal limit is 0.04; for pilots it is 0.02 .
The unit of measurement for BAC is weight by volume (e .g.,
milligrams [mg] per deciliter [dL]). Most European coun-
tries set the limit at 0.05 for driving . England allows 0.04,
Japan's and Russia 's limits are 0.03, and Norway's is 0 .01. In
some countries, such as Hungary, Saudi Arabia, Brazil, and
Romania, there is no permissible BAC level (zero tolerance).
The United States is far more dependent on automobiles
than are other countries, which could be the reason why we
are more tolerant of impaired driving.
If an "average" 200 lb. male consumes five drinks in two
hours, his blood alcohol is 0.108 minus the timetable factor
of 0.030, so his BAC is about 0.078 and he is legally sober
enough to drive. If an "average" 200 lb. female consumes five
drinks in two hours, her blood alcohol level is 0 .126 minus
DrinkEquivalency
l ½oz l ½ oz
l ½oz Liquor Liquor 12 oz 7 ozmalt 5 oz
Brandy with mixer straight Beer Liquor Wine
the timetable factor of 0.030, so her BAC is 0.096 and she is
considered legally impaired in all 50 states even though she
weighs the same and consumed the same amount of alcohol
over the same period of time as the male.
"Currentlq, the AmericanMedicalAssociationhasa resolution
proposingthe levelof impairment shouldbe loweredto 0. 04,
halfthe legallevelin all states.Theq believethat a person's
levelof impairment occursat 0. 04 for everqsignificantfunction
necessarq to drivea vehicle."
Bob, drug counselor, Addictions Recovery Center, Medford, OR
"A lot of the drinkingwassocial,needingit to be socialto
instigateconversations,
to be a fun person,be a funnqperson,
be a confidentperson."
38-year-old recovering female alcohol abuse r
'The pleasurethen that I likedwasjustgettinghigh,
justgettinghigh,just feelinglikeotherpeoplefeel.
Like,I don't knowif qoucallthis, 'feelinghuman,'I guess."
40 -year-old female recovering alcoholic
"I reallqenjoqeddrinking.I reallqdid. And I haven'tfound
anqthing,actuallqI haven'tlookedverqhardbut I just
haven'tfoundanqthingthat I enjoqas much."
65-year-old male drinker
"Escapefromrealitqand blockingmqemotions ...numbing
mqselffromall the problemsI had.That waswhat made
alcoholmq treatmentof choice."
35-year-old male recovering alcoholic
"Ijust drank.It wasn'twhetherI wantedto or not.
It wasautomatic...for18 qears."
39-year-old male recovering alcoholic
One drink is defined as 1.5 oz. brandy, 1.5 oz.
liquor,12 oz. lager beer,7 oz. malt liquor,5 oz.
wine, or 10 oz. wine cooler There is slightly
more than 0.5 oz. of pure alcohol in the average
alcoholicbeverage.
© iStockphoto.com/Serghei
Platonov,/>Jexey
Lysenko,Sean
10oz Bolt,Julian Rovagnati,Sergei Didok,TracyHebden
Wine cooler
 Downers: Alcohol 5.11

Approximate
BloodAlcoholConcentration
(mg/dl)for DifferentBodyWeights
No.of Drinks 1 2 3 4 5 6 7 8 9 10
Alcohol ismetabolized
at a rate
MEN of 0.015m&'dlperhour.
100lbs. 0.043 0.087 0.130 0.174 0.217 0.261 0.304 0.348 0.391 0.435 TIMETABLE
FACTORS
125lbs. 0.034 0.069 0.103 0.139 0.173 0.209 0.242 0.287 0.312 0.346 Hourssince Subtract
fromblood
150lbs. 0.029 0.058 0.087 0.116 0.145 0.174 0.203 0.232 0.261 0.290 fimdrink alcohol
concentration

175lbs. 0.025 0.050 0.G75 0.100 0.125 0.150 0.175 0.200 0.225 0.250 1 hour -0.015

200 lbs. 0.022 0.043 0.065 0.087 0.108 0.130 0.152 0.174 0.195 0.217 2 hours -0.030

225 lbs. 0.019 0.039 0.058 0.G78 0.097 0.117 0.136 0.156 0.175 0.195 3 hours -0.045

250 lbs. 0.017 0.035 0.052 0.070 0.087 0.105 0.122 0.139 0.156 0.173 4 hours -0.060
5 hours -0,075
WOMEN
100lbs. 0.050 0.101 0.152 0.203 0.253 0.304 0.355 0.406 0.456 0.507 O'Brien & Chafetz, 1991

125lbs. 0.D40 0.080 0.120 0.162 0.202 0.244 0.282 0.324 0.364 0.404
150lbs. 0.034 0.068 0.101 0.135 0.169 0.203 0.237 0.271 0.304 0.338
175lbs. 0.029 0.058 0.087 0.117 0.146 0.175 0.204 0.233 0.262 0.292
200 lbs.

I
0.026 0.050 0.076 0.101 0.126 0.152 0.177 0.203 0.227 0.253

Levelsof Use Habituation (establishedpatternof usewith

no major negativeconsequences)
Any substance can be a poison, a powerful drug, or a medi-
cation, depending on the dose and the frequency of use. "Usual/~afterwork,what I do is comehomeand takem~
Alcohol is no exception, and, as with other psychoactive uniformoff and get into m~civilianclothesand go out back
drugs, there are escalating patterns of use. and start drinkingbeerand smokingcigarettesand pla~ing
darts.And I do it ever~da~."
Abstention (nonuse) 56-year-old drinker

"M~brotherexperimented with PuertoRican rumon

NewYear'sEvewhenhe was 15. He threwup all overme
on the wa~to the toilet.That tookcareof his drinking
for five~earsand mineforever."
54-year-old nondrinker
Experimentation (use for curiositywith no subsequent
drug-seekingbehavior)
Abuse (continued use despite negative consequences)
"/ didn't drinkever~da~. I wasa bingedrinker.But when I
drank,I drankand it causedproblems.And I didn't knowit
wasa disease.I just thoughtit wassomethingI couldn'tdo.
I can remembersittingat a barone time, lookingat a glass
and thinking,Wow, this isjust anotherthing I can't do."
32-year-old in treatment

"/ wasat a part~a da~ beforem~ birthda~,and we wasdrinking

Bacardi®151and I didn't reall~likeit but I just drunkit an~-
wa~'causethat's all therewasto drinkthere.And I got drunk,
reall~drunkand startedactingstupid."
17-year-old drinker
Social/Recreational Use (sporadic infrequent
drug-seeking behavior with no established pattern)
Addiction (compulsion to use, inabilityto stop use,
major life dysfunction with continued use)
"I had no stoppingpoint. I wouldstop at a liquorstorewhen
I got off workor takealcoholfromm~job. And I wasusuall~
intoxicatedb~ the time I got home. I didn't havea reason..
I didn't needa reasonto drink.It waswhat I did."
33-year -old female recovering alcoholic

"Weknowwhichdormhas the drinkers,so whenwe feellikea bit
of a part~and a few drinks,that's wherewego. The~'remore
seriousabout theirdrinking;the~likefortiesL40 oz. malt liquor
bottlesor cans], but I can takeit or leaveit."
20-year-old college sophomore
The effects of alcoho l depend on the amount ingested, the
frequency of use, and the duration of use .
• Low-to-moderate-dose use can occur with experimenta-
tion, social/recreational use, and even habituation.
• High-dose use can occur at any level of drinking.
 5.12 CHAPTER5
• Chronic high-dose use occurs with abuse and addiction
(alcoholism).
According to the National Institute on Alcohol Abuse and
Alcoholism (NIAAA), low-risk drinking limits, which usually
avoid health problems, abuse, or alcoholism , are defined as:
• for men und er the age of 65, no more than 4 drinks in
one day occasionally but no more than 14 per week
• for nonpregnant women under the age of 65, no more
than 3 drinks in one day occasionally but no more than
7 per week
• for health y men and women over age 65, no more than
3 drinks on any day or 7 per week
Society's attitude toward an acceptable level of drinking is
often reflected in popular culture.
"Science confirmsJames Bond is an alcoholic."
Time magazine, December 12, 2013
Thanks to an exhaustive study by three British scientists of
I
Ian Fleming's 14 James Bond novels , we now know that the
fictional 007 averaged 92 drinks per week (more than 13 per
day) , more than six times the recommended weekly amount.
According to the research:
"JamesBond'slevelof alcoholintakeputs him at hi9h riskof
multiplealcohol-relateddiseasesand an earlqdeath. The level
of functionin9as displaqedin the booksis inconsistent with the
phqsical,mental,and indeedsexualfunctionin9expectedfrom
someonedrinkin9this muchalcohol.We advise an immediate
referralfor furtherassessmentand treatment."
J ohnson, G., Guha, I. N. & Davies, r (2013)
Low-to-Moderate-DoseEpisodes
Generally, small amounts of alcohol and infrequent mild
intoxication episodes have few negative health conse-
quences for men , even over extended periods of time; how-
ever, even low-level alcohol use is not safe for people who:
• are pregnant
• have certain pre-existing physical or mental health
problems that are aggravated by alcohol
• are allergic to alcohol, nitrosamines, or other congeners
and additives
• have a high genetidenvironmental susceptibility
addiction
• are genetically at risk for breast cancer
• are taking other medications that may negatively inter-
act with alcohol
• have a history of abuse and addiction problems with
alcohol or other drugs
"One drinkis too manqand a hundredare not enou9h!"
Alcoholics Anonymous saying
The term moderate drinking can be defined in many different
ways. The authors ' definition is drinking without causing
problems for the drinker or for those around them . The
NIAAA defines moderate drinking as: "Alcohol use of up to
two drinks per day for men and one drink per day for
women and older people . These levels cause few if any
problems and have a low risk of leading to alcoholism ."
Low-to-Moderate-DoseUse: PhysicalEffects
Therapeutic Uses Alcohol is used as a solvent for other medi-
cations because it is water- and lipid-soluble. It is also used
as a topical disinfectant, as a body rub to reduce fever , and
as a pain reliever for certain nerve-related pain; it is occa-
sionally used to prevent premature labor.31Medically, etha-
nol is used to treat methanol and ethylene glycol poisoning .
Desired Effects Some people drink alcohol because it tastes
good, quenches thirst, and relaxes muscle tension . Con-
sumed in low doses before meals, alcohol activates gastric
juices , improves stomach motility, and stimulates the appe-
tite. The feeling of warmth generated by alcohol is due to the
dilation of blood vessels that increases blood flow to subcuta-
neous tissues. Red wines made from muscadine grapes and
other varieties high in antioxidants have an anti-inflammatory
effect on the circulatory system." In one of many studies,
light-to-moderate use of alcohol (1 to 2 drinks per day for
men and 1 or less for women33 has been shown to reduce the
incidence of heart disease and plaque formation du e to the:
• anti-inflammatory effect
• increase in high-den sity lipoproteins (HDl..s),
particularl y HDL3
• creation of a different int eraction with lipoprot eins
• lowering of stress
"I visitedmq9randadin a nursin9 home whenhe was in his nine-
ties, and I remember seein9 a closetfull of bottles of alcohol;
manqof the patientshad their own bottle withan attached
recipeof one or two drinksa daq. It wassi9nificantlq cheaper
than a sedative or sleepin9pill, and at that low pattern of use,
therewere few unwanted sideeffects."
William E. Cohen , author
Any of the beneficial effects gained from alcohol use are tied
to doses low enough to avoid liver damage , inducing other
adverse health effects, or triggering heavier drinking . The
same beneficial effects from low to moderate use can be
achieved through exercise, a low-fat diet, stress-reduction
techniques, and a daily aspirin . (Upon autopsy many end -
to
stage alcoholics have clean blood vessels, but they also have
cirrhotic livers, flabby hearts , and damaged brains .)
One or two drink s per day decrease the chance of gallstones
in men and women. Postmenopausal women who drink in
moderation have a high er bone mass than those who don 't
drink, indicating that alcohol slows bone loss becaus e of its
effect on estrogen.34 •35
Researchers at Columbia University studied 677 stroke vic-
tims and found that those who have one or two drinks per
day have a lower risk of stroke because alcohol keeps blood
 Downers: Alcohol 5.13

MAY
I !?[COMMEND
nusSPLENDID
RJU.-BOD!(D
MERLO!"?

© Jim Borgman,Cincinnat i Enquirer.

Reprintedby permission of UniversalUClick.
All rights reserved

platelets from clumping. 36 These findings do not imply an
advocacy of alcohol use as a stroke prevention measure
because heavy drinking actually increases the risk of stroke.
The findings do not recommend that those who abstain alto-
gether should drink moderately, because they would gain no
benefi t.
Sleep Alcohol is often used as a sleep aid, particularly if
anxiety is causing insomnia. Alcohol actually does decrease
th e time it takes to fall asleep , but it disturbs the second half
of the sleep cycle especially if consumed within an hour of
bedtime .37 It interferes with rapid eye movement (REM)
and dreaming-both essential to waking fully rested.
Disturbanc es in sleep patterns can also decrease daytime
alertness and impair performance. 38 •39 Chronic drinkers have
a higher risk of experiencing obstructive sleep apnea (upper
breathing passage or pharynx narrows or closes during
sleep). This causes awakenings a number of times during a
sleep period, leading to severe fatigue and causing neuro-
logical and cardiac problems. Alcoholics who have sleep
apnea aggravate the disease by drinking .40
I
Low-to-Moderate -Dose Use:
PsychologicalEffects
The mental and emotional effects of low to moderate use
depend on th e environment (setting) where alcohol is
consumed along with the mood and the general psychologi-
cal makeup of the user (set) . In general, alcohol affects
people psychologically by lowering inhibitions, increasing
self-confidence, and promoting sociability. It calms, relaxes ,
sedates, and reduces tension .
"/ could be moreextrovertedand outgoingwithalcohol
whereas I alwa~sfelt moresh~and introverted
, and alcohol
allowedme to be loud, boisterous
, opinionated
, and I didn't
haveto be held accountable."
46-year-old male recovering alcoholic
For someone who is lonely, depressed , bored , angry, or sui-
cidal, the depressant and disinhibiting effects of alcohol
can deepen negative emotions, causing verbal or physical
aggressiveness and even violence . Low to moderate doses in

MISTER BOFFO by Joe Martin

JU$T ONCE!-JU$TONCE
f!;"l)~ uNCl-i.AIZ II? L.11<:'.E
10 TAKE.
ON -IJ.ji,: CDNCE-P"T"" 11-11!5
1EST €CJBEK'!
l'~ .Sij)W'c.M
!!

© 1995 Joe Martin,lnc.DistributedbyNeatlyChiseled Features. Reprintedbypermission

.
 5.14 CHAPTER5

both men and women can also result in vehicular accidents In addition, alcohol reduces excitatory neurotransmission
and legal conflicts. at the NMDA receptors (a subtype of glutamate receptors),
inhibiting their reactions and affecting memory and
Disinhibition can promote high-risk sexual activity, which
movement. 46
presents the potential for unwanted pregnancies and sexu-
ally transmitted diseases (STDs).
"I alwaqshad to usealcoholto be ableto socialize.If I wentto
a partqand didn't drink,I wouldn'tbe ableto function.I felt
"WhenI used,mq behaviorwasreallqdan9erous.I'd do thin9s
likeI couldn'tdanceri9htor everqbodq waslookin9at me;it
that normalpeoplewouldn'tdo. I wasverqpromiscuous; I had
wasjust reallquncomfortable.One or two drinks,that'dloosen
a lot of unsafesex. I contractedhepatitisC. I don't knowif I'm
me up and then I'd keep9oin9'ti/ I sat to a levelthat I wanted
HIV-positive. I 9et testedperiodicallq
but I'm, like,verqhi9h
to be at, whereI thou9htthat I wasacceptable."
risk.I'vealsohad numerous5TDs."
43-year-old recovering alcoholic
37-year-old female recovering alcoholic

Low-to-Moderate-Dose Use: Sexual Effects

NeurotransmittersAffected by Alcohol
The physical effects of alcohol on sexual functioning are
The psychological effects of alcohol are caused by its alter-
closely related to blood alcohol levels. Initially, low doses of
ation of neurochemistry in the higher centers of the cortex
alcohol usually increase desire in males and females, often
(new brain) that control reasoning and judgment and the
heightening the intensity of orgasm in females while
lower centers of the limbic system (old brain) that rule
slightly decreasing erectile ability and delaying ejaculation
mood, emotion, and craving . Most psychoactive drugs affect

I
just a few types of receptors or neurotransmitters (e.g., anan-
damide for marijuana; norepinephrine, epinephrine, and
dopamine for cocaine). Alcohol, on the other hand, interacts
with multiple receptors, neurotransmitters, cell membranes,
intracellular signaling enzymes, and even genes.
GABA (an inhibitory neurotransmitter) is
the most important chemical affected by
alcohol. Alcohol enhances GABA neurotrans-
mission at the GABA receptors, which turns
off emotional inhibitions and eventually slows
down all brain processes. 41 •42
Serotonin initially elevates mood, and then
alcohol depletes those neurotransmitters as
drinking escalates. Serotonin depletion causes
depression.
Dopamine gives a surge of well-being in the
survival pathway as does norepinephrine.
Dopamine Dl, D2, and, to a lesser extent, D3
receptors are involved. 41 •43 •44
in males .23
"It'sno mqsterqwhq9uqsin colle9efraternities,
manqof
whomdon't haveall that muchmoneq,stillcomeup with
plentqof moneqto haveoutra9eousamountsof alcoholon
handand let anq womandrinkfor free.The wholepointis
theq'resettin9up an environment
wherebqpeopleare9oin9
to 9et drunker.Women'sinhibitions
and a 9uq'sinhibitions
are9oin9to 9et lowered."
Jackson Katz, college peer counselor
More than any other psychoactive drug, alcohol has insinu-
ated itself into the lore, culture, and mythology of sexual and
romantic behavior: "Jager Bombs" downed at a singles' bar to
look for a hookup, a glass of wine and candlelight before sex,
or Champagne to celebrate an anniversary. A survey of
90,000 college students at two- and four-year institutions
found that more than half the students believe that alcohol
facilitates sexual opportunities." Whether that is true
because of actual psychological and physiological changes or
because of heightened expectations is still open to question.

"We[9irls]don't drinkto havesex.Theq drinkto havefun. It

Met-enkephalin reduces pain and stress.
Glutamate intensifies the effects of dopamine
and enhances a certain pleasurable stimula-
tion, thus reinforcing the drinking.
Endorphins and anandamides enhance the
reinforcing effect of alcohol. 45
is easierto openup and talkto 9uqsa~era drink,especiallqif
qouarekindof shqand not usedto the wholepartqatmosphere
thin9that sprin9sup everqFridaqni9ht.Sometimesit leadsto
sex- sometimesnot."
22-year-old female grad student
High-DoseEpisodes
High-Dose Use: PhysicalEffects
Intoxication is the result of a combination of psychological
mood, expectation, mental/physical tolerance, and past
drinking experience as well as the physiological changes
caused by elevated blood alcohol levels. Up to a certain
point, some of the effects of intoxication can be partially

Levelof Impairment
vs. BloodAlcohol
Concentration(mg/dl)
Life-threateningunconscio usness
Difficultyin rousing
Incapacitation, lossof feeling
Confusedspeech
Inability
to walkwithouthelp
Clumsin ess
Hostile, argumentative,and often hostile behavior
Unsteadinessstandingor walking
Further loss of coordination
Impairedabilityto drive
As consumption increases,the amount of alcohol absorbedincreases
and therefore the effects increasebut at different rates, depending on
the phy sical and mental makeup of the drinker.
masked by experienced drinkers (behavioral tolerance). For
some the reason to drink is to become intoxicated, often
with no regard for the physical consequences.
"Onedrau9htaboveheat makeshima fool,the second'mads'
him,and a thirddrownshim."
William Shak espeare, TwelfthNight, Scen e 5
Binge drinking is defined as consuming five or more drinks
at one sitting for males and four or more for females at least
once during the previous two weeks. About 44% of college
students say they are binge drinkers , and 21% (of the total)
say they binge frequently.48 Adults between 21 and 25 went
on drinking binges an average of 18 times in the past year,
while those between 18 and 20 binged 15 times. 49 Underage
binge drinking has increased almost 50% since 1993; about
one-third of twelfth-graders binge-drink or say they have
been drunk. Bingers say that five drinks do not get them
drunk but five does raise their BAC over 0.08, making them
liable for a DUI arrest. In some countries the rates of binge
drinking for 15- to 16-year-olds is higher than in the United
States (e.g., 54% in the United Kingdom, 60% in Denmark);
in other countries , it is lower (e.g., 15% in Turkey; 38% in
Russia, and 35% in Canada).
Heavy drinking is defined as consuming five or more drinks
in one sitting at least five times a month. Any person who
binge-drinks (whether sporadically or frequently) is more
Downers: Alcohol 5.15
likely to suffer hangovers, experience injuries, aggravate
medical conditions, damage propeny, and have trouble with
authorities.
When enough drinks are consumed, the depressant effects
of the alcohol take over ; expectation, setting , and the mood
of the drinker cease to have a strong influence . Blood pres-
sure is lowered, motor reflexes are slowed, digestion and
absorption of nutrients become poor, body heat is lost as
blood vessels dilate, and sexual performance is diminished.
Every system in the body is strongly affected. Slurred speech ,
staggering , loss of balance, and lowered alenness are all phys-
ical signs of an increased state of intoxication (Figure 5-4).
High-DoseUse: Mental and EmotionalEffects
'When a mandrinkswinehe bq;insto bebetterpleasedwith
himself.and the morehe drinksthe morehe is pliedfullof
bravehopes, and conceitof hispower,and at last the strin9
of histon9ueis loosened,and fancqin9himselfwise, he is
brimmin9overwithlawlessness, and has no morefearor
I
respect,and is readqto do or saqanqthin9."
Athenian Stranger in The Laws byPlato, 360 B.C.
High-dose alcohol use depresses most functions of the cen-
tral and peripheral nervous systems, depending on the toler-
ance to alcohol and the physical and mental health of the
drinker. Initial relaxation and lowered inhibitions at low
doses often become mental confusion , mood swings , loss of
judgment, and emotional turbulence at higher doses
(Figure 5-4). At a BAC above 0.12, an experienced drinker
with a high tolerance may not show many effects although
the depressive effects are starting to build , whereas inexperi-
enced drinkers may demonstrate slurred speech and , beyond
that level, progressive mental confusion and loss of emo-
tional control. Heavy alcohol consumption before sleep may
also interfere with REM, or dreaming sleep essential to feel-
ing fully rested. Chronic alcoholics may suffer from fatigue
during the day and insomnia at night as well as nightmares,
bed wetting , and snoring .38 ~ 9 Past a certain point , the physi-
cal depressant effects take over and maintaining muscular
coordination, walking, breathing, heart rate, and con-
sciousness become difficult.
High-DoseUse:AlcoholPoisoning(overdose)
Each year about 724,000 admissions to emergency rooms
(ERs) in the United States are alcohol related. A portion of
the ER visits are due to alcohol poisoning , which occurs
when large amounts of alcohol are consumed too quickly.
The result is depression of the central nervous system
(CNS), leading to unconsciousness, respiratory and car-
diac failure, then coma and death. 117 Some clinicians use a
BAC level of 0.40 as the threshold for alcohol poisoning,
although lower levels can be deadly to novice drinkers.
'We had, like, a couple9allonsof CanadianMist.®and we
mixedthat withSquirt,®and I dranklikea rfth of it. I was
puk,in9up blood,I had, bloodcomin9out mq nose, and I ,,
passedout, and I didnt wakeup for likea daqand a half
32-y ear-old male college student
 5.16 CHAPTER5
When other depressants, including sedative-hypnotics and
opiates, are used along with alcohol, the danger of overdose
is greatly increased because metabolizing alcohol takes prece-
dence over metabolizing other substances, delaying neutral-
ization and elimination of any other drugs and greatly exag-
gerating their toxic effects.
BAC levels as low as 0.20, especially in individuals who have
a low tolerance, can result in severely depr essed respiration
and vomiting while semiconscious. The vomit can be aspi-
rated or swallowed, which can cause infections in the lungs
as well as block air passages to the lungs , resulting in asphyx-
iation and death.
"A freshmandied from alcoholpoisonin9durin9a pled9e
incident,and we have had two otherstudentsdie in the
past 9oin9throu9htheirriteof passa9e-2 1 drinkson their
twentq-rrstbirthdaq.I thinkthere'sa mqth thisa9e9roup
believesthat alcoholis so acceptedthat it is not harmful
and that qou maq9et a han90verbut qou'II wakeup in the
mornin9 , but that'snot alwaqsthe case."
I
Drug and alcohol coun selor, California State University, Chico
High-DoseUse: Blackouts
About one-third of all drinkers report experiencing at least
one blackout; the percentage more than double s for alcohol-
depend ent individuals. 50 During a blackout a person
appears normal and is awake and conscious but afterward
cannot recall anything that was said or done . Caused by
an alcohol-induced electrochemical disruption of the
brain , blackouts are different from passing out or losing con-
sciousness during a drinking episode and are often early
indic ations of alcoholism. Sometimes even a small amount
of alcohol may trigger a blackout . If a drinker has only
1 {Jr.;J-JT. 11./rJ1i1VJIY(::.
Night/Morning by Robert Seymour, etched by Shortshanks , c. 1835. Drinkers generally
don't distinguish between hangover and true withdrawal symptom s.
Courtesyof the National Libraryof Medicine, Bethesda, MD
partial recall of events that occurred, they have experi-
enced a brownout.
A possible indicator of susceptibility to blackouts and brown-
outs and therefore a marker for alcoholism can be seen on an
electroencephalogram (EEG). The marker is a dampening of
the P3 or P300 brain wave induced by visual cues that affects
cognition, decision-making , and processing of short-term
memory. This dampening of the P3 wave is often found in
alcoholics and their young sons but generally not in indi-
viduals without a drinking problem .51 •52 Other research found
that auditory P300 amplitude waves are also reduced in alco-
holics , particularly those with anxiety disorders. 53
'With alcoholI wasout of controlbecauseI woulddrinkto
the point whereI didn't knowwhat I wasdoin9, whichmade
it easierfor the man to do whatever he wantedand mq not real-
izin9it untilthe next daq or the next mornin9when I wokeup
and didn't haveanq recollection of what had happened."
32-year-old female recovering binge dri nk er
A blackoutveryearlyin one'sdrinking
careeris a powerfulsignof a susceptibility
to alcoholism.
High-DoseUse: Hangovers
"A realhan9overis nothin9to trq out familqremedieson.
The onlqcurefor a realhan9over is death."
Robert Benchley, humorist
The cause of a hangover is not clearly understood. Additives
(congeners) in alcoholic beverages are thought to be partly
responsible, although even pure alcohol can cause a hang-
over. Irritation of the stomach lining by alco-
hol may contribute to intestinal symptoms.
Low blood sugar, dehydration , vitamin B12
deficiency, and tissue degradation may also
play a part . Symptoms vary from ind ividual to
individual , but it is evident that the greater
the quantity of alcohol consumed, the more
severe the aftereffects.
"A han9over is the wrathof 9rapes."
Anonymous
The most severe effectsof a hangover can occur
many hours after alcohol has been com-
pletely eliminated from the system. Typical
effects often include a headache, nausea, occa-
sional vomiting, sensitivity to light and noise,
thirst, dizziness, mood disturbances , abbrevi-
ated sleep, dry mouth , inability to concentrate,
anxiety; and a general depressed feeling.54
Hangovers occur at any stage of drinking , from
experimentation to addiction . More-severe
withdrawal symptoms are experienced by
chronic high-dose users who have developed
a physical dependence .

Some research shows that those with a high genetic sus-
ceptibility to alcoholism suffer more-severe hangovers and
withdrawal symptoms and often continue drinking to find
relief. 55 •56
High-Dose Use: Sobering Up
A person can control the amount of alcohol in his or her
blood by controlling the amount and the rate at which it is
consumed, but the elimination of ethanol from the system
is a constant (0.25 to 0.33 oz. of pure alcohol per hour).
Until the alcohol has been eliminated and hormones,
enzymes, body fluids, and bodily systems return to equilib-
rium, hangover symptoms will persist. An analgesic may
lessen the headache pain, vitamin B12 may help balance
nutrition, and fruit juice can help hydrate the body and cor-
rect low blood sugar, but neither coffee, nor exercise, nor an
energy drink, nor a cold shower cures a hangover . It takes
rest and sufficient recovery time to feel better.
A hangover can occur at any level of drinking.
More-severe withdrawal symptoms are
experienced when high-dose chronic users
become abstinent.
ChronicHigh-DoseUse
The effects of long-term alcohol abuse on physical health,
neurochemistry, and cellular function are more wide-
ranging and profound than those of most other psychoactive
drugs . Excessive alcohol consumption has a strong associa-
tion with more than 60 types of disease and injury .
"Inthe past qeardue to mq alcoholismand drugaddiction,
I havehad two overdoses.I havebeenin the mentalwardof
the hospital.I haveset mqselfon fire,passedout witha
cigarettein mq hand, and havefallendownall overthe place,
receivingvariousbrokenbones.The last timemq husband
saw me, I was neardeath."
43-year-old female recovering alcoholic
DigestiveSystemand LiverDisease
There has been a decline in alcoholic liver disease over the
past 30 years due to a small decrease in drinking and sig-
nificant advances in medical care. 57
The impact of alcohol on the digestive system is caused by
its direct effects on organs and tissues . Because roughly
80% of all alcohol consumed passes through the liver and
must be metabolized, high-dose and chronic drinking inevi-
tably compromise this crucial organ . If the liver becomes
damaged due to fatty liver, hepatitis, or cirrhosis, its ability
to metabolize alcohol decreases, allowing the alcohol to
travel to other organs in its original toxic form. Even persis-
tent moderate drinking can damage the liver. Fatty liver-
the accumulation of fatty acids in the liver--can occur after
just a few days of heavy drinking . Abstention eliminates
much of the accumulated fat. About 20% of alcoholics and
heavy drinkers develop fatty liver. 58
Downers: Alcohol 5. 17
If a person continues to engage in heavy drinking, the prob-
lems become more severe. In the United States, approxi-
mately 10% to 35% of heavy drinkers develop alcoholic
hepatitis and 10% to 15% develop cirrhosis .59
Alcoholic hepatitis causes inflammation of the liver, areas
of fibrosis (formation of scarlike tissue), necrosis (cell
death), and damaged membranes. Although the diagnosis of
alcoholic hepatitis often follows a prolonged bout of heavy
drinking, it usually takes months or years of heavy drinking
to develop this condition, which is manifested by jaundice,
liver enlargement, tenderness, and pain. It is a serious condi-
tion that can be arrested only by abstinence from alcohol,
and even then the scarring of the liver and the collateral
damage remain. 56 Alcoholic hepatitis is not directly related
to hepatitis A, B, or C. Continued heavy drinking by those
with alcoholic hepatitis leads to cirrhosis in 50% to 80% of
the cases. 60
"Mq husbandand I werealcoholics,but he had cirrhosisofthe
liver,the most horriblethingto die from. He wasthin, swelled
I
up, huge;hisstomachwas the sizeofa nine-month-pregnant
woman,and his coloringwasjust orange."
34 -year-old female practicing alcoholic
Cirrhosis occurs when alcohol (or another disease like
hepatitis C) kills an excessive number of liver cells and
causes scarring. It is the most advanced form of liver disease
caused by drinking and is the leading cause of death among
alcoholics (besides automobile accidents). Approximately
13,000 Americans die each year from cirrhosis due to alco-
hol consumption .61 •63 The damaging effects of alcohol to tis-
sues occur not only because alcohol itself is toxic but because
the metabolic process produces metabolites, such as free
radicals and acetaldehyde, that are even more toxic than the
alcohol itself.' 6 •62 Cirrhosis is even less amenable to treat-
ment and cannot be reversed, although abstinence, diet, and
medications can often arrest the progression of the disease.
"I wassickto mq stomachand I threwup and littledid I know
it but it was blood,so I turnedon the lightand I had a little
garbagecan damn nearfilledup. Therewasan arterqin mq
liverthat had just exploded,I guess,and theqsaid whenthat
happensit's a gusher.And so aftertheqput me out, theqsaid,
'You'vegot cirrhosisverqbad.' Well, theq put me on the trans-
plant list. I didn't knowit at the time, but qou haveto be sober
fora qearbeforetheq'llevenconsidertransplantingqourliver."
65-year-old recovering alcoholic
Over the years liver cirrhosis rates have gone up and down
with the rise and the fall of alcohol consumption. With the
dramatic increase in hepatitis C, however, increased non-
alcohol-related cases of cirrhosis have altered the statistics . It
is estimated that alcoholic cirrhosis is a major contributing
factor in about 50% of all cases of cirrhosis in the United
States. This figure is up from 44% several years ago, but the
actual numbers of alcohol-related cirrhosis remain about the
same .56 •63 The prevalence of cirrhosis in the United States
varies by age, gender, and ethnic group. In one study by the
 5.18 CHAPTER5

Alcohol
UseperCapitain Liters vs.
Cirrhosis
RateJ>er
100,
_
00_0_9 ___ _

COUNTRY ALCOHOL
CONSUMPTION CIRRHOSIS
TOTAL MEN WOMEN
Ireland 14.41 4.4 0.1 6.1
France 13.66 10.1 15.5 10.1
UnitedKingdom 13.37 9.1 12.1 3.6
Germany 12.81 12.9 19.0 5.3
Italy 10.68 9.8 13.5 4.5
Canada 9.77 5.3 7.5 0.8
UnitedStates 9.44 7.3 10.2 9.7

The fatty liver of a moderate to heavy drinker is caused by the Japan 8.03 5.8 9.1 3.9
accumulation of fatty acids. When drinking stops, the fat deposits
usually disappear
Courtesyof BorisRuebner,M.D.
found that the largest increases in consumption were
among developing countries and those in transition, such

I
as the former Soviet bloc countries.

Other DigestiveOrgans
While lower doses of alcohol can aid digestion, moderate to
higher doses stimulate the production of stomach acid,
which delays emptying of the stomach. Excessive amounts
of alcohol can cause acid stomach and diarrhea.

"I wassix hoursinto mq drinkin9;then I wasin the bathroom

Cirrhosis of the liver usually takes 10 or more years of steady
drinking to develop. The toxic effects of alcohol cause scar tissue to
replace healthy tissue. This condition remains permanent even when
drinking stops.
Courtesyof BorisRuebner,M.D.
NIAAA, Hispanic men showed the highest cirrhosis mor-
tality rates, followed by Black men, White men, Hispanic
women, Black women, and White women. A majority of the
Hispanic men in the study were of Mexican ancestry 64 About
two and a half times more men than women of all races die
from cirrhosis (more men drink than women).
The drinking habits of various cultures worldwide have a
strong effect on the incidence of cirrhosis and other alcohol-
related illnesses . In countries with high rates of heavy drink-
ing, such as France and Germany, rates of cirrhosis are
higher than in the United States (Table 5-4). In many coun-
tries, particularly poorer ones , accurate estimates are impos-
sible to obtain due to unreported alcohol production and
consumption. The World Health Organization (WHO)
reports that in Kenya about 80% of alcohol consumption
goes unreported. In Russia one-half to four-fifths of con-
sumption is unreported, and in Slovenia 50% is unreported.'
In comparing the increase in drinking, the WHO report
bq the toiletall ni9htlon9.I couldn'tleave. Everqminute
I wasthrowin9up; and whenI couldn't throwup, I wasdrq
heavin9.And at the end whenI wasn'tthrowin9up anqmore,
I wantedto drinka9ain."
16-year-old female recovering alcoholic
Gastritis (stomach inflammation) is common among heavy
drinkers as are inflammation and irritation of the esophagus,
small intestine, and pancreas (pancreatitis). Inflammation
of the pancreas is often caused by blockage of pancreatic
ducts and overproduction of digestive enzymes. The risk of
cancer and other serious disorders, including ulcers, stom-
ach hemorrhage, and gastrointestinal bleeding, are also
linked to heavy drinking.
Pure alcohol contains about 150 calories per drink but
almost no vitamins, minerals, or proteins. Heavy drinkers
receive half their energy but little nutritional value from
drinking. As a result, alcoholics may suffer from primary
malnutrition, including vitamin B1 deficiency, leading to
beriberi, heart disease, peripheral nerve degeneration,
pellagra, scurvy, and anemia (caused by iron deficiency).
Heavy drinking irritates and inflames the stomach and the
intestines, so alcoholics may suffer from secondary mal-
nutrition (especially from distilled alcohol drinks) as a result
of faulty digestion and absorption of nutrients even if they
eat a well-balanced diet.
Alcohol wreaks havoc with the body's sugar (glucose) supply
Alcohol can cause hypoglycemia (too little sugar) in drink-
ers who are not getting sufficient nutrition and have depleted

their own stores of glucose. When the liver is busy metaboliz-
ing the alcohol, it cannot use other nutrients to manufacture
more glucose. Blood sugar levels can drop precipitously, caus-
ing symptoms of weakness , tremor, sweating, nervousness,
and hunger. If the levels drop too low, coma is possible, par-
ticularly for those with liver damage or for diabetics who are
insulin dependent. If there is sufficient nutrition, alcohol use
can cause the opposite effect-hyperglycemia (too much
sugar)-in susceptible individuals. This condition is of
particular danger to diabetics, who already have problems
controlling their blood sugar because of the disease.59
CardiovascularDisease
Though many headlines tout the positive cardiovascular
effect of light-to-moderate drinking , chronic heavy drinking
is related to a variety of heart diseases, including hyperten-
sion (high blood pressure) and cardiac arrhythmias (abnor-
mal or irregular heart rhythms). Heavy drinking increases
the risk of hypertension by a factor of two or three. 65
Coronary diseases occur in alcohol-dependent people at a
rate up to six times the norm. 48 One form of irregular heart
rhythm-holiday heart syndrome-appears in patients from
Sundays through Tuesdays or around holidays , when a large
amount of alcohol has been consumed. Research shows that
even in moderate drinkers, the incidence of irregular heavy-
drinking episodes negated the protective factor of moderate
alcohol use. 66
Because acetaldehyde, a metabolite of alcohol, directly dam-
ages striated heart muscles , cardiomyopathy-an enlarged,
flabby, and inefficient heart-is found in some chronic heavy
drinkers. The heart of a heavy drinker can be twice the size of
a normal heart. This condition is also known as alcoholic
heart muscle disease (AHMD). Full-blown AHMD is found
in a small percentage (2%) of heavy drinkers, but the great
majority (80%) show some heart muscle abnormalities.
"After30 qearsof drinkin9I havedevelopedmitralvalvepro-
lapse,a heartcondition;fibrilmalaise
, the deterioration
of mq
muscles;I havethe earlqsta9esof osteoporosis;havean ulcer
in mq esopha9us;mq memorqis not aood at this pointof48
daqsofsobrietq.It's hardfor me to makedecisions,and I have
probablqlost 15 qearsof mq naturallifedue to mq alcoholism
and dru9use."
4 7-year-old female recovering alcohol abuser
A Romanian study to determine the cause of a rapid increase
in heart disease found it to be directly related to increased
alcohol consumption (which coincided with decreased alco-
hol taxes and a greater availability of alcoholic beverages). 67
Heavy drinking also increases the risk of stroke and other
intracranial bleeding within 24 hours of a drinking binge. 68
The exact mechanism for many of the cardiovascular prob-
lems is gradually being uncovered.
Alcoholcauseshypertensionand
damagesheart musclesdirectly,making
for an increasedriskof strokeand
heart disease.
Downers:Alcohol 5.19
On the left is a nonnal heart . On the right is the fatty and enlarged
heart of a heavy drinker.
© 2000 CNS Productions, Inc.
I
NervousSystem
Alcohol limits the brain's ability to use glucose and oxygen,
thus killing brain cells as well as inhibiting message trans-
mission. Low to moderate use does not cause permanent
functional loss, but chronic high-dose use causes direct
damage to nerve cells that can have far-reaching conse-
quences in susceptible individuals. Alcohol-induced malnu-
trition , along with the direct toxic effects, can also injure
brain cells and disrupt brain chemistry.
Both physical brain damage and impaired mental abilities
have been linked to advanced alcoholism. Some level of
brain atrophy (loss of brain tissue) has been documented in
50% to 100% of alcoholics at autopsy. Breathing and heart
rate irregularities caused by damage to the brain 's autonomic
nervous system have also been traced to brain atrophy.
Dementia (deterioration of intellectual ability, faulty
memory, disorientation, and diminished problem-solving
ability) is another neurological consequence of prolonged
heavy drinking. One of the more serious diseases due to
brain damage caused by chronic alcoholism and thiamine
(vitamin B1) deficiency is Wemicke 's encephalopathy.
Symptoms include delirium, imbalance, visual problems ,
and impaired ability to coordinate movements, particularly
in the lower extremities (ataxia) .
Korsakoff's syndrome is another serious condition that
involves thiamine deficiency. Its symptoms include disorien-
tation , memory failure, and repetition of false memories
(confabulation). Most alcoholics suffering from Wemicke's
encephalopathy develop KorsakofPs syndrome .69 •70
"Exactlqwhat I haveis calledatrophqof the cerebellum,
whichis the backpart of the brainthat 9oes into qourspinal
cord that has to do with coordinationand balance. Mq
drinkin9forprobablq20 qearshas causedit to shrink."
63-year-old recovering drinker with Wemicke's encephalopthy
 5.20 CHAPTER5
I
Colored magnetic resonance imaging (MRI) scan of the brain of a
patient with alcoholic dementia. The brain has atrophied (shrunk) ,
shown by the enlarged central ventricles (black) and deep
indentations around the brain~ edges. Alcoholic dementia is caused lry
excessive drinking over a prolonged period. It causes memory loss,
confusion , impaired judgment, and personality changes. If caught at
an early stage, the dementia can be reduced or even reversed if the
patient abstains from alcohol and has a healthy diet supplemented
with vitamin Br
Du Cane Medical Imaging LTD/Science Photo Library
More than 2,300 years ago, Greek physician Hippocrates
observed an association between alcohol and seizures, writ-
ing that the prevalence of epilepsy is up to 10 times greater in
those with alcoholism. 7 1 Although the seizures could be the
result of head trauma due to drunkenness or other causes, the
direct damage to neurological systems as well as the adrena-
line storm caused by withdrawal is strongly implicated.
Sexual Desire and the ReproductiveSystem
Females Although light drinking lowers inhibitions, pro-
longed use decreases desire and the intensity of orgasm.
Chronic alcoho l abuse can inh ibit ovu lation, decrease the
gonadal mass, delay menstruation, and cause sexua l dys-
function. 25 Heavy drinking also raises the chances of infertil-
ity and spontaneous abortion. 71 -73
"l£cher~
. sir,it [drink]provokes,
and unprovokes;
it provokes
the
desire, but it takes awa~ the performance. Thereforemuch drink
ma~ be said to be an equivocatorwith lecherr it makeshim and
it mars him; it sets him on and it takes him off"
William Shakespeare , Macbeth
Males Though low to moderate levels of alcoho l can lower
inhibitions and enhance the psycho logica l aspects of sexual
activity, the depressant effects soon take over. Chronic use
causes effects beyond a temporary inability to perform. In
one study of 66 alcoholics, researchers found an erectile dys-
function rate of 71% vs. just 7% for abstainers. 74 Long-term
alcohol abuse impairs gonadal functions and causes a
decrease in testosterone (male hormone) levels, resulting in
an increase in estrogen (a female hormone) that can lead to
male breast enlargement, testicu lar atrophy, low sperm
count, loss of body hair, and loss of sexual desire. When
resuming sexual act ivity, a recovering alcoholic may experi-
ence excessive anxiety; dysfunction can be intensified by one
or two bad performances.
One effect of alcohol abuse that carries over into recovery is
an ina b ility to exper ience normal sexua l relationships
because, before recovery, romance was usually initiated in
bars or at parties where alcohol was readily available.
"/ don't real/~remembermakin9foye with a woman when I was
sober. It wasusua/1~
whenI had a coupleof drink,in meor if I
wasthat far9one,then I wouldprobabl~90 withthe womanor
brin9the womanhome,and I would90 to bedwithher,and I
wouldprobabl~fallasleep."
43-year-old recovering alcoholic
Cancer
Chronic alcohol abuse is listed by the WHO as one of the top
10 risk factors for a host of illnesses, including cancer. In
its report on the state of alcoho l-related cancer research,
Alcohol and Cancer, The Internationa l Agency for Research
on Cancer identifies cancers of the upper digestive tract,
colon, liver, and breast as particu larly vulnerab le, either
directly or through metabolites, including acetaldehyde, and
through epigenetic changes. 75
Breast Cancer The association between heavy drinking
(three or more drinks per day) and b reast cance r is we ll
documented. The evidence connecting drinking small
amounts of alcoho l with the incidence of breast cancer is less
compelling. In one study of 1,200 women with breast cancer,
there was an association between moderate alcohol use and
breast cancer; amounts as low as one drink per day increased
the risk by 50%. Even the briefest use of alcohol was associ-
ated with 25% of the breast cancer subjects studied. 76
Conversely, other research found only small increases in the
incidence of breast cancer due to alcohol use. 77 ,78
Othe r Can cers Th e risk of mou th, th roat, larynx, and esopha -
geal cancer is 6 times greater for heavy alcoho l use rs,
7 times greater for smokers, and an astonishing 38 times
greater for those wh o smoke and drink. 78A Liver cancer
is also a risk for those with long-standing cirrhosis. Some
studies assign different rates of cancer for heavy drinkers. 79
SystemicProblems
Musculoske letal System Alcohol leeches minerals from the
body, which reduces bone density and increases the risk of a
fracture of the femur and femoral head, wrist, vertebrae, and
ribs. Liver disease and malnutrition are also associated with
bone density. The unbalancing of electrolytes decreased by
chronic or acute use, along with direct toxic effects, can
cause myopathy (painful swollen muscles).
 Downers:Alcohol 5.21

Some
Alcohol-Related
Causes
ofDeath
(directlycausedbyalcoho0
DISEASES DISEASES causedbyalcoho0
Ond,rectly INJURIES/ADVERSE
EFFECTS
Alcoho
lic psychoses Tuberculosis Boating
accidents
Alcoho
lism(depende
nce) Cancerof thelips,mouth,andpharynx Motorvehicle,bicycle,otherroadaccide
nts
Alcoho
l abuse Cancerof thelarynx,esophagus,stomac
h,and liver Airplane accidents
Nervedegeneration Diabetes Falls
Heartdisease Hypertens
ion Fireaccidents
Alcoho
lic gastritis Stroke Drowning
Fattyliver Pancreatitis Suicides,self-inflicted
injuries
Hepatit
is Diseases
of stomach,
esophagus,
andduodenum Homicides,
shootings,stabbings
Cirrhosis Cirrhosisof bile tract Choking on food
Other liver damage Domestic
violence
Alcoho
l poisoning or daterapes
Rapes
Seizure
activity

Dermatologic Complications The reddish complexion and making it difficult to concentrate and absorb information

other skin conditions of chronic alcoholics are caused by a
number of factors: the dilation of blood vessels near the
skin, malnutrition, jaundice, thinning of the skin, and liver
problems. One misperception people have is thinking that a
red face-or a big, red, bulbous nose-is directly caused by
alcohol. Rosacea, as it is called , is actually caused by hered-
itary susceptibility, aggravated by sunlight, heat, and envi-
ronmental stress. But it can be triggered and inflamed by
alcohol, especially wine and beer. Other infections and con-
ditions aggravated by the toxic effects of alcohol include
acne, psoriasis, eczema, and facial edema.
Immune System Heavy drinking disrupts white blood cells
and weakens the immune system, resulting in greater sus-
ceptibility to infections. Excessive drinking has been linked
to cancer as well as to infectious diseases such as respiratory
infections, tuberculosis, and pneumonia. This is especially
common if the person is a moderate to heavy smoker .
ChronicHigh-DoseUse:Mental/EmotionalEffects
With chronic high-dose use, almost any mental, emotional,
or psychiatric symptom is possible, including memory
problems, hallucinations, paranoia, severe depression,
insomnia, and intense anxiety. These symptoms, particularly
amnesia and blackouts, become more common as alcohol
abuse progresses. The inability to implement problem-
solving techniques necessary to cope with life is a long-
lasting effect of alcoholism.
"It's likeI'm a 30-~ear-oldwomanstuckwiththese
12-~ear-old issuesand I don't knowwhatto do withthem,
not because I'm not willin9or not because I don't have m~
intellectualmind, but it's what is9oin9 on insideof mq heart
and m~feelin9s, not knowin9what to do withm~feelin9s
and thenjust pushin9it all down."
30- year-old female recovering alcoholic
Alcohol and memory problems go hand-in-hand. Alcohol
damages activity in the frontal lobes and the hippocampus,
I
into the brain. Retrospective and prospective memories are
affected by heavy drinking . Retrospective memory is the
retention and the retrieval of previously presented informa-
tion, whereas prospective memory is the memory function
day to day (pick up the dry cleaning today) and in the near
future (a dentist appointment next week).
Heavy drinking shortens a person 's life span (e.g., 4 years
from alcohol-induced cancer, 4 years from heart disease, and
9 to 22 years from liver disease). 7A.so Heavy drinkers are
likely to die 15 years earlier than the general population. 81
• About 12% of the 145 million adult drinkers in the
United States are alcohol dependent (about 17.7 mil-
lion Americans). 1
• Alcoholism rates in men are approximately two times
greater than in women over 18 years of age (9.9% of
male drinkers vs. 4.6% of female drinkers).
• The onset of alcoholism usually occurs at a younger age
in males than in females.
20% of drinkers consume
80% of all alcohol in the
United States."
Classification
Over the years there have been many attempts to classify
different types of alcoholism. The purpose of classification
is to develop a framework by which an illness or a condi-
tion can be studied systematically rather than relying
strictly on experience.
 5.22 CHAPTER 5

EarlyClassifications • Gamma alcoholics lose control quickly, and their pro-

One of the earliest attempts
at imposing scientific reason-
ing on drinking patterns was
by Dr. Benjamin Rush, phy-
sician, medical educator,
reformer, and the first U.S.
surgeon general. He pub-
lished the first American trea-
tise on alcoholism in 1804-
An Inquiry into the Effects of
Ardent Spirits on the Human
Body and Mind. It was a col-
lection of the prevailing atti-
tudes toward alcohol abuse.
At about the same time, Dr.
Thomas Trotter in An Essay,
Medical, Philosophical , and
Courtesyof the Libraryof Congress Chemical, on Drunkenness and
Its Effects on the Human Body
gression to continued uncontrolled use is marked.
• Delta alcoholics have strong environmental and physi-
ological vulnerability. Their progression to alcoholism is
much slower than that of gamma alcoholics. 84 ,85
Modern Classifications
As valuable asJellinek's classification was, the scientific basis
for alcoholism was not as clear-cut in those days as it was
with other illnesses and conditions. Four developments led
to a deeper understanding of alcoholism as a biological
phenomenon.
• First was the discovery in the 1950s of the nucleus
accumbens, the area of the brain that gives a surge of
pleasure and a desire to repeat the action when stimu-
lated by an experience, by an electrical stimulus, or by
psychoactive drugs. 86 '87
• In the 1970s the discovery of endogenous opioid neuro-
transmitters (e.g., endorphins and enkephalins) showed
that opioids and other drugs of addiction worked by

I
expounded, in scientific terms, his the.sis that drunkenness
was a disease produced by a remote cause that disrupts
health.
According to scientific literature from the nineteenth and
early-twentieth centurie.s, researchers developed dozens of
classifications of alcoholics (e.g., acute, periodic, and chronic
oenomania; habitual inebriate; continuous and explosive
inebriat e; and dipsomaniac, among others). It was not until
the 1930s that scientific progress on the study of alcoholism
accelerated, due in part to the creation of Alcoholics
Anonymous and the founding of Yale's Laboratory of Applied
Psychology. 83 Researchers Yandell Henderson, Howard
Haggard, Leon Greenberg, and later E. M. Jellinek made the
study of alcoholism scientifically respectable, aided by their
founding of the Quarterly Journal of Studies on Alcoholism and
the Yale Center of Alcohol Studies.
E. M. Jellinek
In 1941 psychiatrist Karl Bowman and biometrist E. M.
Jellinek presented their review of alcoholism treatment
literature , which contained a section integrating 24 classifi-
cations of alcoholism into four types of alcoholics:
• primary or true alcoholics: immediate liking for alcohol
and rapid development of an uncontrollable need
• steady endogenous symptomatic drinkers: alcoholism is
secondary to a major psychiatric disorder
• intermittent endogenous symptomatic drinkers: periodic
binge drinking, often with a psychiatric disorder
• stammtisch drinker (stammtisc h is a German term mean-
ing "regulars table"; in this context it translates to "socia l
drinker")
Twenty years later Jellinek, in his landmark book The
Disease Concept of Alcoholism, proposed five types of alco-
holism: alpha, beta, gamma, delta, and epsilon. Gamma and
delta alcoholics were considered true alcoholics. 84
influencing existing neurological pathways and receptor
sites in the central nervous system, including the reward
pathway. 88
• In the 1980s and 1990s, genetic research tools devel-
oped insights into hereditary influences on addiction. In
1990 the first gene (DRD, A, allele) that seemed to have
an influence on vulnerability to alcoholism was discov-
ered. '° By 2009, 89 genes had been linked to the devel-
opment of alcoholism and other addictions. Some 900
others are also suspected of contributing to addiction. 89 ,90
• In the 1990s and 2000s, imaging techniques visualized
the brain's real-time reaction to drugs.
These developments moved the classification of alcoholism
and addiction away from a qualitative classification toward a
more quantifiable and empirical basis.
Type I and Type II AlcoholicsThese classifications were based
on an extensive study of Swedish adoptees and their biologi-
cal or adoptive parents conducted by Dr. C. Robert Cloninger
and his colleagues. Type I alcoholism (also called milieu-
limited) was defined as a later-onset syndrome that can affect
both men and women. It requires the presence of a genetic
and environmental predisposition, it can be moderate or
severe, and it takes years of drinking to trigger (much like
Jellinek's delta alcoholic). Type 11 alcoholism (also called
male-limited) mostly affects sons of male alcoholics, is
moderately severe, is primarily genetic, and is only mildly
influenced by environmental factors. 91 ,92
Type A and Type B Alcoholics Dr. T. E Babor and his research
colleagues at the Universit y of Connecticut School of Medicine
introduced the A/B typologies in 1992 . They are similar to Dr.
Cloninger's type I/II typologies. Type A, like type I, is a later
onset of alcoholism with less family history of alcoholism and
less severe dependence. Type B, like type II, refers to a more
severe alcoholism with an earlier onset, more-impulsive
behavior and conduct problems or disorders, more co-occur-
ring mental disorders, and more-severe dependence. 84

The DiseaseConceptof Alcoholism
Much of the current research in the treatment of alcohol-
ism is based on the disease concept. The idea of alcoholism
as a disease goes back thousands of years but has only
recently become widely accepted.
• In 1972 the National Council on Alcoholism devel-
oped Criteria for the Diagnosis of Alcoholism, Signs
and Symptoms and defined it as a "chronic progressive
disease, incurable but treatable."
• In 1980 the American Psychiatric Association (APA)
made Substance Use Disorders a separate major diag-
nostic category in its Diagnostic and Statistical Manual of
Mental Disorders, also known as the DSM.
• The Natural History of Alcoholism, published in 1983 by
Dr. George Vaillant, professor of psychiatry at Harvard
Medical School, was based to a great extent on a long-term
study of two groups of men (college students and inner-
city young men). He concluded that poverty and pre-
existing psychological problems were not predictors of the
development of alcoholism. The predictors of alcoholism
were more likely a family history of alcoholism and/or an
environment with a high rate of alcoholism.
• In 1994 remission and substance-induced conditions
were defined in the DSM-IV
• The last edition of the DSM-IV-TR lists alcohol depen-
dence and alcohol abuse under Alcohol Use Disorders.
Under Alcohol-Induced Disorders, alcohol intoxication,
alcohol withdrawal, delirium, and 10 other conditions
are listed. 93
• ln 2013 the new DSM-5 of the APA replaces the DSM-
N-TR's categories with simply Substance-Related and
Addictive Disorders, which include the behavioral
disorders of gambling and online gambling behavioral
disorders. Each drug in DSM-5 has its own category, such
as Alcohol Use Disorder, mild, moderate, and severe.
Both the World Health Organization and the American
Medical Association view alcoholism as a specific disease. In
1992 a medical panel from the American Society of Addiction
Medicine and the National Council on Alcoholism and Drug
Dependence defined alcoholism as follows.
"Alcoholism is a primary chronic disease with genetic,
psychosocial, and environmental factors influencing its
development and manifestation. The disease is often pro-
gressive and fatal. It is characterized by impaired control
over drinking, preoccupation with the drug (alcohol), use
of alcohol despite adverse consequences , and distortions
in thinking, most notably denial. Each of these symptoms
may be continuous or periodic. " 94
"/ don't considerm~selfan alcoholic. I ha,e Rvedrinks
a da~-and that's an avera9e. It's alwa~sthree and sometimes
it's a lot more, but it's neverinterferedwith m~ work. I haven't
been to the doctor for 15 ~ears. But since it's neverinterfered
with m~ work. I see nothin9 wron9with sittin9 down and
havin9a drink."
4 7-year-old avowed habitual drinker
Downers:Alcohol 5.23
Heredity,Environment,and
PsychoactiveDrugs
Instead of focusing on typologies, it is useful to look at alco-
holism and addiction as continuums of severity that depend,
to varying degrees, on genetic predisposition, environmen-
tal influences (family, workplace, stress, nutrition), and
the actual use of alcohol and other psychoactive drugs,
which can alter the body's neurochemistry and instill an
intense vulnerability to craving.
Heredity
9ive birth to childrenwho
"Womenwho drink wine excessive/~
drinkexcessive/~of wine."
Aristotle, 350 B.C.
As early as the fourth century B.C., philosopher Aristotle
wrote about the tendency for alcohol abuse to run in fami-
I
lies, but only in the past 40 years has the scientific basis for
this belief been explored.
"/ think that there are9enes that impact a varietqof different 0
characteristicsthat increaseor decrease~our riskfor afcoholism.
We a/read~know the aenes related to the alcohol-metabolizin9
en211mes ; some ver~900d laboratoriesare closin9in on some of
the aenes like/~to contributeto disinhibition. Other laboratories
are certain/~active!~searchin9for9enes that mi9ht indirect/~
increase~our riskfor alcoholismthrou9h ps~chiatricdisorders,
such as schizophreniaand bipolardisorder. And our 9roup and
others are searchin9for the 9enes that are contributin9to the
low responseto alcohol, which indirect/~increases~our riskfor
alcoholismin a heav~-drinkin9soc/et~.95 Obvious/~, there are
9oin9 to be a whole slew of 9enes that contributeto the alco-
holism risk. but alto9etherthe~'reexplainin9aver~ important
part of the picture, probabl~60% of the risk."
Marc Schuckit , M.D., profes.sor of psychiatry,
University of California Medical School , San Diego , CA
Family studies , twin studies, animal studies, and adoption
studies show strong genetic influences particularly in severe
alcoholism. 27 .i 9 ,3i :;o.97 ,9 s At least 89 genes have been discov-
ered that could have an influence on susceptibility to addic-
tion. A study that assessed alcohol-related disorders among
3,516 twins in Virginia concluded that the genetic influence
was 48% to 58% of the various influences, a rate much higher
than what was assumed in the past. 99
Most susceptible individuals have more than one of the
genes that affect an individual's susceptibility to alcoholism
and other drug addictions. A person could have a single
gene, such as the dopamine DRD2 A 1 allele receptor gene, or
all the genes that make someone susceptible to addiction. 2952
A drinker could have a defective ALDH2 gene that encodes
aldehyde dehydrogenase, a key liver enzyme that helps
metabolize alcohol. This defective gene (ALDH 1) is more
prevalent in Asians. Because the defective gene means fewer
enzymes to rid the body of alcohol, its presence acts as a
 5.24 CHAPTER5
Chemicalstructure of a molecule
I
of human alcoholdehydrogenaseb3.
The ADH enzyme catalyses the breakdown
of ethanol to acetaldehyde.Some ethnic groups
are genericallyshort on ADH and so are more affectedby alcohol.
0 2014 molekuul. Reprintedby permissionof 123RF.
preventive to alcoholism because it makes the drinker
uncomfortable or ill after even a few drinks.
Other markers for a strong genetic influence are a tendency
to black out, a greater initial tolerance to alcohol, an
impaired decision-making area of the brain, a major shift
in personality while drinking, an impaired ability to learn
from mistakes, retrograde amnesia, and a low level of
response (LR) to alcohol. LR is one of the stronger markers.
One study of adolescents (average age 12.9 years) showed
that a low level of response correlated with a higher level of
drinking at an early age. 100
'When I was~oun!J'r
. I wasalwa~ssurroundedb~alcoholand
dru.9s. M~ mom becamean alcoholic, m~ sisterused, and so
did m~two stepbrothersand stepsister.M~ stepdadalsoused
to 9row [marijuana].So I was around it a lot."
19-year-old recovering alcoholic
There is usually a hereditary link to the physical conse-
quences of alcoholism, especially cirrhosis and alcoholic
psychosis. 101
Environment
For some people environmental factors are the overwhelm-
ing influences: child abuse or any early childhood trauma;
alcohol or other drug-abusing parents, friends, and/or
relatives; chaotic family relationships; peer pressure; and
extreme stress. Easy access to alcohol, a permissive societal
view of drinking, unsafe living conditions, poor nutrition,
and limited access to healthcare and drug recovery programs
are also contributing factors.
"/ rememberholida~s... drinkin9
.. it bein9prett~dis9ustin9
;
m~fatherwouldbe prett~intoxicated.And I remember the
Tooth Fair~,the EasterBunn~,and Santa Clausall
smellin9the same wa~."
23-year--old recovering alcoholic
Sexual, physical, and emotional abuses at a young age are
the most powerful environmental factors in raising a per-
son's susceptibility to alcohol/drug abuse. In one study of
275 women and 556 men receiving detoxification services,
20% of the men and 50% of the women said that they were
subjected to physical or sexual abuse in childhood. 102 Abuse
is also a powerful factor in the development of behavioral
addictions.
PsychoactiveDrugsand CompulsiveBehaviors
Once the genetic and environmental factors have increased
susceptibility, the toxic effects of alcohol and other drugs
that change neurochemistry come into play. This includes
behaviors such as compulsive gambling, shopping, and
Internet compulsions. A person who never uses a drug or
never practices a behavior will not develop an addiction.
Heredity, environment, and use of psychoactive drugs or
compulsive behaviors all change brain structures and brain
chemistry, both of which govern the release of neurotrans-
mitters and the communication between brain cells. With
continued exposure to these drugs or behaviors, the brain
adaptations become necessary for any functioning, albeit an
abnormal functioning known as allostasis. If a person quits
and then starts up again, he or she will relapse more quickly
than before because the brain is already set up to function in
that allostatic way.
"Howcomeif alcoholkillsmillionsof braincells,it neverkilled
the ones that made me want to drink?''
Author unknown
Tolerance, Tissue Dependence,
and Withdrawal
"Exposureof the brain to alcohol initiatesa processof adapta-
tion that worksto counteractthe altered brainfunction resultin9
from initialexposureto alcohol. This adaptation or chan9e in
brainfunction is responsiblefor the processescalled 'alcohol
tolerance:,:,
alcoholdependence,'and 'alcoholwithdrawal
s~ndrome.
Tenth Special Report. to Congress on Alcohol and Alcoholism (N IAAA, 2000 )
Tolerance
Tolerance is a process through which the brain defends
itself against the effects of alcohol. Dispositional (meta-
bolic) tolerance, pharmacodynamic tolerance, behavioral
tolerance, and acute tolerance are four ways the body tries to
adapt to the effects of alcohol. Tolerance allows the chronic

HowAgingandHeavyDrinking Affect
theLiver's
Ability
to HandleAlcohol
20 JO 40 50
Ageof moderate-to
-heavydrinker
Thisgraph shows the decrease in liver capacity to process alcohol as a
person ages. As the liver gradually ages and is stressed and poisoned
over time by alcohol, its capacity to metabolize alcohol is diminished
to the point where an older chronic drinker can get tipsy from just one
or two drinks.
drinker's body to handle larger and larger amounts of alco-
hol. It also indicates the body's growing dependence (tissue
dependence) as it attempts to maintain a normal physiologi-
cal balance in the face of alcohol's toxic effects. The rate at
which tolerance develops varies widely among drinkers.
"Well,I starteddrinkin9one beerand then I wenton to two.
A weeklaterI wenton to a six-pacl and then throu9hthe
~earsI wenton to two six-packs,and then I endeduf drinkin9
tequila.Two ~earsa~er I 9ot addictedto the a/coho, I was
up ta drinkin9a p~h of tequila."
38-year-old female recovering alcoholic
Dispositional (metabolic) tolerance occurs when the body
changes so that it metabolizes alcohol more efficiently. As
a person drinks over a period of time, the liver adapts and
creates more enzymes to process the alcohol and its metabo-
lite acetaldehyde. 31 -103 This accelerated process eliminates
alcohol more quickly from the body along with prescription
drugs, lessening their effectiveness. Because liver cells are
destroyed by drinking and the natural aging process, the
liver eventually becomes less able to metabolize alcohol, a
process called reverse tolerance. A heavy drinker who could
handle a fifth of whiskey at the age of 30 can become totally
incapacitated by two glasses of wine at the age of 50.
Pharmacodynamic tolerance occurs when brain neurons
and other cells become more resistant to the effects of alco-
hol by increasing the number of receptor sites needed to
produce an effect or by creating other cellular changes that
make tissues less responsive to alcohol (e.g., GABA becomes
less sensitive to ethanol). 39 Brain cells also deactivate their
receptors, so they become less reactive to alcohol. This is
known as down-regulation.
Downers:Alcohol 5.25
Behavioral tolerance occurs as drinkers learn how to "han-
dle their liquor," modifying their behavior so that others
will not notice that they are inebriated . 104
'Therewasna time, in all m~wakin9time,that I didn't wanta
drink.I be9anto anticipatethe completionof m~dail~thou-
sand wordsb~takin9a drinkwhenon/~pvehundredwordswere
written.It wasnot lon9until I prefacedthe be9innin9
of the
thousandwordswitha drink."
Jack London, American novelist
Acute tolerance also develops from high-dose alcohol use.
This rapid tolerance starts to develop with the first drink
and is the body's method of providing instant protection
from the poisonous effects of ethanol.
Select tolerance means that tolerance has not developed
equally to all the effects of alcohol, so while a person may
not become nauseated with a 0.14 BAC, he or she will still
have trouble driving.
I
Withdrawal
"I hurtso muchwhenI soberedup that I said, 'the heckwith
this.' I said, 'If that's9oin9to killthe pain, I'll90 backto
drinkin9,'and I real/~thou9htaboutit severaltimes,and it
was a war within m~selfwhetherto drinkor not drink."
65-year-old recovering alcoholic
'Your bad~is 9oin9throu9hso man~chan9es,~aucan hard/~
breathe; ~au'reshakin9.A han9over,~eah, ~aumi9htbe sick
far a coupleof hours.That's differentthan withdrawal;
but
withwithdrawal,it can kill ~au."
32-year--oldfemale recovering alcoholic
The presence of true withdrawal symptoms is an impor-
tant indication that the drinker has developed a tolerance
to and a dependence on alcohol. An alcoholic entering
treatment will often blame what he or she is feeling on a
hangover instead of recognizing it as true withdrawal.
Although many heavy drinkers exhibit significant symptoms
of withdrawal upon entering detoxification and treatment
for alcoholism, 85% to 95% of those experiencing with-
drawal will not have life-threatening symptoms. 105 -106
A recent study of the symptoms of withdrawal in alcohol-
dependent patients found that after three weeks of with-
drawal, craving and negative emotions (all generated by the
old brain) significantly improved while control functions of
the supervisory attention system, part of the "stop" circuit in
the new brain, did not improve. 107 What this may mean is
that although the intensity of cravings subsides, the ability
of the alcoholic in treatment to stop those cravings is still
badly impaired. It also means that it takes months or years
for the brain to rewire itself to maintain abstinence. The
"stop" switch remains weaker in a recovering alcoholic than
it is in a person who never abused or developed a depen-
dence on alcohol.
 5.26 CHAPTER5
The brain images (PET scans) show the differencesbetween the brain
of a young male nondrinker and that of a heavy drinker.The red and
pink areas show brain activity during a memory task. Brain activity in
the heavy drinker is greatlysuppressed, indicating potential problemsin
later life. Accordingto one study, 4 7% of those who begin drinking
alcoholbeforethe age of 14 becomealcohol dependentat some time in
I
their lives comparedwith 9%of those who begin drinking after age 21.
Courtesy of SusanTapert, Ph.D., Universityof California, San Diego.
Various classic experiments have shown that minor with-
drawal symptoms develop in people who drink heavily for
7 to 34 days, and major withdrawal symptoms develop
after 48 to 87 consecutive days of heavy drinking. 108 Many
withdrawal symptoms involve the autonomic nervous sys-
tem. Minor symptoms of withdrawal include rapid pulse,
sweating, increased body temperature, hand tremors, anxi-
ety, depression, insomnia, and nausea or vomiting.
Major symptoms of withdrawal include tachycardia; tran-
sient visual, tactile, or auditory hallucinations and illusions;
psychomotor agitation; grand mal seizures; and delirium
tremens.
"/ was ver~sick- ver~nauseous, pains in m~ stomach,
headaches,shakin9,~lied with sheer terror. I've neverknown
fearlikethat in m~life. Thishas beenthe hardestthin9
I've had to do, but the alternative is worse."
34-year--old reco vering alcoho lic
Because the main symptoms of severe withdrawal can
include physical complications (such as malnutrition or
liver disease) and major symptoms (which include seizure
activity), medical care for a chronic alcohol abuser must be
considered in any course of treatment. In less than 1% of
serious cases of alcohol withdrawal, full-blown delirium tre-
mens, called "the DTs," occurs. The DTs usually begin 48 to
96 hours after the last drink following a period of heavy
drinking and can last for 3, 5, or up to 10 days. Some cases
have lasted up to 50 days. 115
The dramatic symptoms can include whole-body trembling,
grand mal seizures, disorientation, insomnia, delirium, and
severe auditory , visual, and tactile hallucinations. The DTs
are a serious condition requiring hospitalization. 109
Untreated, the mortality rate ranges from 10% to 20%.
Neurotransmitters and Wrthdrawal Initially, alcohol increases
the effectiveness of GABA, blocking the actions of the brain 's
energy chemicals, causing drowsiness and depressing other
body functions. Over time the brain compensates by creat-
ing an excess of energy chemicals and decreasing (down-
regulating) the number of GABA receptors, resulting in
hyperarousal. During withdrawal the rebound excess of
energy chemicals causes anxiety, increased muscle activity,
tachycardia, hypertension, and occasionally seizures. The
brain becomes less able to control the hyperactivity. 110
Current research explores the role of serotonin in the alcohol
withdrawal process. A 30% reduction in the availability of
brainstem serotonin transporters is found in chronic alco-
holics, which correlates to self-reported ratings of depression
and anxiety during withdrawa1. 11 u 12
Kindling In many long-term heavy drinkers, a process called
kindling occurs: repeated episodes of intoxication and
withdrawal actually intensify subsequent withdrawal
symptoms and can cause seizures. 113 Kindling is also known
as inverse tolerance. This suggests that even patients experi-
encing mild withdrawal should be treated aggressively to
diminish the severity of subsequent withdrawal symptoms.
Directionsin Research
As it becomes more evident that the cause of alcoholism is a
combination of heredity , environment, and the toxic effects
of alcohol, research is being conducted on each of these
aspects.
Research into heredity is focused on identifying the genes
that make a user more susceptible to addiction (e.g., DRD2
A 1 allele , CREB gene). Research conducted by nine universi-
ties for alcohol-associated genes in the human genome found
a region on chromosome 11 that is strongly associated with
alcohol dependence . 114
Once the genes responsible for alcohol dependence-and
the proteins and enzymes related to those genes-are identi-
fied, researchers can focus on new medications to control the
specific neurochemicals associated with those genes.
Research into environmental causes of alcoholism focuses
on identifying which changes in an addict 's surroundings
decrease the use of alcohol and other drugs. Studies report-
ing on the effectiveness of raising the drinking age, reducing
child abuse in the home, limiting sales of alcohol, and lower-
ing stress in everyday life are published every month in
dozens of professional medical and sociological journals
worldwide.
Research into drug-caused physiological and psychological
changes that occur with chronic and high-dose use is con-
ducted by many researchers. Studies measuring the impact
on the immune system, on the development of dispositional
and pharmacodynamic tolerance , on the beneficial cardio-
vascular effects, and on the learning disabilities in drug-
affected infants-all contribute to the development of treat-
ment and prevention strategies for alcoholism.

Research and development on drugs that could reduce the
craving for alcoho l is intense. CBI receptors (which are sen-
sitive to cannabinoids) have been targeted because they have
been foun d to help modulate the reinforcing effects of alcohol
and other abused drugs. 115
Consequences of alcohol use- polydrug abuse, mental
problems, alcohol use during pregnancy, aggression and vio-
lence, drunk driv ing, suicide, and associated injuries-can
occur at any level of use but occur more frequently with
high-dose chronic use and alcoholism.
PolydrugAbuse
Most people who use abuse drugs also drink alcohol, and
most alcohol abusers use other drugs . In one Euro pean
study of 600 ado lescent drug users, 80% used both mari-
juana and alcohol. 116 In the Un ited States, 58% of heavy
drinkers smoke cigarettes, while on ly 16% of nondrinkers
smoke. 1 The reasons for polydrug use vary.
• Alcoho l and tobacco are wide ly used to facilitate social
situations.
• Alcoho l and marij uana can be used together to rapid ly
increase relaxation.
• Alcoho l taken before using cocaine will pro long and in-
tensify the cocaine's effects by creating the metab olite
cocaethy lene, which can intensify a predisposition to
violence.
• Alcoho l can be used to come down off a three-day meth-
amphetam ine run.
• Sedative-hypnotics or op ioids can be used to get loaded
if alcohol is unavailable.
• Alcoho l can be used if one's drug of choice is unavailable.
• Compulsive gamb lers drink while gambling or gamble
while drinking.
"I used downers just to come down off the alcohol because I was
so shak~. And then I wouldtr~usin9amphetamines just to lift
me up so I wouldn'tdrinkso much. But what I woulddo was
sta~awakelon9erand drinkmore,so that didn't work."
40-year-old recovering polydrug abuser
Polydrug abuse has become so common that clinics must
often treat simultaneous addictions. Although the emo-
tional roots of addiction are sim ilar regardless of the drug
used, the physiological and psychological changes that each
drug causes, particularly during withdrawal, often have to be
treated differently. For example, if a client has a serious
alcohol and benzodiazep ine problem, the clinic must exer-
cise extreme caution if a benzod iazepine is used to control
any alcohol withdrawal symptoms.
Downers:Alcohol 5.27
JO%
Past-Month
Illicit-Drug
Use
withAlcoholUseinthe
UnitedStates - 2012
Don't drink light Occasional Heavy
now drinkers bingedrinkers drinkers
I
This chart shows that excessive drinking is associated with the use of
other psychoactive drugs, usually illicit. Whether it~ because of the
association with other people who drink and use drugs, the lowering
of inhibitions that makes drug use acceptable, or the desire for
stronger and more intense experiences, the association is quite clear.
In terms of percentages, 83% of the illicit -drug use is marijuana and
17% is cocaine (multiple drug use is common).
0 2014, CNSProductions,Inc.
Although 70% of alcoholics who smoke are heavy smokers
(more than one pack a day) compared with 25% of the gen-
eral smoking popu lation, the converse is not as dramatic:
smokers are only slightly more likely to drink alcoho l com-
pared with nonsmokers. There is also a strong link between
alcohol and early use of tobacco. Adolescents who smoke are
three times mo re likely to begin us ing alcohol in thei r
teens. 118
Alcohol and Mental Problems
Alcohol and other psychoactive drugs are most often used to
ch ange one's mood or mental state. The mood could be mild
anxiety, confusion, boredom, sadness, or depression. The
mental state could be symptomatic of a pre-existing menta l
illnes.s such as major depression or a personality disorder. 119 A
study of adults with panic disorder showed that the subjects
reported significantly less anx iety and fewer panic attacks if
they were drinking. However, the use of alcoho l to control the
symptoms resulted in a higher rate of alcohol use disorde rs
among those with panic disorde r.110
"/ wouldpickup somebeerto put me out of it.
I didn't likethe effectthat re9ularps~chiatric
dru9s,
such as antidepressants, had on m~ brain and I'd.rather
justput m~self out withthe booze."
46-year-old male with major depression and an alcohol problem
 5.28 CHAPTER5
There is an association between drinking and certain mental
illnesses . In a study of alcohol-dependent men and women,
4% also had an independent bipolar disorder-four times
the rate of the general public. 121Whether the relationship is
causal or associative, it is the subject of much debate among
professionals in the mental health community and those in
the chemical dependency treatment community In two
major studies on dual diagnosis, the incidence of major
depression among those diagnosed with alcohol depen-
dence was about 28% and the incidence of anxiety was
37%, which is considerably higher than that of the general
population (5 .3% and 16.4%, respectively). 122 •123
Excessive drinking or withdrawal can induce symptoms of
mental illness. A person who uses alcohol to escape sadness
might advance to depression though chronic drinking. In
one study depressed subjects with a history of alcoholism
showed higher lifetime aggression and impulsivity and were
more likely to report a history of childhood abuse, suicide
attempts, and tobacco use .124Alcohol causes mental prob-
lems because heavy drinking disrupts neurotransmitters that
I
trigger feelings of well-being in the mesolimbic/dopaminer-
gic survival (reward) pathway Heavy drinking also raises
the levels of neurochemicals that cause tension and depres-
sion .125The brain tries to compensate for the depletion
of neurotransmitters by releasing corticotropin-releasing
factor, a stress chemical that can induce depression. Alcohol-
induced mental problems, particularly if they are adult onset,
abate as the brain chemistry rebalances itself .126
'The problemsdid get worsewhenI wasdrinking.That was
one reasonwhq I neverfiguredout I wasa manic-depressive.
I figuredI wasdepressedbecauseI wasdrunkall the time."
Alcoholic with bipolar illness
Any psychiatric diagnosis must consider the possibility of
drug-induced symptoms, so a treatment professional must
often wait weeks or months for a user's brain chemistry and
cognition to stabilize before making an accurate diagnosis.
In one study the majority of alcoholics who came into the
Haight Ashbury Detox Clinic in San Francisco for treat-
ment were initially diagnosed as suffering from depres-
sion, but after treatment and a period of abstinence (often a
month or more), the percentage of depressed clients dropped
dramatically from approximately 70% to 30%. 127
At the other end of the spectrum, a hasty diagnosis of alcohol
dependence might attribute all of the client's erratic behavior
to the effects of the drug and miss the psychiatric diagnosis . A
client with a co-occurring disorder will continue to relapse
because the more serious psychiatric problems have not
been addressed . Experience proves that if there is a true dual
diagnosis, both conditions must be treated to achieve an effec-
tive recovery Research of bipolar patients with alcoholism
discovered the importance of determining which illness came
first because those who exhibited the bipolar illness first were
slower to recover from alcoholism.126
An accurate psychiatric diagnosis of antisocial personality
disorder (ASPD) and borderline personality disorder (BPD)
is made more complicated because the symptoms of these
two illnesses are very common in those who seek drug treat-
ment. The symptoms of high impulsivity, no remorse for
causing harm to others, and an inability to learn from mis-
takes are found in both those with ASPD and among drug
abusers. 129 BPD is characterized by intense negative emo-
tions such as depression, self-hatred, anger, and hopeless-
ness . Individuals with BPD often use impulsive maladaptive
behaviors such as compulsive gambling, suicidal actions,
and substance abuse to deal with their feelings.
To diagnose BPD or ASPD, the patient's symptoms should
exist outside of the drug-seeking/using behavior and must
have existed prior to the drug use . There is much debate as to
the number of actual incidences of these diseases, particu-
larly BPD, because its symptoms often shift from moment to
moment and can be drug induced. Some treatment profes-
sionals consider the diagnosis ofBPD as a "catchall diagnosis"
assigned because a patient's real problems are not clear.
Patients who actually have BPD are difficult to treat and con-
sume a disproportionate amount of the staff's time.
One evaluation of public and private inpatient alcohol-abuse
programs measured the incidence of ASPD at 15% for male
alcoholics and 5% for female alcoholics. Conversely, 80% of
those with ASPD develop substance dependence. 48 ·131
In one study conducted in the 1980s of alcohol treatment
admissions, the incidence ofBPD was 13%.13°
Alcoholand Pregnancy
There are so many environmental influences on the health of
a developing fetus that it is often difficult to ascertain which
combination of foods, drink, stress, or a dozen other factors
is responsible for any birth defects or anomalies . There is a
vast amount of research on the physical effects of alcohol on
a fetus, but it is difficult to spot the neurological deficits.
Many researchers think that the lifestyle of the mother has
almost as much of an effect on the fetus as the alcohol use
itself, especially when the damage is not full-blown fetal
alcohol syndrome. 131
Maternal Drinking
"I had beenusingfor qearsbeforeI got pregnant;and when I got
pregnant,I triedto stop but I just couldn't do it. I wantedthe
drugmorethan I wantedthe babq."
27-year-old recovering alcoholic
Alcohol use during pregnancy is the leading cause of mental
retardation in the United States. 132 · 133 Excess drinking dur-
ing pregnancy also increases the number of miscarriages and
infant deaths, causes more problem pregnancies, and results
in smaller and weaker newborns. 7A
A survey of pregnant women in the United States found the
following.
• 7.6% consumed some alcohol during pregnancy in
the past month . (This figure was 5.5% in nonpregnant
women drank alcohol in the past month .)
 Downers: Alcohol 5.29

The University of Washington in Seattle studied two groups

of children with FAS. By the time the children in the first
group reached the age of five, 38% of their bio logical moth-
ers were dead as a direct result of their alcoholism. By early
adolescence 69% of the bio logical mothers were dead from
alcoholism .

FetalAlcohol Spectrum Disorder (FASD)

When diagnosing an infant who has been affected by alco-
hol , diagnosticians look at four factors:
1. retarded growth before and after birth, includ ing height ,
weight, head circumference, brain growth, and brain size
2. facial deformities, including shortened eye openings ,
thin upper lip , flattened midface , and a missing groove
(philtrum) in the upper lip; there are also occasiona l
problems with the heart and the limbs
3. central nervous system involvement, such as delayed
intellectual development, neurologica l abnormalit ies,
© Angela Wayne.Reprinted by permission of l 23RF. behavioral problems, visual problems, hearing loss, and
balance or gait problems .me

• 1.4% of pregnant women and 15% of nonpregnant wom-

en were binge drinkers .131A
• Less than 1% were heavy drinkers.
4. prenatal alcohol exposure determined by interviews,
medical records, review of drug/alcohol treatment his-
tory, and blood tests
By judging the severity of each of these symptoms, diagnosti-
cians can place the infant in one of several specific diagnoses
under the banner of FASD. The diagnoses go in and out of
favor, depending on the latest research or on the experience
I
• 10. 7% smoked cigarettes in the last three months of
of the diagnostician.
pregnancy. 1318
• FAS (fetal alcohol syndrome) involves all four factors.
"WhenI waspregnantwith m~ daughterCase~, I wasdrinking • PFAS (partial fetal alcohol syndrome) is similar to
betweenthreeand fourlitersofwinedail~until I wasabout FAS but lacks the maximum growth deficiency or facial
eightmonthsand got into the recover~ network.And anomalies .
consequent/~she wasbornwith fetalalcoholeffects.She
alsohad a holein herheart, her digestives~stemwasall
messedup, she had projectilevomiting
, and she didn'tgain
an~weightfor abouta month."
24-year -old recovering alcoholic

The lifestyleof a heavy-drinkingpregnant

woman (e.g., nutrition,violence) has as much
of an effect on the fetus as the alcoholitself.

A survey of mothers of 293 infants born with fetal alcohol

syndrome (FAS) or alcohol-related neurodevelopmental dis-
order (ARND)-both caused by heavy drinking-conducted
through Legacy Emmanuel Children 's Hospital in Portland,
Oregon, discovered that during their pregnancies about
89% of the women used alcohol with at least two other
drugs and 49% used on ly two drugs, usually alcoho l and The rate of alcoholism in Russia is extremely high, as is the incidence
cocaine . All the women smoked , so nicotine was included as off etal alcohol syndrome. These two children at an orphanageoutside
of Yelisovoin Kamchatka, Russia, have FAS, identified by theirfacial
one of the toxins . Most were single moms, most were school
anomalies. In a few areas of Russia, the rate offetal alcohol syndrome
dropouts , most had been or were being physically or sexu- disorder, which includesf etal alcohol syndrome and other less severe
ally abused, and often there was a history of alcohol or drug alcohol-induced disorders,is more than 50% of all births, an
abuse in the family. There is also a suspicion that a number incredibly high percentage.
of the women had learning problems in school caused by Courtesy of DouglasG. Smith,O.D.,optometric physician, Medford, OR
alcohol or drug use by their mothers .
 5.30 CHAPTER5
• ARNO (alcohol-related neurodevelopmental disorder)
primarily reflects CNS damage/dysfunction that is con-
firmed to be due to prenatal alcohol exposure; physical
anomalies are not present or are minimal.
• ARBO (alcohol-related birth defects) covers any num-
ber of physical anomalies in multiple organ systems.
• FAE (fetal alcohol effects) is now designated as ARNO
and ARBD.134
The term fetal alcohol syndrome was coined in 1973,
although the diagnosis was first written about in France in
1968.135 Initially, it was thought that the defects were the
result of malnutrition, but the toxicity of alcohol was even-
tually recognized as the cause . Symptoms can range from
obvious pronounced physical defects to mental deficits to
behavioral problems .136 Not all women who drink heavily
during pregnancy bear children with FAS.
"He was ver~inconsolable. He would take 10 cc of feed; he
wouldn't sleep. He slept for ma~be15, 20 minutesat a time,
I
24 hours a da~. That 's what we went throu9h, and it was
like that for a couple of ~ears.He was a ver~hard bab~ to
parent, but we loved him."
Foster mother of child with FAS
Alcohol kills cells and changes the wiring of a fetus's brain.
Huge gaps during brain development destroy natural con-
nections that can never be regained . SPECT (single-photon
emission computerized tomography) scans from a Finnish
study show smaller brain volume in a group of FAS and FAE
children as well as abnormalities in serotonin and dopamine
function .137 Dr. Ira Chasnoff also notes major abnormalities
of the brain 's corpus callosum that impair communications
between the brain 's two hemispheres.
In tests of 178 individuals with FAS, IQ test scores ranged
from 20 to 120 with a mean of 79; in 295 individuals who
were diagnosed with FAE, PFAS, or ARNO, IQ scores ranged
from 49 to 142 with a mean score of 90 .138 Mental retardation
is defined as an IQ of less than 70. Other specific problems
associated with FAS and ARNO in terms of a neurocognitive
profile include:
• difficulty with short-term memory
• problems storing and retrieving information
• impaired ability to form links and make associations
• difficulty making good judgments and forming relation-
ships
• problems controlling temper and aggression
• oversensitivity to stimuli like a bright light, a loud sound,
a sharp smell, or certain kinds of textures or tastes
"Our other son has some of the characteristicslike the
philtrum, but in ever~other wa~ he looksnormal.
But his IQ is low, ~et he comes across as bein9ver~smart.
He has severebehavioralissues."
Mother of adopted children with FASor FAE
These cognitive/behavioral deficits are not unique to alco-
hol exposure . Many other substances and physiological
The greatest danger from alcohol abuse by a pregnant woman is f etal
brain damage. The largerbrain on the left is the normal brain of a
human newborn (who died in a car accident). The smaller brain on
the right is that of a child born with FAS. The FAS brain is malformed
and significantly smaller More-subtledamage can be missed on a
brain scan.
Courtesy of Sterling K. darren, formerly at Children's Hospital, Seattle, WA
problems can cause similar conditions in children. For that
reason a diagnosis of PFAS or ARNO is often missed in the
absence of those unique facial features. Many of the symp-
toms are not obvious until several years after birth. An
Australian study found that only 4 7% of birth defects were
identified in the first months after birth.
"What ~ou see at birth is a disorderof the brain'sabilit~to
re9ulateitselfand its emotions;later on, especial/~in the
toddler and preschool~ears,~ou see problemswith sleep and
behavior;the~'resittin9and plafn9 and the~'re prett~ happ~
and then sudden/~out of the blue the~ becomea99ressive.
The~ throw temper-tantrums,and ~ou real/~don't know
what's9oin9 on. But that's the up-and-down emotional
instabilit~that these childrendemonstrate."
SarojiniBudden, M.D., FASspecialist,
Legacy Emmanuel Children'sHospital, Portland,OR
Fortunately, researchers have found that early diagnosis of
FASO in newborns plus a supportive environment can give
those children a chance at a better , more functional life.139
Worldwide studies estimate that FAS births occur in 0.33 to
2.9 cases per 1,000 live births. The incidence can vary
greatly (e.g., the rate in one survey in South Africa where
alcoholism is rampant was 40 cases per 1,000).14° The world-
wide incidence of ARBO and ARNO (which are difficult
to diagnose) is probably five to 10 times greater than the
incidence of FAS and FAE.134
In the United States, FAS rates of up to 1.5 per 1,000 are the
accepted figures. Asians, Hispanics, and Whites have 1 to 2
FAS births per 1,000; African Americans have about 6.
American Indians have about 30, although rates from 10 to
120 per 1,000 have been reported in specific American
Indian and Canada 's First Nations communities . In the
United States, the incidence of ARNO and ARBO is three
times the incidence of FAS.141

CriticalPeriod Because the brain is among the first organs to
develop and the last to mature, it is vulnerable throughout
pregnancy. Weeks three through eight at the onset of embryo-
genesis (formation of the embryo) are crucial.
• During the first trimester, alcohol interferes with the mi-
gration and the organization of brain cells.
• During the second trimester, especially the tenth to
twentieth weeks, facial features are greatly affected.
• During the third trimester , the hippocampus is strongly
affected, which leads to difficulties encoding visual and
auditory information. 142, 143, 144 , 14'
CriticalDose Animal models suggest that peak blood alcohol
concentration rather than the total amount of alcohol con-
sumed determines the critical level where the damage begins .
A pattern of rapid drinking resulting in a high BAC is the
most dangerous style of drinking.
How many drinks is it safe for a pregnant woman to con-
sume? One study concludes that a pregnant woman con-
suming seven standard drinks per week is a threshold level
below which most neurobehavioral effects are not seen.
This might lead some healthcare professionals to believe that
recommending total abstinence is unnecessary. Seven drinks
a week is an average, however ; if a pregnant woman con-
sumes most of those drinks in one sitting, the fetus is more
at risk.
"I thinkthe messa9ereallqis that if qou knowqou're
pre9nant,don't drinkbecauseqou don't knowwhetheran
ounceis9oin9to causea problemor whether12ouncesis
9Din9to causea problembecausealcoholhas a different
effecton differentpeople."
Sarojini Budden, M.D., FAS specialist,
Legacy Emmanuel Hospital, Portland, OR
A recent study in rats showed that when the developing
brain is creating neurons and neuronal connections at a furi-
ous pace, even one high-dose use episode of drinking kills
brain cells rapidly. Normally, 1.5% of brain cells die during a
certain period in a rat's growth; but in rats exposed to alco-
hol during that critical period, 5% to 30% of neurons died.
When extrapolating these results to humans, the BAC would
be 0.20, exceeding the legal allowable limit to drive a vehi-
cle, and the crucial period would be six months into the
pregnancy. During the brain growth spurt, a single pro-
longed contact with alcohol lasting four hours or more is
enough to kill vast numbers of brain cells. 146
The U.S. surgeon general advises women to not drink at all
while pregnant because there is no way to determine if a
baby might be at risk from even very low levels of alcohol
exposure .21,134,141
"I think,likeanqbodqwho has a childwith FASor FAE,we
havea tendencqto takea closerlookat peoplewho arenot
actin9quiteri9ht.The behaviorsarea littlebit different,and
qoustart to wonderif thereisn'tsomealcoholin theirpast."
Foster fatherof 13-year--0ldwith FAS
Downers:Alcohol 5.31
PaternalDrinking
"Forchildrenwhosefathershavechancedto be9etthem in
drunkenness arewont to be fond of wine,and to be9ivento
excessivedrinkin9
."
Plutarch, Moralia:The Educationof Children,A.D. 110
There is evidence that some of the detrimental effects of
alcohol on the fetus may be transmitted by paternal alco-
hol consumption, although researchers are unable to say
definitively if paternal exposure to alcohol results in FAS or
in some other damage. 148 In laboratory tests , alcoholic-sired
rats of nonalcohol-using mothers produced male offspring
with disturbed hormonal functions and spatial learning
impairments. Adolescent male rats subjected to high alcohol
intake produced both male and female offspring that suf-
fered from abnormal development , including decreased body
weight. 149
Observations of male children of alcoholic fathers indicate
no gross physical deficits but do show an association with
I
intellectual and functional deficits. In addition to the deficits
in verbal, thinking, and planning skills, sons of male alco-
holics exhibit deficiencies in visual/spatial skills, motor
skills, memory, and learning .7A Explanations for these abnor-
malities suggest that alcohol may mutate genes in sperm , kill
off certain kinds of sperm, or biochemically and nutrition-
ally alter semen and influence sperm. 150
Aggressionand Violence
In a situation involving violence, there are usually three
people involved: the victim, the perpetrator, and one or
more bystanders.
• The victim is the recipient of a physical or sexual assault
(by a spouse, parent, acquaintance, or predator).
• The common denominator found in a majority of perpe-
trators , regardless of age, is anger; and often alcohol is
part of the mix.
• The bystanders are usually children, who witness vio-
lence in their homes and neighborhoods.
"I'vealwaqsjust beenan anarqchild,9rowin9up with a lot of
an9erthat's beenstuffed.And then it's likeon the r~h
drink
I'm a partq9irl, but on the seventhdrinkI'd kickin qourcar
door,qou know.I'djust totallqchan9e-that Dr.Jekqlland
Mr. Hqdesqndrome . There'sno end to mq an9erwhen I drink.
Mine comesfroma lot of past abuseas a kid, and it comes
fromjust not rttin9 in."
28-year-old female recovering alcoholic
Most research suggests that a tendency toward violence is
deep-seated in some people and is due to a combination of
factors (heredity, environment, and alcohol or other drug
use) working together to biochemically and emotionally put
them at risk . In one study of violence involving intimate
partners, the participants were four times more likely to be
intoxicated at the time of the incident. 15 1-152
 5.12 CHAPTER 5
Alcohol
andDrug
AbuseLinked
to
Family
Violence
- probationers, 0.20 for local jail inmates, and an incredible
0 Almost half of the perpetrators had been frequently loaded on
ill,
f! *Figuresdonotto
tal l(X)(¼i
becausemanyabuserstake
0 morethanonesubstance
Alcohol Any illicit drug Cocaine
I Three out of four of those arrested for family violence tested positive
for alcohol . Half had used some illicit drug, and more than one in four
tested positive for cocaine.
National Research Council
"Hewas a prettqmean9uqwhenhe wasn'tdrunk,whenI think
aboutit, so it is reallqhardforme to tell.But I knowthat when
peopleareaddictedand arealcoholics , theqcanbe drqdrunk,,
which makes them just as mean when the~'re not usin9 as when
theqare."
38-year-old victim of domestic violence
Among many neurochemical effects, alcohol can increase
aggression by interfering with GABA (the main inhibitory
neurotransmitter) in ways that provoke intoxicated people
with pre-existing aggressive tendencies. In addition, alco-
hol decreases the action and the levels of serotonin, thus
lowering impulse control, which can cause drinkers to act
out their aggressive impulses and make them less able to
stop drinking once they start. 153-154
-155
"Ona tqpicalFndaqni9ht, at least50% of ourcalls willbe
some kind of alcohol-and dru9-relatedviolentbehaviorsitua-
tion, whetherit be a shootin9,a stabbin9,or a beatin9.A lot
of those involvesi9nipcantothers, a spouse, or cohabitants."
Emergency medical technician, San Francisco Fire Department
The expectation that alcohol will make one braver can lead
some people to be more aggressive--even if they are drink-
ing a nonalcoholic beverage that they believe contains alco-
hol.156J57 Drinking can impair the way a person processes
information; social cues can be misjudged, and a benign
statement such as "Hello, how are you?" can conjure up
misperceptions of epic proportions. Misjudgin g intentions
can also cause a person to perceive a threat where none
exists, leading to a violent overreaction. 154
Based on Bureau of Justice Statistics data, 33% of robberies,
40% of aggravated assaults, and 50% of all homicides
involved alcohol use. About 36% of the victims of violent
crime reported that the offender had been drinking alcohol
at the time of the offense, with BACs two or three times the
drunk-driving threshold. The levels registered were 0.18 for
0.28 for state prisoners at the time of their offenses. In situa-
tions involving domestic violence, alcohol is involved at
least three-fourths of the time. 8 •159
-160
A classic study in Memphis, Tennessee, examined police calls
for domestic violence and found that 92% of the perpetrators
used alcohol and 67% used cocaine on the day of the assault.
alcohol and/or cocaine during the 30 days prior to the inci-
dent. 161Other studies showed similar results (Figure 5-7).
>
About 36% of the victimsof violentcrime
reportedthat the offenderhad been drinking
alcoholat the time of the offense.
"O God, that menshouldput an enemqin theirmouthsto
stealawaqtheirbrains!That weshould, withjoq,pleasance
,
revel,and applause, transformourselvesinto beasts!"
William Shakespeare , Othello
Alcohol can encourage the release of pent-up anger, hatred,
and desires discouraged by society, especia lly in people
prone to viol ence. Alcohol can also undermine moral jud g-
ment and reasoning, suppressing the common sense that
keeps a person out of trouble. 161
"Seemslikealcohol is alwaqsreferredto as this 'liquidcoura9e,'
qouknow?And I 9uessit dependswhereqou'reat Couraaeto
do what?Couraaeto aska 9irlon a date that qouhadn'thad
the coura9eto do before,or coura9eto dance likea fool on the
~oar,or is it coura9eto beat qour wifeor beat qour9irlfriend
becauseqoudidn't havethe9uts to do it before?"
College peer counselor
There are three major kinds of interpersonal violence, and
one can esca late into another: emotional violence, physical
violence, and sexual violence. The most common and
underreported is emotional violence, which includes verba l
abuse often caused by alcohol's freeing effect on the tongue.
"Ifqoutalkaboutsomeonebein9emotionallq
violated,
who9oes to jail for that? You don't haveanq bruises
that qou can see, but there are scarsthere."
36-year--old ex-wife of an alcoho lic
Any type of violence can cause permanent bioch emica l
changes in a victim, which can create a susce ptibilit y to
drug abuse and other emotiona l problems. Magnetic reso-
nance imaging (MRI) studies conducted by Yale and Harvard
in 1997 on physically and sexually abused childr en showed
permanent changes to their brains. These changes often led
to behavioral problems lat er in life, including hyperactivity,
impukh,eb<ha,ior . incr<a«d a~on,<uggeratcdfens • Morethanlin~dri,.,f'.'fg<t b<hind1h<wh« l wi1hintwo
mdnigh1m>=,troublekttping a job . mddifficultywith hour,ofdrinking.
r<lotiomhip> . Th e .i udies,howcith.otthechang«oould • Onanyw«knightb<tw«n!Op.tILand l• .m ., linlJ
•lsoh<ca~byo,verermotiono l•bu>< drhn> io legally drunk; on w«k<nd morn ing, b<tw«n l
and6a.m .,l in 7 dri,n> i<drunk. "'
"/tdo,,n'tmatt<rifakold ....,,itn<,/ .,Ju,tl,,~ta.,tion. H,
• Oftho.,convict<doFD L!l.61 %d.-.n kbttT. 2%drank
rap,Jm,_Tl,,,<,"""'att<n!ionp ,,;d rotl,,f.,,,::tthattl,,r,"""
wine.18%drankliquor, a nd20%drankmorethanon<
alrohal...,j.,dthantl,,fa.ctthata=n""'"'"',.,/t,Jand typ<of• lroholicb<v<r>g<
thath<,!if,d,a"8'Jandthatailoftl,,,,th"'l/'l,"Pf>'"'d"'o
,,,..ltofthat.Alrol >,l',;...,/,,,J;,,ol..,,1,,,flj,odal,itu.:ation. • Alrohol,rd • t<d • uto•cciden1'rostm<>T<th2n$ l'IObi l-
b.titdon,,.tm,anthat""'"" '9" "' il0<"1liJat< it" lioninthe l! ni t<dSt.ot<•<vnyyn.r.

.,_.,,,i.,.,40.000armlf""lj'l'"'inW:islwyjtonStot<fo,
Depending on th< study. l-t% to 74% of ...xual.a,; .. ult DU/.O..,,,n..,t,;,ti.,taptffO<ldrowJn,nl or undtrtl,,
p<IJ><lr>tor5hadbttndrinkinguhad30%to79%ofth< illfl•,.uKln....-pm,to~armtedfo,tl,,~r,ttim, "
'ct'm , . lnmo<tca«>lh<p<rp<t ratormd t h< 'cf, , ,.,._,c_._JO. , "~ Sw<P'"""""'1!'""""'
bothdrinking;rare ly wa,;th<victimdrinkingalone ."' ·'"'"'""""""""""'"'
""',....
AnFBl<tudyloundth.otevrnthoughth er<wer<l.,million
DrivingUnderthe Influence DWl a rre,ts in .ZOil. thedriv,n haddriv<nim pair<d•n
•v•~<ol79othertimeswithoutb<ing • rn<t<d ."''· -

"/do""nth>""j/...,,ina...-..:lat.,..,!im, . '""'"Pf!<dm~

~!,::
~'TJ!';'17;
.......,,
i:::..z~~':.':!~"'
r.:'u
~-- ... "'"'f'k~ O....,,,<ttd-, , DUl o c

Nn.rly 1.5 million driv,,. •re ETnt<d n.ch yen for

impaircidriving. Depend ingon the,ut<, thethr« mo.i
oommonl egal d<>ignatiomar,DUl(drivingundertheinflu - A majority of drunk drivers with , upended lieu,.,.
rnce), D\Vl (drivi ng whileintoxi cat<d),and occ.1.<ionally, rontinuetodriv,, They thinkthcycan avoidn otic<
DUH(driv!ngunderth ei nfiu enceolintoxiC2I115 ). DUl•nd
DV.1u,u•llyrelertodrunkdriving but canb<uo,dto "l(Pont [DU/Jandth<o/dro,, witlioota!uns,
includedrug -impa ir<ddriv! ng.&c•u «tht=ng<EIACfor andtl,,nl8"!01>Xl,,r°"' , a..Jonoth<ront . lt"'°"""'ll,J"
tho,.eactu.ally•rr<'1<di>0.16-twicethtlegollimitof ..,_,.,.,_,, _ _ DUI"" "' "'
0.06-the driver i, token into cu,tody. handcuffed, •rul
trm,poncdtoj•ilwhil e thecorisimpourul<d
Aper.;onarrestedforaDU ( for
thefirsttimehasalreadydrivendrunk
anaverageofBOtimes.

Beforepoliceofficerspullsomro n,over. 1heyfir<tobserv<

th e dri,.,,fo,t<llt.o le,igmolimp•irment
Jn20l2 . forthtlirsttime,ince200 5. trafficfatilitiuinth<
United Stot<S ro,.e (J ,J%). Of JJ,561 tnffic fatil iti«,
•pproxim.ot<lyJO'l,{10,Jll) involv<dakohoLlnaddition,

!i:~o~
~~= ,~.J' ~h;:c:!:'1bet":':n
we r, probably du, to inc=
';:c:,
~•:n:~~~7
in the drinking age •nd
<tricterprn.,.lti<>fordrunkdriving

Susceptibility to <nffic acdd<nt, •nd !.t.oliti<5 i, dir« tl)·

r<latedtotheblood•kohol lev<l: coon:hruotionisd ecr<ll<d ,
m djudgmentioim pair<d. Som<,kill,.,-,impair<devrnot
The National High way Tnffic >Ofrty Administ rati on pro- 0.02 BAC, ,uch>< t he a bilitytodivid e >tt<ntionb<tw, en
,id<>thelollowing, t.oti<tic,i two or mor, visu•l input, . At• 0 .05 BAC, <y< mo, ., mmt,
 5.14 CHAPTER5

The cost of traffic accidents goes well beyond

medical costs and fixing or replacing the
vehicle. The expenses of dozens of safety
personnel , lost work time due to traffic jams ,
court costs, and lawsuits can be hundreds of
thousands of dollars. About 30 % of traffic
fatalities involve alcohol.
Reprinted by permission of Pond 5

glare re.sistance, visual perception, and reaction time are • impounding or towing the vehicles of drunk drivers
affected. 167 Impairment for operating other forms of transpor- • requiring mandatory treatment for DUI arrestees

I
tation also begins at relatively low BAC levels. Flight simula-
tors show impaired pilot performance at 0.04 BAC and for up
to 14 hours after reaching BACs between 0.10 and 0.12. 168
In every state it is illegal to drive with a BAC over 0.08.
There are no exceptions. An arresting officer needs no
additional proof that a driver is impaired, and there is no
recourse to "guilty as charged." When officers do pull a
driver over, they test coordination and physical abilities for
physical or mental impairment before requiring a breath or
blood test. One of the most effective tests given on the spot
is the eye nystagmus test.
"Forsomereasonalcoholaffectsthe e~eballs
. and the e~eba/1
willstart jerk,in9when it tries to follow a movin9 ~n9er or object.
It's amazin9: ~ou can watch people'se~esjust twitchin8awa~
when the~'re under the inRuence. The~ can't followa fin9er to
the side; the~'returnin9theirwholehead back and forth."
Traffic lieutenant , Police Depanmen t, Ashlan d , OR
Among those arrested for DUI, two-thirds have never been
arrested before, so laws and DUI classes and programs have
to be aimed at all segments of the population. In fact, a
majorit y of drivers in fatal alcohol-related crashes did not
have a previous DUI conviction, and many did not have a
history of problem drinking. 169
These prevention strategies reduced the number of alcohol-
related traffic fatalities and injuries:
• lowering the BAC limit from 0.10 to 0.08
• imposing administrative license revocation , allowing a
police officer or other official to immediately confiscate
the license of a driver whose BAC exceeds the legal limit
• training alcohol servers and mandating sanctions and
liability; legally servers are forbidden to serve drinkers
who appear intoxicated
• requiring ignition devices in cars that measure the alco-
hol in a person's system
"I'm required to have a Breathal~zer machinein m~ car for
10 ~ears,and for me I was ver~happ~to have that. knowin9
that if I were to relapse, m~ car would not take me an~where.
I have to blow at a certain rate and hum at the same time
in order to pass - to make sure / 'm not drunk- before
startin9to drive the car."
S4-year-ol d DUI driver in Washin gto n State
A combination of all of these strategies implemented through
community-wide efforts is the most holistic way to approach
prevention. Media campaigns, police training , high school
and college prevention programs , and better control of liquor
sales are just a few examples of ho w states, cities , and towns
have tried to address this issue .
In 2012 the National Transportation Safety Board issued
a Safety Report on Eliminating Impaired Driving. It recom-
mended lowering the allowable BAC to 0.05 or lower.
Drivers with a BAC as low as 0.05 are 38% more likely than
sober drivers to be in a crash. 1698
BACandChances of BeingKilledin a
Single-Vehicle
Crash
BLOOD
ALCOHOL
CONCENTRATION CHANCES
OFBEINGKILLED

• increasing the minimum legal drinking age to 21 years 0,02to0.04 l.4timesnormal

• imposing zero-tolerance laws for dri vers under 21 (i.e., 0.05 to0.09 11.0timesnormal
prohibiting driving with any or a minimum amount of 0.lOto0.14 48.0timesnormal
alcohol in the system {0.01 or 0.02 BAC for drivers un- 0.15 andabove 380.0timesnormal
der 21]); these laws have reduced alcohol-related crashes
involving youth by 17% to 50% Zador, 1991

To:ting while driving can bejus t as dangerousas driving under the
influence. A sober te,:tingdriver is 23 times more likely to be in an
accident. That is about the same as a driver whose BAC is 0.08 to
0.10. If to:ting and alcohol are combined, the risk goes up
dramatically. Talking or listening on a cell phone only increases
the risk about 1.3 times. 169A
© 2014 CNSProductions, lnc.
For many convicted drunk drivers, even though their expenses
ranged from $5,000 to $15,000, their DUI was a stepping
stone to a different perspective rather than a millstone.
"I am so thankfulthat I got this DUI becausenow I thinkof
the peopleI'velost in mq lifeand the peoplethat are loston
the highwaqs . I'm the fatherof threechildren,and if anqthing
were to happento mq childrenor if I waseverresponsible for
takingsomebodqelse'slife,... whenI'm soberand processthat
properlq, it breaksmq heart."
54-year -old DUI recipient who comp leted his DUI treatment
requ irements and continued recovery
Injuriesand Suicide
"I wouldtakea sports bottleof winewithme to workin the
morning . I wasa heavqmachineoperator.I wouldgo homefor
lunch,refillit, and comebackand drivea forkliftand operate
this thingwithspinningblades- it wasjust insanitq."
40-year -old female recovering alcoholic
Medical exam iner repo rts indicate that alcohol dramatically
increases the risk of non-automobile- invo lved injur ies.
• Emergency room studies confirm that 15% to 25% of
emergency patients tested positive for alcohol or re-
ported alcoho l use, with relatively high rates among
those involved in figh ts, assaults, and falls.
• Alcoholics are 16 times mo re likely to die in falls and 10
times more likely to become bum or fire victims.
• The U.S. Coast Guard reported that 31% of individu-
als involved in boating fatalities had a BAC of 0.10
or more.
Downers: Alcohol 5.35
• In the workplace up to 40% of industrial fatalities and
4 7% of injuries involved alcohol. 171•172
"Puttinga guq in the grounddid nothingto alterour feelingof
beingindestructible,qouknow,kidsthat we were- that ageof
believing,'God, we'reqoungand strongand there'snothingwe
can't do. Thereareno consequences to this behavior.'
And even
seeingit, goingto the funeral,watchingthe hearsedrivebq, it
waslike,'Duh.. . didn't makethe connection"'
40 -year -old recovering alcoholic whose friend died while driv ing drunk
Among adult alcoholics, suicide rates are twice as high as in
the general popu lation . The longer the alcoholism is active,
the greater the social, health, and interpersonal problems. An
alcoholic suicide victim is typically a White, middle-aged,
unma rried male who has a history of drinking. Additiona l
risk factors for suicide include depression, loss of job, living
alone, little social support, and illnesses.
"I just didn't wantto live.I mean,mq familqand peoplethat I
loveso much, I felt liketheqhated to seeme coming,and that
I
is somethingthat I wouldn'twishon anqbodq.I wasdrinkingon
a daq-to-daqbasis,just drinking-and then I woundup at the
hospital. I had triedto commitsuicide,and theqput me in the
psqchward."
38-year-old female recovering alcoholic
In the workplace,
400/oof industrialfatalitiesand
470/oof injuriesinvolvealcohol.
Patternsof AlcoholConsumption
Whether it is sho chu from Japan, a beverage distilled from
buckwheat; bojalwa, a home-brewed beerlike drink from
Botswana; mosto, a grape wine from Argentina; arrack, a tra-
ditional drink distilled from fermented molasses in India; or
pontikka, distilled spir its from Finland, alcoho l consumption
is a worldwide phenomenon .
"A pragmaticrace,theJapaneseappearto havedecidedlongago
that the onlqreasonfordrinking
alcoholis to becomeintoxicated
and thereforetheqdrinkonlqwhentheqwishto be drunk."
William Gibson, Tokyo Pastoral, 1982
"Russiais a drinkingculture. Rtfusingto drinkis unacceptable
unlessqougivea plausibleexcuse,suchas explainingthat health
or religiousreasonspreventqou fromimbibing."
Sergei Ivanchuk on the Russian business culture website Executive Planet, 2006
"O qe who believe!Intoxicantsand gambling... arean abomina-
tionof Satan'shandiwork:eschewsuch [abominations] that qe
maqprosper."
Qur'an 590, YusafAli, Mohammed's brothe r-in-law
 5.36 CHAPTER5

In the Qur'an (Koran), the drinking of wine is frowned upon
because drunkenness interferes with one's religious duties.
For this reason alcohol is banned in many Islamic coun-
tries. The Bible is ambivalent about drinking, but there are a
number of Christian sects that ban or discourage alcohol,
including the Church of Jesus Christ of Latter-day Saints, the
Seventh-day Adventist Church, and some fundamentalist
Protestant sects.
Culture is one of the main determinants of a person's
drinking behavior. Culture is composed of dozens of factors,
including social mores, religious beliefs, economic structure,
form of government, and the temperament of the people. It
is difficult to get accurate, comparable, and consistent alco-
hol use data in other countries, but, as Table 5-4 illustrates,
most European countries have higher per capita alcohol con-
sumption rates than the United States while most Asian
countries have lower per capita consumption. Drinking pat-
terns are different in "wet," "dry," or "mixed" drinking cul-
tures, although recent research suggests that the distinctions
are not as clear-cut as they once were. 69 •172 -' 72A. 173 ,i 74
Dry drinking cultures (e.g., Denmark, Finland, Norway,
and Sweden) restrict the availability of alcohol and tax it
more heavily. Dry cultures consume more distilled spirits-
almost 1.5 times the amount in wet cultures-and are
characterized by binge-style drinking, particularly by males
on weekends. 172A
"WhenI wascomingup, ever~bod~ drank.I mean, I couldn't
wait. I wastold when I was 12 ~earsold that the on/~wa~to
get hairon ~ourchestwasto havea drink.The olderpeople
reall~didn't so muchmind ~oudrinkingas longas ~oudidn't
act a fool behindit."
41-year-old American male recovering alcoholic
Mixed drinking cultures (e.g., Canada, England, Germany,
Ireland, Wales, and the United States) exhibit combinations
of both wet and dry cultures. Drinking patterns such as
binge drinking in social situations or several bottles of wine
at dinner are common. A higher incidence of violence against
women is found in mixed drinking cultures versus dry or

I
Wet drinking cultures (e.g., Austria, Belgium, France, Italy,
and Switzerland) sanction daily or almost daily use and inte-
grate social drinking into everyday life. In France children
are served watered-down wine at the dinner table. Wet cul-
tures consume more wine (five times as much) and beer as
do dry cultures. While there is less drunkenness in wet
drinking cultures, there is a greater prevalence of health
problems such as liver disease. 69 •174
"In France,whenwe celebratethingswith famil~.
we havea meal.We'renot drinkingon/~alcohol-
~ouknow,the wineand thingslikethiscomewith the meal.
You know,nobod~isgoingto comeout of that complete/~
drunk.We ma~be probabl~happ~becausewe drinka
littlebit, but we won'tbe drunk."
53-year-old French male social drinker
wet cultures.
Chinese families drink infrequently, often because of
cultural pressures. In Japan and South Korea, however,
social pressures to drink are very strong. In Japan most of
the men and half of the women drink, yet the alcoholism
rate is half that of the United States. This could be due to an
allergy-like face "flushing" reaction that many in these
cultures experience. It is believed that the flushing reaction
causes embarrassment, which in a cultural way protects
those who experience it from developing alcoholism.
In Russia vodka is traditionally consumed in large quanti-
ties between meals. The country's preference for vodka
dates back 500 years, when Czar Ivan the Terrible forcibly
replaced the sale of beer and mead with state-controlled
vodka served in state-run taverns. Alcoholism was so ram-
pant in Russia over the centuries that in 1985 Premier

Alcohol is used in many ways, often patterned by the culture and yet very similar in purpose.
A. Frenchmen spend an afternoon in friendship warmed by wine.
© 2006 CNSProductions,
Inc.

B. Russian women in a village near Minsk celebrate Koliady, an ancient pagan holiday that has become associated with Christmas.
© Viktor Drachev/GettyImages

C. While relaxing at a hot springs resort, a Japanese man expands his relaxation with sake,Japanese rice wine.
© 2010 John S. Lander/GettyImages

Mikhail Gorbachev severely restricted the availability of
alcohol almost to the point of prohibition. The number of
illegal stills escalated along with the consumption of any-
thing containing alcohol, such as shoe polish and insecti-
cides . In one year, despite prohibition, 11,000 Russians died
of alcoho l and alcohol-related poisonings. After many of the
restrictions were lifted, the number of alcohol-poisoning
deaths is reported to have soared to 40,000 . When the
restrictions had been in place for a few years , the life expec-
tancy for Russian males started to increase . Once the restric-
tions were lifted, male life expectancy dropped six years.
Drinking on the job is common due to the easy availability of
alcohol and a culture that has few recovery programs .175 •176•177
In January 2010 about half of England's 60,000 pubs curbed
the promotion of happy hour and removed the 11 p .m . closing
hour , which had encouraged binge drinking and expelled
thousands of drunks onto the streets at one time. These are
significant changes in a country with a centuries-old tradition
of warm beer and darts at the local pub. About 70% of Britons
drink regularly; two-thirds of the alcohol consumption is
beer. The alcohol-related death rate almost doub led between
1991 and 2005 to 12.9 per 100,000. In response, a recent cam-
paign to stem alcoholism urged Britons to reduce their average
daily consumption to just three drinks . A group of British
physicians urged the government to raise alcohol taxes, raise
drink prices, and lower the allowable BAC for drivers -"'
>
The United Statesis a
mixed drinkingculturewhere
binge drinkingis common.
In the United States, most drinking is done in social set-
tings away from lunch and dinner tables . In a land of many
different cultures and lifestyles, there is a wide variety of
culturally influenced drink ing customs .
PopulationSubgroups
Men and Women
Regardless of age or culture, men drink more per drinking
episode than do women . Much of this difference has to do
with the cultura l acceptability of male drinking and the dis-
approval of female drinking . Men are able to efficient ly
metabolize higher amounts of alcohol. This capacity some-
times creates more adverse social and legal consequences
and leads to alcohol abuse or alcohol dependence at a higher
rate in men than in women . Alcoho l-dependent women as a
group drink about one-third less alcohol than alcoho l-
dependent men_1.179 Alcohol problems escalate in a woman 's
thirties compared with men's problems , which increase in
their twenties .24 •25
The magnitude of the genetic influence in women from one
or two alcoholic parents has not been as widely examined as
it has in men , but research indicates a similar genetic suscep-
tibility between men and women .180•181•182 In fact, the rate of
alcoholism in relatives of females diagnosed with alcohol-
ism is somewhat higher than in relatives of male alcoholics.
Downers: Alcohol 5.37
Several studies demonstrate that even low levels of drinking
in women with a certain genetic susceptibility can result in
major health consequences such as an incr eased risk of
breast cancer .78 Proportionally, more women than men die
from cirrhosis of the liver, circulatory disorders, suicide,
and accidents . Generally, female alcoholics' death rate is
50% to 100% higher than that of male alcoholics. But just as
health prob lems develop after sustained heavy drinking ,
some health disorders, especially depression, may precede
heavy drinking and even contribute to it. Also, because
women register higher BACs than men after consuming the
same amount of alcohol, negative health consequences
develop faster for women than for men.
Because society more readily accepts the alcoholic male but
disdains the alcoholic female, women are less likely to seek
treatment for alcoholism but are quicker to utilize mental
health services when, in fact, their primary problem is alco-
hol or other drugs. Women are also mor e likely to enter
treatment when their physica l or mental health deteriorates ,
whereas men are more likely to seek treatment when they
I
encounter prob lems at work or with the law.
Adolescents
Alcoho l is a legal drug for adults , and it is readily available in
most every home in the United States and abroad .
Experimentation by children of elementary school age hap-
pens more often than one would think: 3 .9% of fourth-
graders , 5.5% of fifth-graders, and 10.4% of sixth-graders in
the United States drank alcoho l. 183 When students enter the
eighth, tenth , and twelfth grades, those numbers jump to
23.6%, 48.5%, and 63.5%, respectively (2012). 48 In some
other countries (e.g., the United Kingdom, France, Germany,
and Denmark), the percentage of 15- to 16-year-olds who
PerCapitaAlcohol
C Consumptioninthe
6 UnitedStates,
0.
1700-2012
0
C
.2
"'
CJ
o-----~--~--~--~--~- - ~~
1700 1750 1800 1850 1900 1950 2012
Year
In the United States, the per-capita consumption of pure alcohol is
2.2 gallons, but as this chart shows, the rate has varied wildly with
the rise and fall of prohibition movements, health concerns, and
availability of a good water supply.
Musto, 1996; Carlson, 2008
 5.38 CHAPTER5

Women
andAlcohol
Problems
MORELIKELY
TOHAVE
DRINKING
PROBLEMS LESS
LIKELY
TOHAVEDRINKING
PROBLEMS
Younger
women Olderwomen(6D+)
Lossofrole(motherhood,
job) Multiple
roles(wife,employed,
mother)
Nevermarried Married
Divorced,
separated Widowed
Unmarried
andlivingwitha partner Children
inthehome
Whitewomen Black
andH~panicwomen
Using
otherdrugs Minimal
useofotherdrugs(e.g.,prescription
painkillers)

drink regularly is two or three times higher than in the
United States.
Research indicates that the younger someone starts smok-
ing or drinking, the more likely he or she will have a prob-
Most adolescents believe that they are invincible and dismiss
any and all cautions associated with activities they wish to
pursue . Drinking alcohol and smoking tobacco are the most
pervasive activities. Often the drinking pattern is to binge,
and the purpose is to get drunk.

I
lem with tobacco or alcohol later in life. This conclusion
stems from the fact that the brain does not fully develop A major survey of students called Monitoring the Future
until age 23 to 25, particularly the prefrontal cortex, which found that the percentage of teenagers who had been drunk
controls executive functions and decision-making. On the in the past month was less than in previous years but still
other hand, the emotional center of the brain-the limbic high:
system-develops earlier, so there is a period of time during AnyMonthlyUseofAlcohol
"
adolescence when emotions and cravings are very strong but
Grade 1993 2003 2013
the brain's regulatory functions are not yet developed, which
leads to more than a fair share of bad decisions. In addition, Eighthgrade 24.30/o 19.70/o 10.20/o
the hippocampus-an area of the brain responsible for learn- Tenthgrade 38.20/o 35.40/o 25.70/o
ing and short-term memory-is smaller in adolescents who
Twelfthgrade 48.60/o 47.50/o 39.20/o
began drinking at an early age; those who were heavy drink-
ers in their teens have memory problems as adults. 184 In
early adolescence, environment greatly influences behavior; BeenDrunkin thePast30 Days
as people move toward their twenties, genetics becomes Grade 1993 2003 2013
more influential. 18' Eighthgrade 7.80/o 6.20/o 3.50/o

Tenthgrade 19.80/o 18.50/o 12.80/o

The youngersomeonestartsdrinking,
the greaterthe chancethat they will develop
alcoholor tobaccoproblemslater in life.
Researchers also found that the use of alcohol to relieve
stress in adolescents makes them significantly more likely
to continue its use and abuse in later life. 186 Preschool chil-
dren who exhibit antisocial behavior, poor self-regulation,
poor self-control, anxiety, a tendency toward depression, and
shyness are more likely to use alcohol during early adoles-
cence and to develop alcohol and other drug use disorders in
adulthood. 187 Almost one-third of all teenagers report having
had their first drink before they were 13 years old, most
often due to peer encouragement.
"I was a cit~ kid, and it was prett~ much a standard rite of pas-
sage when ~ou're12, 13, 14 to, ~ou know, one wa~ or another,
get ~our hands on a six-pack for a Saturda~ night-and that's
how drinkingstarted for all of us in m~ neighborhood."
22-year-old recovering alcoholic
Twelfthgrade 30.80/o 32.50/o 26.00/o
The 2013 study found that the percentages of daily use
were only 0.3%, 1.0%, and 2.5%, respectively, emphasizing
the binge nature of teenage drinking. 48 Adolescent binge
drinkers are 17 times more likely to smoke than nonbinge
drinkers, a combination that can cause gastrointestinal,
respiratory, and other problems .
The teen years are a time of intense emotional growth, and
the disinhibiting effects of alcohol can encourage unsafe
sexual practices, which lead to higher rates of unplanned
pregnancies, sexual aggression, and sexually transmitted dis-
eases. If adolescents are heavy drinkers (and/or users of other
drugs), their emotional growth is stunted; if they do stop
using, they are emotionally the same age they were when they
began using. For this group, recovery is not just a matter of
stopping use but also of learning the coping skills they failed
to learn while using. They must learn to rely on common
sense to deal with adverse events, unwanted moods, and
painful emotions rather than on alcohol or another drug.
 Downers:Alcohol 5.39

CollegeStudentsand Learning "Secondhanddrinkin9is a lar9eproblemon a colle9ecampus,

An article in USA Today reported on a study that sampled
30 ,000 freshmen from 76 campuses and found that 35% of
them spent more time drinking in a week than studying:
10.2 hours of drinking and 8.4 hours of studying. 188 Students
who survive their freshman year are better able to control the
amount and the frequency of their drinking.
"Wedrankquite a bit in mq dorm, and, 9enerallq,when
somebodqcame into mq dorm roomon a weekendni[jht,
qou had to drinkfroma beerbon9. And we'd havea funnel
that held liketwo and a half beers, and it was just the rule.
We kindapressuredpeopleto keepup, like~ou had to do it
to staq with the crowd."
College stud ent in hisjunior year
In decades past , a college freshman finally free from parental
control would begin heavy drinking. But in the 1990s and
2000s , the age of first use and heavy use dropped to where
many students had "done it all" by the time they finished
and it is a problemon our campus.We havea lot of students
complainabout theirroommateor theirbo~friendor9irlfriend,
~ou know, bein9drunk violenceoccurrin9,vandalismoccurrin9,
bein9unableto studq, havin9to staq up all ni9ht with that
personwho maq havehad too much to drinkand the~ need to
sta~ with them to makesuretheq makeit throu9hthe ni9htand
the~ don't die fromalcoholpoisonin9."
Shauna Quinn, drug and alcohol counselor, California State University, Chico
"I9uessstudqin9on the weekendswasa lot moredifficultbecause
a lot of peopletend to partqand drinka lot more. Peopleare
ban9in9on the wallsand comin9into qourroom, tr~in9to
9et ~ou to comeout and partqwith them. On a Frida~or
Saturda~ni9ht, qou had to take qourstudieselsewhere ."
College senior, SouthernOregon University
In general , the following is true.
• Male students binge more than female students (48.6%

I
their senior year in high school. Studies show that the major-
ity of students continue the same pattern of drinking from to 40 .9%).
high school to college. 189 • White students (50.2%) are more likely to binge than
Hispanic (34.4%), Asian/Pacific Islander (26.2%), or
"O~en it's the stqleof drinkin9,not experimentation,that 9ets Black (21. 7%) students.
colle9estudents in trouble.Man~ think the nameof the 9ame
is to 9et drunk.Theq drinktoo fast, the~drinkwithouteatin9,
theqplaq drinkin99amesor havecontests, or theq bin9e-drink.
But becausetheq drinkheavil~on/~once or twicea week theq
Doonesbury BY GARRYTRUDEAU
thinkthat thereis no problem.But thereusuallqis a problem: 7/.15[)fi6/GNA7W
SOWONe NPl.l,NO 7H& 8//6R . CJNc.{¥={/S
lowererades, disciplinarqaction, or behaviortheq re9ret,which ATPIIIPHAT Q',1/;BUT MiATf (3eT,77WJ<ef) AJ.lf)
usuallqmeanssexualbehavior." IJRINK5AT 7Hii[)8. 1HeNa3GCl<IB65
All, f?ARR&N?' \ 7Ht;exP!:RJ/fNCI;
Drug and alcohol counselor, California State University, Chico I 7lJ 7He 07'}{l;RS ...

Forty-seven percent of college students admit to binge '\

drinking at least once every two weeks. 190•191 One in four col-
lege drinkers consumes alcohol more than 10 times in a
month, 40% get drunk once a month, and 29% get drunk
r;.
three or more times per month. 48 Binge drinking is defined as
having five or more drinks at one sitting for males, four for
females, at least once or twice a week. Many students,
particularly males, object to this definition. Many binge
drinkers miss classes on a regular basis, and about half the
students in one study who admitted to binge drinking also
admitted to the fact that their grades fell into the C-to-F
range. 192 In a national study, there was a direct correlation
between the number of drinks consumed per week and a
student's grade-point average (Table 5-8).
Women's grades start to deteriorate at slightly less than half
the drinking level it takes for men's grades to go down. The
National Survey on Drug Use and Health indicates that the
higher the level of education, the more likely the person was
currently using (not necessarily abusing) alcohol. Although
this seems to contradict the statistics presented in Table 5-8,
the rate of heavy alcohol use in the 18-to-34 age group who
had not completed high school was twice that of those who
Doonesbury © 1998 G.8. Trudeau. Reprinted by permission of UniverdalUClick.
had completed college. In general, college students learn to All Rights reserved.
moderate their drinking before they graduate.
 5.40 CHAPTER5

Average
Numberof Drinks
perWeek,
byGrade-Point
Average
DRINKS
PERWEEK
(ot-,IG~A1UU\1,~~.

t=iN/\Lct
SiMMot{S
M'?-
fo'1t\1
'(oU'RG\(~1)~
.
~~e~M;e "~$'
'f U.f2
e'Xc~e'Qei) 0
GRADE
AVERAGE Males Females Overall
A 5.4 2.3 3.3 L~\Jel.
iLoot)-fiJco\-\oL
B 7.4 3.4 5.0
C 9.2 4.1 6.6
Dorf 14.6 5.2 10.1

College Core Studyof 56 four-year and 22 two-year colleges by Southern Illinois

University, Carbondale, 1993
Wechsler, Lee, Kuo, et al., 2002

• Fraternity members (75.4%) drink more than dormitory

residents ( 45.3%), off-campus residents (54.5%), and
married residents (26 .5%). 192
Tragically,binge drinking in college leads to about 1,800 deaths
per year, 696,000 physical assaults, 599,000 injuries, and

I
97,000 sexual assaults. 193·194Given these statistics many
treatment professionals strongly oppose the Amethyst
Initiative , which advocates lowering the drinking age to 18
to match the age at which a person can smoke , go to war, be
tried as an adult, and marry Part of the impetus for the
Amethyst Initiative comes from a group of academic leaders
from independent liberal arts colleges who believe that the
current drinking age:
• is unrealistic and routinely violated
• encourages dangerous binge drinking
• pushes students to make ethical compromises, such as
using fake IDs, thus eroding respect for the law
• inhibits development of ideas to better prepare young
adults to make responsible decisions about alcohol
47% of college
studentsbinge
drink.
Those against lowering the drinking age note that after the
drinking age was raised, teenage automobile fatalities and
many of the problems related to drinking in this population
went down. Also, because most college drinkers learned to
drink in middle schoo l and high school, lowering the age
would have no impact on what they learn and what they
drink in college. Alcohol education does help , but it is not
the automatic fix that some people believe it to be. Drug
education has to be realistic and continued throughout
the years.
Older Americans
"Forcertainlq
, old a9e has a 9reatsenseof calmand
freedom; when the passionsrelaxtheirhold, then, as
Sophoclessaqswe are freedfrom the 9raspnot of one
mad masteronlq, but of manq."
Pla!o, The Republic, 30 B.C. (transla1ed by &njaminJow elt)
Flying McCoys® 2006 Garyand Glen McCoy.Reprintedby permission of Universal
Udick All rights reserved.
People 65 and older have the lowest prevalence of problem
drinking and alcoholism for the following reasons .
• People who abuse alcohol usually do so before the age of
65, suggesting a high degree of self-correction or sponta-
neous remission with age.
• Cutting down or giving up drinking altogether may be
related to the relatively high cost of alcohol for those on
a fixed income.
• The body is less able to handle alcohol because liver
function declines with age. The general aging process
also decreases tolerance and slows metabolism , so the
older drinker often has to limit intake.
• Side effects are increased if someone is ill or is taking
medications that warn of harmful interactions when
used with alcohol.
By 2020, 54 million Americans (one in six) will be 65 years
or older, so though the percentage of senior alcohol abus-
ers is low, the actual numbers will be high. 195Of the current
elderly population of 40 million, 48% of men and 32% of
women drink, most in moderation. Only 10% of older men
and 2.4% of older women are heavy drinkers (more than
four drinks per day and more than 30 per month) , or one in
nine older Americans . From 6% to 21% of elderly hospital
patients , 20% of elderly psychiatric patients , and 14% of
elderly emergency room patients exhibit symptoms of alco-
holism.196In nursing homes as many as 49% of patients have

drinking problems. 197 Generally, older drinkers are White
and male, have higher levels of income and education, and
are more likely to be single and to smoke. Studies suggest
that the percentage of heavy drinkers is probably higher
because "hidden alcoholics" go undiagnosed by physi-
cians, their families, and their friends .198
Research indicates that patterns of drinking persist into old
age and that the amount and the frequency of drinking are a
result of general trends in society rather than the aging pro-
cess. Hip fractures, one of the most debilitating injuries
suffered by the elderly, increase with alcohol consumption
because the deleterious effects of alcohol decrease bone
density .199 •200 Because the average American over 65 takes
two to seven prescription medications daily, alcohol/
prescription drug interactions among older people are
quite common. 201 Pharmacologic research identified more
than 150 prescription and over-the-counter medications that
interact negatively with alcohol. 202
"It was hard to tell if Maw Maw was drinkinga little too much
or if the blood pressure,osteoporosis,hormones,or the three or
fiveother prescriptiondrugs weremakingher dope~. Later on,
a~er much discussionwith her doctor, we found it was both.
The amount of alcohol was hard to figure. .. possibl~three to
four vodka tonics, fiveor six da~s a week."
Son of a 78-year-old retiree
About one-third of elderly alcohol abusers are of the late-
onset variety .203 This is often the result of isolation, retire-
ment, financial pressures, depression over health, the loss of
friends or a spouse, a lack of a day-to-day structure, or sim-
ply the access to and availability of alcohol in their own
home or in the homes of their friends . This group is less
likely to have interactions with people in a workplace, the
criminal justice system, or drug-abuse treatment providers,
so identifying those who need help is more difficult. Another
barrier is society's tolerant attitude toward drinking by the
elderly. Reactions like, "So what if they are heavy drinkers?
At their age, they deserve to do whatever they want. They
have contributed to society and, at their age, what harm
could it do now?"
Diagnosing drug or alcohol problems in the elderly is made
more complicated by the coexistence of other physical or
mental problems that occur due to the aging process.
Dementia, depression, hypertension, arrhythmia, psychosis,
and panic disorder are just some of the conditions where
symptoms are mimicked by either the use of or the with-
drawal from alcohol and other drugs .20' It is often up to the
physician treating a patient for a routine medical condition
to recognize an alcohol problem and to take action . A brief
intervention may be all it takes to get the elderly patient to
be more involved in correcting the drinking behavior .
U.S. Military
From 1998 to 2009, according to the U.S. Army, the rate of
Gls seeking treatment for alcohol dependency has gone
from 7 .2 to 11.4 per 1,000 active-duty soldiers. The increase
is a reflection of extended tours of duty in war zones and the
Downers: Alcohol 5.41
general stress of combat. m The number of alcohol-depen-
dent active-duty soldiers who did not seek treatment is very
high and would increase the ratio significantly.
The macho atmosphere that permeates drinking in the ser-
vices makes many loathe to admit any problems . One survey
found that 20% of active military personnel admit to heavy
drinking while 53% admit to binge drinking (rates similar to
those of college students) .208 Those who might seek help
often hesitate because the military does not grant them con-
fidentiality-commanders are notified if one of their soldiers
enters treatment. Excessive alcohol consumption costs the
U.S. military $1.12 billion per year, with medical expendi-
tures accounting for 42% of the total. 210
About 85% of those seeking treatment for substance abuse
list alcohol as their primary drug of choice . The relatively
new Department of Defense Alcohol Abuse and Tobacco Use
Reduction Committee has a goal of reducing alcohol abuse
5% per year by focusing on prevention because so many in
the military with drinking problems do not seek help.
I
In contrast, the prevalence of illicit-drug use, including pre-
scription drug abuse, declined from 28% to 12% between
1980 and 2008, a much better record than that obtained
from dealing with alcohol abuse in the military .
The Homeless
The recent economic recession cost many people their home,
their livelihood, and their mental health, leading some to
join the ranks of the homeless. Falling on hard times is not
the only reason people are homeless .
• The situational homeless, who because of poverty, job
loss, spousal abuse, a shortage of affordable rental
housing, or eviction, find themselves on the street.
• Street people have made the streets their home and have
chosen to live outdoors.
• The chronic mentally ill have been squeezed out of inpa-
tient mental facilities over the past three decades in favor
of less costly outpatient health facilities, which do not
offer housing .
• The homeless substance abusers, particularly alcohol
abusers, whose lives center around their addiction,
making them incapable of living within the boundaries
of normal society.
"I had a double addiction- alcohol and gambling- that kept
me brokeand livingin m~ car for months at a time. I would
general/~park overnightin the parking lot of 24-hour restau-
rants such as Shari's or Denn~'s.To me the~'resafer than road-
side restsand have clean restrooms.In addition, if I'm drunk,
the cops don't hassleme as much as the~ would on the street."
64 -year-old retired mechanic
The last two groups include mentally ill people who have
begun to use drugs (often to self-medicate) and drug abusers
who developed mental/emotional problems as a result
of drug use. One of the common denominators among all of
these groups is their lack of affiliation with any kind
 St,,,t'l"""li,,d"!t-W,""l:tupo/'1.,,Jrinl.
S1,,,tr~n·0n.lab«r .·
5t
:I:;!';~
-~n;
:&rJ:z~~.•t~""t/~j
tl,,linl,.comtont!lj."
St,,,tt«"l/'rl3,"E.c,ptfo,ri/jht,.,..·cou.,w,,b,'tl.,,.,,

~~~::::;-f'"l,«n~thatY
St::''l"""l},,d"/t"Allmilif,.pr,tt~m""h<in«l"""o
c::::::r;,.Hoo.o/Jor,'l"""""',"
St::7:!1!'.!~;~;=~11t:2Ei•:.?,J:/~
_.,.
~•eflliawto,-..,,wlf·
,_ ,.,.,.....
°"""""'""°""""'
..,.._,,,...,...,""""
"""'""
'""""'
"-
All""".!hlNpt"""inW!"',.,,;,,....,""""'"''"ln.:lf"'"""'J Comprehemiv, programs de,igned 10 • lleviat< drug and
p,up/L,..,,,,N~ ·onlht>m<kssl,..,,,,"'"'.l,'"""Jalll"1o<N
menulproblem,;amongthehome lu,indude a noutruch
•l""""""'li.:-lt<><-"'J'°"' '"4Jo"W<>"'f"""'J.
romponmtth.o1provid«!i0mebasicservic«mdmrour-
•0 '.' n1>tomt<rtt< atmen · ' ·•·v3 . N• t'on ·dethere
a r<e730,J76emergency•ndtr2I1Sitionalye•,,.roundbed•
distributedequ•ll)' a mong<metj!mcy<h<lt<r,•ndhomel<>•
ofsuppon,yst<m . ><TVice,th.otidrntify•ndtrut,ub<unce
hou,ing. "-' M•nyciti«trytoprovideser.ic,.>t<helt<r<md
• bu,, •nd mrn ul h<•lth probl<m, •re hard tofindor, if
gotheringpbcnforthehomde<S,butbecan«cnumerou,
• vail>ble. ne, hunnedbymE1yofthehomeless B'
«TVice,•re n«dedtome<tthewid,varietyofproblems
ltish>rdto«timot<thetoulnumb<rolpeople•ff«tedby ~=bl';n<lnina oftm make funding of these «TVice,
homek,on<>• in the United s ... ,.. . A survey conducted
before theeconomicdownto m olthe lat< .WOO. by the
Dep.nmrntofHousingan d Urb•nO.,.dopmrntputthe EthnicPopulations
numbero f, hdt<redandunslttlteredhomd,s,>1610,000
Biological •nd neurochemical dif!uenc« among ethnic
:'e ::rm't::ti~:1:.~ir:r~i~l~nt~~t,711::r ;;;.::
prn:entofthueindhidn•ls • res.aidtobechronicallyhome - gro~p, =~unt lor the,':'~~ patl~ of ~roh;I _anddrug
less."' Tbe"'·er•gelengthoFhomtles,ne"i••ixmonth,
trib ut<gr utlytoalroholuse•ndabu,epatt<rn<a<doe,
The •ppro ximat< breakdown of the homde,spopul>tion thedegruol ... imibtionintothedr!nkingpa tt<msolthe
(d<p<ndingonthe!iOun:<)is dominmtculture.S.nsitiv!tyto<thniclr2dicion<andd,gree,

• 30%fam ili«withchildre n EJect< te

of ... imib tionc•nhel p!iOCi.al«TVice•gen cie,und em.md
~ow al~oho\~" har'.:ih: family life. -:;.,!iOCi.al
• I7%employed,18 .7%,,et<ra n,,and2 '1%disab led mo,,.."ct'wtr<atmentandprevmt'on .'"
• 2%•re62-p lu,;yur,of•ge
AfricanAmericans
lnthelOllNation.a!Surv,yonDrugU« a ndHe•lth,heovy
2%MWl.•nd~.1%mulcipler.tcn u .. oF•koholbythoseowrll"'2<loweramongAfri=
Ameri=• (5.2%) tlun • mong Wh ites (7.9%) and Hispanics
~:::!:~:nd menu! problem>>t< found in• llgroup,ofth e {S.6%). U,e on• monthly bas i, by Black men (53%) i< al,o
le,s than tha t by Whit< mm (66 .2%).1 More Black womm
absu in thE1 do Whit< women, but then is • higher inci -
• 30%wouldbediognosedu,eriouslyment1llyill dence of havy drinking •mong Bl•ck women who drink
Pe•kdrinkingfo,Dlacboocu,.aFt<rtheageof30 . while
• 23% have 0<eriouo akohol probltms, and 27% have
drinkingamongWhite,pe•k<at•)'OUng<rage . Twore=n•
other drug problems
lortheh igherrateof•bst<n tionandthelower r.tt<ofhe avy
• 10% to 20% have • dual diagnosi s (menu! illn ,.. and drinking •mong African-American youth is the cultural
drugor•icoho l prob l<m) hi<tory of ,piritu.ality •long with a otrong motri>n:hal
• ::;mde .. molealroltolicsoutnumberltTrullealroholics !.mily structunc, both of which di<rourage hav)'drink-
ing ." ' Th«e!actors•l.,.oha ,,.animpacto nreco,,ef} '
 communili<, in 1012 wa,;: pa.,l-monthuS< . 16 .4%; bing e u«,
·s..i,~.th,r,wa,arffll/n!oour'l""tl, , b..clrothtti"" 13 .2%; h<>vy drinking , 3.1%; •nd thos.< reportingd<p<n ·
"""'""'"""att,nd"'8chY,d,,,w,J,,1h,li""1"oc,ofo1<r drnc,cinthepa.,t)=r . 8.8%'

~;!,t~·t:~i$E;E~~~J~
ij""Ondrais,'l""a,iJlow'l""andfr''r"'"'l,,,tlff"''I""
Unlik<thegrneralpopubtion,drinkingincr<>«sinth<
H',pan' rommun·ty••<du ti ••nd'ncome'nrne•S< . On,
oltheba rrier,; tod iminotin g• lrohol• buse•ndoddic tionin
inork,~'l""rob,onaddi<:t- the Hispanic community i, • lack of culturally relevant
........,,.,._""""",...,
' """odoo!P
_,,....,..._ tr<>tm<nt &ciliti<• and p<rliOru><l.Whrn 50mrone dou
c.""'""""""'°"""''""'-'-' rnt<rtr<C>tm<nt,theroodto=:m-e rymusth<c•r<fullyruo,i -
g:,t<d•ccordingu,theindividu•l>rultura l mo=mdthe

>
structureofthelamilyunit
s,.,., .d,inkinsin.•t..Uni~Statesi!i
lowestamonsAlncanAmencanscompared
toWh~esandH,spamcs. ,!,.:r.~;oic
-~:;(t=:~tt:ir;:;:,;~"::~ 0

Contr•ry to popula r b<lid. the African-American rommu •

nityi, a ctuallyadP,u..,multkultur.,lsoci<tywithotl<><t
:""~:::~i.::~;:j7/,;:t,7:::t~
h<rthot,h,~l,,, .. 1oka,-,h,,,,t,..,,.-1.pi(,h,.....i,J
fourrnbgroup< to<laijd,oo_Andltl.ooy,t.Thi....,..,n,Mtobolt.
• ~~::: d::::,. :~;;;::n i:;,;n the Unil<d S<at<S ~•.:x~=:t±"',i;tA~d~'::~~"!7:,;t,/
• descend.ntso/Afri can<l•v<>fromtheC.ribb<anwho
migr.u <dtoth< Unit<dS t.ol<>
Ther.u,olalcoholuS<•mongfema leHispmicoha,;grown
• Afric•nnofr,1e,whomigr.,t<dtothe Unil<dS tat<••nd
overthepa.,t2071e•r:s,po55ibl)·du et o•chmg<in>ttitudu
whorepre«nt•numb<rofcu ltu=mdro untri es
tow•rd women> rights , an incra « in th< number of !<male
• those wh0« loreb<u, int<rmHri ed with other rthnic h<.adsolhon><hold,andcont<mponrycultura l tradi tion,
groul"overth<put350y<ar:> Gener.illy.Hispn,icwomrndrlnkconside'2hlyle .. th•n
Each,ubs<qurntgenera tionofth «<group<devdop<its H'•p•n 'c mrn. Wh<nHis,•n'cmrnorwomrn<nt<rtR>t •
ownun'querultur< mrnl . strong f.omily im-olvemrnl i, n<e<>sary •long with th<
counS<lorO ,inctr<>pprrciationofthe, .. lu<>ofdigttida.:I,
Th<T<i,ilit~e ..... rchtho1uk<sthlsdh-.nityinu,accoun1.so r<>p<<oyc.uillo(digni1y , r<Sp<ct,md lo,1e)."'
thedauon•lcoho l useamongAfricmAm<rican,•r,cnol ti
,p,cific.,th,yrouldh< .'" Onedi,iturbingdiff,renc,h<tw«n Asiansand PacificIslanders
Whit<>>ndAfri canAmericansi,lh<.,,..,rityofmedicalprob-
Asi•nsmdPacificl,la ndas (APl•l•r<thef.o st,,a-growlng
ltmsbrough ton byheavydrinl<ing . Theh<althi>suesreach
ethnic group in the United Stat<>, though curr<n~ y they
critical,~ because,rompam:lwithWhit<> . African
Americans oft<n hove l<» acres, 10 hulthcar< !xiliti<S, in,ur - constitut<only•bout 5.6%ofthetoalpopubt ionor •ppro x-
imat<ly 17.Jl million people ."' ll<cau« th < W><l APJ
•nce, p="<ntion progr.,ms , and <2rly rntry into tR>tmrnt. ""
rncompassesdo,rn,ofdistinc1<thnicitksthroughou1th<
Hispanics Pacific S..in (includingJ apan<«, Chin«<, Ind ian , U<>ti m,
Filipino,Kore•n ,Vi<truom<><e,Thoi,lndone,im,Bunn«<,
In 2000 there""""' 33.J million Hispan ics in the United
Hawaiian . andotherPacificl,iandeB).mokinggrnmilized
Su«s,or•boutU.3%olth<tou l popub tion. Thotfigure
,ut<mrn<>•boutAPbcan l<>du,inaccuraci<>regardingth<
gr,wto33millionby2012(13. S%ofthepopub t ion)•nd
ut<ntofth<irdruguS< a ndth<r<~omlorit;however, a frw
ise,q,,ct<dtor<achl02millionby2050(H .~%o fthepo p-
gener•liuionscanh<mad<
ulation) .'" One of the challenge, inher<n t in examining
Hi,panic • lcoholmddrugu .. i, thedivasityolru ltur,s AslanAm<ricans>r<r,port«lU>havethtloweotrat<of

;;:~~~
1!:::;:~:~:;..; ~~;~~:7ro":do!';.'.:~
drinking•nddrugproblemointhtUnit<dSa
then.t<oFalroholdep,nd<ne<andabu..,fou
ta , aboutholf
nd inWhi t.,,. '
other Spmhli-,p<aki ng counlri<,_ Each ofth<>< culture,

Ame~c>ns .f ~rchfishow , that ti'.::gmor< ~rult~ra,rth<

::~':r~:'oou':
b,com,
:."::': :;;::t~,:.'
~~P1;:
more highly acrultur.ited (mote g<n<ratiom in
p,rsono/Hispanicd<>«ntis,themor<h<o r ,hedrinks. "' America and• b<tt<r command of Engiish) , drinking
incras<> .' " "'T houghth<T<•r<g,n<ticfacton. lik<the
About60'l,ofallHi•p•nicsinth<Unit<dSa«s=of
"flushing•yndrom< ."thatdod<t<rh<>,)'drinki ngamongth is
Mrnc2Ilorigin. 9.5%ofPuenoRicanorigin,md3 .2%ol
group,cultur.il influencnarethemostpov,ulul(i .<.,ha,y
CubanorigirL "' ln••urveydone!nthe<.arlyl980,; . h<»y
drlnkingis,tronglydisappro,..dolinma,tAPlcultm~)
•lcoholUS<w:il5high<Stinth,Maican-A m<ricancommu -
nity, somewhat l<>W<T in the Pu,no Rican community, •nd Survey,; confinn that then ""' significant differrncuin
,1ery!ow • mongCubanAm erican , .Alcoholn><inHispanic drinking pattemo•mongd iff<r<ntruotion •I APlgroul"••
w<ll a,; dif!e=,cn between A<ian and A,.i,,n.American varioustribes,especi,,.llytho,.elivingonrese=tionsth.ot
drinking pat<= lor the .. me roun,ry,-foreign•born vs accounllfOl'thehighlyvi,ibleAmerk•nlndianalcoholk
American •bornAsiansof the .._meeth nicorigin a r.devrn (ln a ,ur.'<yo/Siouxtribes,ho""'""'•thewomendranka,
an;o"[' ~me gmer:otion of A<ian Americam with idrnti • much., the men.) The UctthatmE1y,ur, ~.,! nterview
onlytho.,individu.al,liv!ngon•=tion,whereonly
one-third of the toOI! Ameri can Indian population lives
lnonestudyinLo. Angd es,F ilipino A- ·-• oo
oftencoupledwiththegrindingpovutyon50mer=TV> •
J•pane!i<C Americans were twic e H likely a,; Chine,..
tiom,mayex plaintherate,ofhe »ydrinkingreportedfor
Americanstobehn.vydrinken . KoremAmericamrum,
thkpopulation ." '
the highest number ofabsl2inen. Educated, middle-clas,
Asim •America n m.olesunder~3 a re most likely to drink HH1orically,Americanlndi>mconsumedonly"ukbttnor
bu1,tilltherearelewerprobkmdrinkenamongthisgroup otha fumented bevenge, fOTceremonial pu~ . When
thm•mong,imilargroup,withotherethnicities,although dktilled alcoholk bevenges were introdue<d . mo,t
:,:c~ .,1:co me more culturally •cdim.oted. drinking Americanlndianculture,hadnotdev,lopedethia.l,leg,1
orsocialcustomstoh2ndlethestrongerdrink,
There>r<genet ic factorsthath.ovemeffec tonhow anindi • AstudyolagroupofAmericanMi55ionlndi>menmined
vidu.alr=ato a kohol.Abouthallof•llJ•pane><,alongwith theirinherited5ensitivltyto•lroholandfoundthattheir
,omeotherAsimpopulations(e.g .,Chine><),arebomwith >=>itivity was low, requiring them 10 consume greater
a genethatcontroisADH(alcoholdehydrogenne),called amou nao l a lcoholtoget.,drunk • ••personwithan•ver •
atJpi<alADH, a r.d a ksodlicirntfonnofALDH.knowna,; agelevdofsemiti vity (••igno fg ene tic ,u,cq,ti bilityto
KM ALDH,. Drinking e\'en mW! •mouna of •lrohol causes developing•lroholi,m) ."'

~~;:::r:::~
thetoxicacetaldeh)'detobuildupto IO tim es thenornllll
amount,w hichthencau. u•flu<hingr<>c tiondueto vaoodi• :::::.,;.r~,:c::,~,-::::!~n~::f.~:.!.o
Lation;tachyC2ffii>•ndh~che,•OOocrur . A1highudo.es
motor,.,hiclede.atM>r<e 5.5timnh igherth.on fortherestof
edema (water retention), hypotension, ar.d ,umiting
the US popubtion. CiTThosi, of the liver i, ~.5 times highu;
emue .ll.llO-l
JU" Arecrn ttttnd • mongyoungAPl ,livlngon
alcoholi,m . 3.8 time, higher ; homicide, 2.8 cime, highu;
theWe>tCoHl>ndinHawaiiistheuseofPepcid. " oranother
and,uicide. 2.J times higher . Although American Ind ian
medicationlorg,,triculcusorgastroesophage.alrdluxdis-
=, which block, the fiu.hing r=tion of•icohol, thu, ::::~~ ~;::;,77o;- ~1:::,·:.;i:ia~~~~:!1~:
allowingth emtodrinkwithoute,qxrien cingfiu,hing .''"
rhosH.' '" One,tudyinOkbhom.ofoundthat•lrohol •r<bted
Treatingme mbe rsol•nye thn icgroupkmoreeffectivewhrn caus..ofdeathv:oriedlromk55thanl'll,uptoli'll, among
iti,culturallycon,istent . For<Umple,in the late 1980, :;ih:';!.•urveyedcomparedwithl'll,forBlacks a r.dJ%
relative lyfewAPl ,c•me10SanFr.mci.sro ~ Haigh t Ashbury
DetoxCliniclortreatmentbecauseofthestigm,.involved

=
lntum,ofrecovery,tr.tditioruolNativeAmeric•nreligions'
in•dmittingthattheyhad•problem.Rese.archenstudied
emphasi,ontheimporunceol,pir!tualityseemtobequite
~:n!~ c~~::;::-edotf~~:n ~:~,.=:u ,7:,ti~u~':..r,ao~ effective . lnaddition,theuseolpeyotehasbttnusedinrite,;
toOd'nreco,.,r,·
APlrouns,lorshiredbytreatmentcenten,andtheopen•

:::!0
,fi: •::=~~7~i:::.:::::!': i~orn~:/:i'~r!P~i:

AmericanlndiansandAlaskanNatives
Thereare approximatelyl .7m illionAmericanlndi>nsmd Humanityhash.odtemofthou .. nd,ofyearoto•doptphy,i •
Ai»Uil Native, in the Un ited SUtes. representing more callyand menullyto•lcohol,andto a cauinextentthe
th2n300tr!balorWlgu2gegroup,andromprisingabout remictedkga!ityandlimiaondrinkingh.ove"urked;but
l'll,ofthepopulation.' " Drinkingpattem,varywidely becau.,iti,apowerlulp,ychoactivedrugandcau=crav•
amongthes,tr!bes0!'.,paratelndianrwiom;about70'I',
l\,. "nru r.tl•rea• ,man;unrese rnt'ons. '" Sometibesare
mostlyabstinenl,50medrinkmoderatelywithfewproblem,;
~';;t
t~ereui~:~:~~~t :=:~~
=~~~t;~:i:::,•
remictionsontheu«of•icoholwereimpooedbythefed .
andsomehavehighmesolhe.a,ydrinkingandalcoholi,m
::..g::i~:\:d ;~i;e:::l: overturned because of
Stereotype,createdbyfolkloreandoldwestemmovinha,., 0
influenced much of the th inking•boutAmeri can Indian,
Theroadtoalcoholkmcanl2keth reemonth>or30)'<>r,._
anddrinking . Thebelidtha t "lnd ian ,ca n\holdtheirliquOT "
orilm>)'neveroccur . Tho,ewhochoo,etod rink,hould
hHbunperpetuatedforgrner.ttion,
nccognizethatalcoholi,ap,ychoacth'<drugthatcancause
Althoughther:,teof•bstinencekquitehighinmonytribes irreversibkphy,iologicalchange,thatrouldcreatea,u«:q>,
iti,1hepattemofheavybingedrinkingamong1111.lesFrom tibility toa lroholkmwithcontinuedu se

Overview
Introduction
• 2 billion people worldwide and about 135 million in
the United States drank alcohol last month. About
17 million Americans are considered heavy drinkers.
History
• Alcohol is the oldest legal psychoactive drug in the
world; Islamic countries are the exception. Around
10,000 years ago, grain was cultivated for bread and
alcohol (beer).
• Throughout history, societies' laws and morals regard-
ing alcohol have wavered from prohibition and tem-
perance to unrestricted consumption. Prohibition of
alcohol in the United States lasted from 1918 to 1933.
Until an income tax was levied, taxes on alcohol (ex-
cise taxes) had been a significant part of federal and
state budgets.
Alcoholic Beverages
The Chemistryof Alcohol
• Ethyl alcohol (ethanol) is the main psychoactive
component in all alcoholic beverages. Beer is 5% to
9% alcohol, wine is 12% to 15%, and distilled liquor
is 40% to 50%.
Typesof AlcoholicBeverages
• Beer is produced from fermented grain. Wine is pro-
duced from fermented fruit. Distilled spirits have
varying concentrations of alcohol and are made
from fermented grains, tubers, vegetables, and other
plants. Spirits can also be distilled from wine or other
fermented beverages.
Absorption,Distribution,and
Metabolism
Absorption and Distribution
• Alcohol is absorbed by the body at different rates de-
pending on weight, gender, age, and a dozen other
factors.
• The absorption of alcohol into the bloodstream takes
place at various sites along the gastrointestinal tract,
including the stomach (mostly in men, not in women),
the small intestine, and the colon. Once alcohol cross-
es the blood-brain barrier, psychoactive effects begin.
Downers:Alcohol 5.45
• Women register higher blood alcohol concentrations
(BACs) than men from the same amount of alcohol
because they absorb 30% more alcohol into the blood-
stream than do men of the same weight; women feel
its psychoactive effects faster and more intensely.
Metabolism
• Alcohol is metabolized at a steady rate, mostly by the
liver, and subsequently excreted through urine, sweat,
and breath. The higher the BAC, the more severe are
the effects. A BAC of 0.08 is considered legal intoxica-
tion in every state in America.
• The actual reaction and level of impairment varies
widely and depends on a person's drinking history,
behavioral tolerance, mood, age, and a dozen other
I
factors.
Desired Effects,Side Effects,
and Health Consequences
Levels of Use
• Alcohol use ranges from abstinence, experimenta-
tion, and social/recreational drinking to habitual use,
abuse, and addiction.
Low-to-Moderate-Dose Episodes
• If a person is not at risk (e.g., pregnant, genetically
susceptible, in recovery), documented health benefits
from light alcohol use include sedation, muscle relax-
ation, some heart benefits, and lowered inhibitions.
The inhibitory neurotransmitter GABA, the mood
modulator serotonin, the reward neurotransmitter
dopamine, and glutamate (a receptor-site enhancer)
are most affected by alcohol. Alcohol increases sexual
desire while slightly decreasing erectile ability in
males.
High-Dose Episodes
• A range of effects occurs, from decreased alertness
and exaggerated emotions to shock, coma, and death.
Effects are directly related to the amount, frequency,
and duration of use. Effects also depend on the user's
tolerance to alcohol.
• Alcohol poisoning causes central nervous system
( CNS) depression, which can result in respiratory
arrest and cardiac failure. Blackouts (amnesia) are
common among alcoholics.
• Hangovers usually pass within a day, whereas with-
drawal can last for days or weeks. Hangover remedies
are not very effective. Rest and time eliminates the
alcohol.
 5 .46 CHAPTER 5
Chronic High-Dose Use
• Depending on a drinker's habits and susceptibility,
organ damage (particu larly alcoholic hepatitis and
cirrhosis of the liver), cardiovascu lar problems, CNS
damage, gastrointestina l damage, reproductive dis-
ruption, cancer (especially breast cancer), and im-
paired sexua l, mental (e.g. memory), and emotiona l
processes are common. Alcoho l has a direct toxic
effect on organs and tissues.
• The life span of chronic high-dose drinkers is 10 to
22 years shorter than the genera l population. Alcoho l
is directly responsible for 130,000 deaths each year in
the United States.
Addiction
I
Classification
• Historically, there have been many attempts to clas-
sify alcoholism as a disease. Benj amin Rush, Thomas
Trotter, and E. M. Jellinek are some of the key
researchers.
• Modern classifications have been aided by the dis-
covery of the nucleus accumbens, endorphins, and
enkephalins and the development of genetic research
tools and imaging techniques.
• Alcoho lism is a pr imary chronic disease with genetic,
psychosocia l, and environmental factors influencing
its development.
Heredity, Environment, and
Psychoactive Drugs
• Various studies place the influence of genes on alco-
holism and other addictions at 40% to 60%.
• The environment, particu larly physical, sexua l, and
emotional abuse, raise susceptibility to addiction.
• The actua l use of drugs or the practice of compulsive
behaviors are precursors to habituation, abuse, and
addiction.
Tolerance, Tissue Dependence,
and Withdrawal
• Tolerance defends a user against the toxic effects of
alcohol. The liver becomes able to hand le more and
more alcoho l but eventua lly it reaches a point of
declination, especially as the drinker gets older.
• Because the body's tissues have become dependent
on the continued use of alcoho l, stopp ing suddenly
results in the onset of withdrawa l symptoms that can
range from hangover-like symptoms such as head-
aches to severe and occasionally life-threatening
reactions such as convulsions.
Directions in Research
• Much of the current research in the field of alcohol
dependence involves identifying the precise biological
mechanisms involved in the development of addiction
(e.g., genes and epigenetic changes).
• Studies are being done to identify and modify envi-
ronmenta l causes of alcoholism.
• New drugs to reduce craving and relapse are one of
the current directions in clinical research.
Other Problems with Alcohol
Polydrug Abuse
• Alcohol is used with many other psychoactive drugs
to enhance, counteract, or change the effects.
• In on e study, 80% of the participants used alcohol and
marijuana together, and up to 70% smoked cigarettes
and drank.
• An upper such as cocaine or methamphetamine and
alcoho l are combined to make a "speedball," which is
used to counteract the depression that chronic alcohol
use can induce.
Alcohol and Mental Problems
• Alcohol is used to change mood or menta l state. It is
a depressant, so the incidence of depression in heavy
dri nkers (often alcohol-induced) is five times that of
the general public.
• Anxiety is a condition found more than twice as often
in heavy drinkers. Pre-existing mental problems must
be treated at the same time as alcoho lism to avoid
relapse.
• Symptoms of alcoholism can be confused or obscured
with those of certain mental health thought, mood,
and personality disorders.
Alcohol and Pregnancy
• Feta l damage during pregnancy from fetal alcohol
syndrome (FAS) and other fetal alcohol spectrum dis-
orde rs (FASDs) is common. The lifestyle of a pregnant
woman who is using or drinking can have as much of
an effect on the fetus as the alcohol or drug itself.
• FASD is sign ified by a combination of symptoms, such
as retarded growth, facial deformities, CNS problems,
and a h istory of prenata l alcohol exposure. The spec-
trum includes FAS (fetal alcoho l syndrome). PFAS
(partia l fetal alcoho l syndrome), ARND (alcoho l-
related neurodevelopmental disorder), ARBD (alcoho l-
related birth defects), and fetal alcoho l effects (FAE. a
designation rare ly used today).

Aggressionand Violence
• The victim, the perpetrator, and one or more bystand-
ers are involved in any act of violence . A predisposi-
tion to anger and violence is magnified or triggered by
alcohol use .
• The three major kinds of interpersonal violence are
emotional, physical, and sexual violence.
• 34% to 74% of those convicted of sexual assault had
been drinking at the time of the crime as had 30% to
79% of the victims .
DrivingUnder the Influence
• 1.5 million drivers are arrested each year for impaired
driving . The average BAC is 0.16, twice the legal blood
alcohol concentration limit of 0.08.
• About 30% of traffic fatalities involved alcohol use,
mostly beer .
• Distracted driving (e.g., texting while driving) is as
dangerous as a 0.10 BAC.
Injuriesand Suicides
• 15% to 25% of emergency patients tested positive for
alcohol.
• 31% of boating fatalities had a BAC of0.10 or higher .
• 40% of industrial fatalities and 4 7% of injuries in-
volved alcohol.
• Suicide rates are twice as high among alcoholics as in
the general population.
Epidemiology
Patternsof Alcohol Consumption
• The culture of the drinker, ethnic background, gen-
der, age, and socioeconomic factors help determine
how a person drinks.
• Cultures are defined as wet (e.g., France and Italy),
dry (e.g., Denmark and Finland), mixed (United
States and Germany), or abstinent (e.g., Islamic
countries).
• The use of vodka in Russia has caused large segments
of the population to have problems with alcoholism.
It is consumed mostly between meals .
• Chinese families generally do not drink as much as
those living in western countries . In Japan and South
Korea, the social pressure to drink is significant, but
the rate of alcoholism is half that of the United States.
PopulationSubgroups
• Women are more likely to die from alcoholism than
men.
Downers: Alcohol 5.47
• The younger someone starts smoking or drinking, the
more likely he or she will have an addiction problem
with cigarettes or alcohol and engage in unsafe sexual
practices.
• Drinking patterns are continued from high school to
college .
• 47% of college students admit to binge drinking, 40%
get drunk at least once a month, and 29% get drunk
three or more times per month.
• Older Americans have the lowest prevalence of prob-
lem drinking and alcoholism. Side effects are in-
creased if someone is ill or taking certain medications.
Elderly alcohol abusers are of the late-onset variety.
• The rate of those in the military seeking treatment
for alcohol dependency has gone from 7.2 to 11.4 per
1,000 active-duty soldiers . Excess alcohol consump-
tion costs the U.S. military more than $1 billion per
I
year, with medical expenditures accounting for 42%
of the total.
• 30 percent of the homeless have drug and alcohol
problems.
Ethnic Populations
• Of all ethnic groups in the United States, American
Indians have the highest rate of alcoholism, followed
by Whites, Hispanics, Blacks, Pacific Islanders, and
finally Asian Americans.
• The lower rate of heavy drinking in the Black com-
munity is due to a large extent to the long history of
spirituality, a valuable concept that aids recovery.
• The Hispanic community will grow to 24% of the
U.S. population by 2050 (60% Mexican origin,
9.5% Puerto Rican, and 3.2% Cuban). There is a lack
of culturally relevant treatment facilities .
• Asians and Pacific Islanders have the lowest rate of
drinking and drug problems in the United States,
mostly due to cultural disapproval of excess drinking.
• American Indians and Alaskan Natives have a high
rate of drinking among certain genetically vulnerable
tribes, especially if they are living in poverty. Alcohol
abuse accounts for five of the 10 leading causes of
death in most American Indian tribes.
Conclusions
• Humanity has had tens of thousands of years to adapt
to alcohol and develop a culture of drinking .
• To a certain extent, the restricted legality and limits on
drinking have worked.
• Alcoholism can take from three months to 30 years
to develop, so it is important for drinkers to assess
their current level of use and their susceptibility to
compulsive use .
The Seattle Hempfest was begun in 1991 to pressfor the decriminalizationof
marijuana. The three-dayfestival grewfrom 500 attendeesto 310,000 in 2013, and
persistenceseems to have paid off Washingtonvoters (and Coloradovoters) elected
to legalize marijuanafor recreationalpurposes. The legislatorsof both states are now
strugglingwith legislationto implement the statutes. Use in the workplace, impaired
driving, secondhandsmoke (especiallywith children),use during addiction
treatment,and the right of landlordsto ban smoking in their buildings, especially
becauseit is legal to smoke tobacco,are some of the questionsneedingresolution.
© 2013 CNSProductions,Inc.
 All Arounders
Wewillexplonethevastnumbusof•ll•round<nthathavebernuS<dto a lter, tat<>
ofcorncioum=throughouthistory . in clud ingth<rume nt e,q,IOOoninnew
d«ign<rp<ychooctiv,,ubsta nc<>lik<thes;nth<ticC2I1nabinoids (e.g, , B<nzolury,
• bromo-drago nFLY. and C-boom ) . We cW<ify th <>< ,.,ri011<p<ych«ldic• into five
broadgroup<
Th<h i,tory , theq, idemiology, a ndthedfect5ofthem.o j or•bu5<d,ubs t.or.c,.of
thts<group<willbep=t«l . >j>«i•l=pia.i,willb<giv<ntomariju•ruo•nd
oth<rcannabino id,,!ncludingbotan ical,p,c ie,andthe,ynth<ticcmruobino id,
Wewillenmin,theendogenous cannabino id,andthemed icalbrn e fi"ofcan -
nabidio l and m a ncbmid< u w<ll a,; th< external canruobir.oids. Though most all
arounder,m e notadd icting( <xctptlo r PCPandm.ori juana ), t h<y can cauxmajor
psychologicalprobl<mswhen abU«d

·=:zt'~
:~\,;~
~~,rt"""~
the,,,
:;,,:=::;
t.~ 7:.:~'.? :uof~~!
,\,.,I ,o I "'9,,•tal;'l:i lru ood/,,, fr,qu,mUj, ood thtn tht l.,,t f,w
~""' ltri.dtotok,~.jtl,o.1,.,</ftt:tota11"

l'pp<r> like cocain e, mrt lu.mphruomir.< . and tobacco stimul•t< th< body, wh<T= down -
us like preocription op iot<s, •lcoho l. •nd scdotive -h)'J'""tics dep~ it. All •round -
us-particulll lyl..SD , p<ilocybinmu.shroom,,peyot< . e<:>11<y. • ndmoriju• ,..........,.n act
._. stimula nts OT depres<>nts, but most of these psychedelks dnmot ically • lter the
usnSperee ptionsoFthtsurround ing,andthoug hts•ndcrttte> wor ldinwh ich
:::::i'i7,~..: ,:::.~otto t h<int<ruifiedsenY.tiorugrner.uedbyillu,iom , delus ions,

Psychedelic pl.mt> and fungi have exi sted fo,-l'SO million ynn; their,.., by humans
goe,;backmoreth2nlO,OOOye2n. As pbntsandfungimuutedtodevelopchemical
defenses'-1¢nst•n imal<, irutt1>,•ruldi«a«,th0«tideraesw<I<of trnbitter•llwoids,
suchHoocoine(roal<=•l, n irotine(t<>NCCOl=<>),andtn<SCaline(peyotecactus)
 6.2 CHAPTER 6

Some of these alkaloids also induced psychoactive and some-

times psychedelic effects. More than 4,000 plants have psy-
chedelic (hallucinogenic) or psychoactive properties, but
only a few hundred have a history of use down through the
ages. Primitive people probably tried these plants and fungi
as a possible source of food and were both frightened and
intrigued by the hallucinogenic and psychoactive experi-
ences that resulted. 1
Neanderthals and eventually shamans, brujas, curanderos,
witches, and healers ritualized different methods of inges-
tion: boiling and drinking, smoking in a pipe, eating, or
absorbing through the nasal passages, gums, or skin. Even
after the hypodermic needle was invented in the 1850s, hal-
lucinogens were rarely injected because the object of using
psychedelics was to alter one's consciousness and percep-
tion of reality rather than to induce an immediate rush. 2

> More than 4,000 plants have psychedelicor

psychoactiveproperties.

"Whenthe mushroomstook effecton them, then theq danced,

then theq wept. But some,whilestillin commandoftheir
senses,enteredand sat therebq the house;theq dancedno

I
more,but onlqsat therenodding.And whenthe effectsofthe Pygmies (Batwa) in Uganda,East Africa, grow marijuana and smoke
mushroomshad le~ them, theqconsultedamongthemselvesand it in bongs madefrom gourds. The tradition goes back hundredsof
told one anotherwhat theq had seenin vision." years.
© AriadneVanZandbergen.Permission by AfriPics.
Bernardino de Sahagun, Spanish missionary and archaeologist
specializing in Aztecs, 1542

Over the past four millennia, Amanita mushrooms were eaten
in India, belladonna was drunk in ancient Greece, marijuana
was inhaled in ancient China, yopo snuff was snorted in
South America, and the poisonous ergot found in rye mold
(a natural form of LSD) was accidentally ingested in renais-
Some of the early synthetic marijuana was labeledSpice Silver, Spice
Gold, and K2. Before law enforcementstepped in, there were no
specific testsfor these drugs. As quickly as tests were devised, street
chemists would change theformula.
© 2014 CNSProductions,Inc.
sance Europe. Regardless of where explorers and anthropolo-
gists ventured, they discovered that every culture used one
or more psychedelic substances. 3 •4
The majority of psychedelics are grown and used in the
Americas, Europe, and Africa; the exception is marijuana,
which is grown and used throughout the world. Hundreds of
tribes in the Americas, such as the Aztecs and the Toltecs in
the past and the Kiowas and the Huichols in the present, have
used peyote, psilocybin mushrooms, yage, marijuana, and
morning glory seeds for religious, social, ceremonial, and
medical purposes. 5 ,6
For decades lion's tail (Leonotis leonurus), also known as wild
daggha, has been smoked in South Africa as marijuana is
smoked in the United States. Recently, lion's tail has become
more available in Europe and America as an herbal product
or as a constituent of the herbal incense blend Spice (syn-
thetic marijuana) .
Over the past 100 years, the development of synthetic hallu-
cinogens expanded the psychedelic alphabet. Hallucinogens
such as DMT, LSD, MDA, MDMA, 2C-B, and PCP, along
with marijuana, were part of the fabric of the counterculture
revolution of the 1960s and 1970s, adding a psychedelic
cornucopia to that generation's experimentation with drugs.
The use of all arounders declined after 1979 (the year of
maximum use), followed by an upsurge in the mid- to late
1990s among U.S. college, high-school, and middle-school

students. By 2000 people again lost interest in most all
arounders except marijuana. Psychedelic drug use for 2012
for those 12 years old and up is as follows.
• MDMA: 2.3% in 2000, down to 1% in 2012
• LSD: 4% in 1995, down to 0.5% in 2012
• Marijuana: 37.4% in 1979, 11.9% in 1992, 23.9% in
1999, and 20.4% in 2013 7•8
Other than marijuana, psychedelics are more popular
among young White users, followed by Hispanics. The Black
community has the lowest per-capita use. 7
Over the centuries the legality of psychedelics varied widely,
and often when one substance becomes illegal others pop up.
For example, legal and quasi-legal psychedelics such as lion's
tail, bromo-dragonFLY, and Salvia divinorum, along with
synthetic preparations including designer cannabinoids
(Spice), dextromethorphan, and even the AIDS medication
efavirenz, have been used and abused in recent years while
various government agencies debate making them illegal or
severely restricting access.
From alphabet soup psychedelics (MDMA, LSD, PMA) to
naturally occurring plants used socially, therapeutically, or in
religious/spiritual ceremonies (marijuana, peyote, mush-
rooms, belladonna), all arounders represent a diverse group
of substances. Over the centuries, terms such as psychotomi-
metics (imitating psychoses), entheogens,entactogens,empa-
thogens,eidetics,psychogenics,and psychodyslepticshave been
used to describe all arounders. Psychedelicsand hallucinogens
are the most commonly used names for these drugs. 4
There are five main chemical classifications of psychedelics:
• indoles (e.g., LSD, psilocybin mushrooms, ayahuasca)
• phenylalkylamines (e.g., peyote, MOMA [ecstasy])
• anticholinergics(e.g., belladonna, datura)
• individually classified (e.g., ketamine, PCP, Salvia
divinorum, dextromethorphan [DXM])
• cannabinoidsfound in marijuana (Cannabis) plants
Assessingthe Effects
Even though many psychedelics have been used for thou-
sands of years, formal research has been minimal because
most psychedelics are grown illegally, found in the wild, or
manufactured by street chemists or foreign interests. For this
reason much of the information on the effects of psychedel-
ics is anecdotal rather than the result of extended scientific
testing. In addition, most plant-based psychedelics contain
more than one active ingredient, making it difficult to deter-
mine which chemical is causing which effect. Also, many
All Arounders 6.3
drugs that are sold as one psychedelic may actually be
another, cheaper psychedelic; common examples of misrep-
resentation include ketamine sold as THC (the active ingre-
dient in marijuana) and LSD analogues DOC and DOA often
sold in liquid form as LSD itself.'
In addition to the toxicity, the effects of many psychedelics
are dependent on the amount of drug ingested. A drug like
LSD is thousands of times more powerful by weight than a
similar amount of peyote. Other factors also help determine
the type, duration, and intensity of the effects:
• the emotional makeup of the user
• the user's mood and mental state at the time of use
• the surroundings in which the drug is taken
• experience with the drug
• pre-existing mental illnesses
For instance, a first- or second-time psychedelic user may
become nauseated, anxious, depressed, or totally disoriented,
whereas a frequent user may experience only euphoric
feelings or some mild illusions. LSD use could trigger a
psychotic episode in someone with schizophrenia or major
depression because the drug destabilizes the balance of
neurotransmitters.
Physicaland Mental Effects
I
Physically, most hallucinogens stimulate the sympathetic
nervous system, raising the pulse rate, breathing, and blood
pressure. Many psychedelics also cause sweating, palpita-
tions, and nausea during onset. Generally, psychedelics
interfere with dopamine, norepinephrine, acetylcholine,
anandamide, glutamate, alpha psychosin, and especially
serotonin. Serotonin affects sensory perception; and because
serotonin neurons are amply represented in the limbic sys-
tem (the emotional center of the brain), psychedelics greatly
affect mood and have been known to cause permanent
changes in one's personality.
The stimulation of the brainstem, and specifically the reticu-
lar formation, can overload sensory pathways, making the
user acutely aware of all sensations. Disruption of visual
and auditory centers can confuse perception. An auditory
stimulation such as music might jump to a visual pathway,
causing the music to be "seen" as shifting light patterns;
visual impulses might shift to auditory neurons, resulting in
strange sounds. This crossover or mixing of the senses is
known as synesthesia . Some practitioners of certain forms of
religion or mysticism say that many psychedelic experiences
are similar to the transcendental state of mind achieved
through deep meditation. Recent research at Yale suggests
that LSD increases glutamate, which in turn affects other
synapses not directly in the pathway usually activated by
some electrical stimulus. Such spillover is posited to induce
certain cognitive, affective, and sensory abnormalities,
including synesthesia_lD
With psychedelics,reasontakes a backseat
to the intensifiedsensationsgenerated by
illusions,delusions,and hallucinations
.
 6.4 CHAPTER6

AllArounders
(Psy
chedelics)
COMMONNAME ACTIVE
INGREDIENTS STREET
NAMES
INDOLE
PSYCHEDE
LICS
LSD(LSD25& 49) (Schedule
I) Lysergic
aciddiethylamide Acid,sugarcube,windowpane,
blotter,illusion,beamers,
yellow
sunshine,
doses,drops
Mushrooms
(Schedule
I) Psilocybin Shrooms,
magicmushrooms
Tabe
rnantheiboga(Schedule
I) lbogaine AfricanLSD
Morninggloryseedsor Hawaiian
woodrose Lysergic
acidamide Heavenly
blue,pearlygates,
weddingbells,ololiuqui
DMT(synthetic
or fromyopobeans, epena, Dimethyltryptamine,
5-MeO-DMT, Businessman's
special,
cohobasnuff
Sonoran
Deserttoad,ColoradoRivertoad) bufotenine
(Schedule
I)
Ayahuasca
(hoasca),
yage,caapi,daime Harmaline
(alsomixedwithDM1) Visionary
vine,vineof thesoul,vineof death,mihi,kahi,dimitri
Foxy5-Me-DI
PT Foxymethoxy
diisopropyltryptamine Foxymethoxy
Metryptamine,
AMT Alpha-methyltryptamine,
IT-290 Spirals

PHENY
LALKYLAMINE
PSYCHEDE
LICS
Peyotecactus(Schedu
le I) Mescaline Mesc,peyote,buttons
Designer
psychedelics,
e.g., MDA,MDMA Variations Ecstasy,
of methylenedioxy-amphetamines Molly,rave,lovedru&XTC,Adam,Eve,thizz,stunna
(MDM),MMDA,MDE(Schedule I)

2C-l or 25B,C,
I-NBOMe,
2C-lNBOme 2,5-dimethoxy-4-iodophenethylamine
and Smiles
bromo-2,5-dimethoxy-N-phenethylamine C-boom,N-bomb
2C-Bor CBR(Schedule
I) 4-bromo-2,5-dimethoxy-phenethylamine Nexus
2C-T-7(Schedule
I) 2,5-dimethoxy-4-propy
l-thiophenethy
lamine BlueMystic,
Tripstacy

I
2C-T-2(Schedule
I) 2,5-dimethoxy-4-ethyl-thiophenethylamineTripstacy
6-APB 6-(2-aminopropyl)benzofuran Benzofury
STP(DOM)(synthetic)
(Schedu
le I) 2,5-dimethoxy-4-methylamphetamine Serenity,
tranquility,
peacepill
STP-L
SDcombo Dimethoxy-amphetamine
withLSD Wedgeseries,orangeandpinkwedges,
Harveywallbanger
PMA(Schedule
I) Para-methoxyamphetamine Death,Mitsubishi
double-cstack
U4Euh(Schedule
I) 4-methylpemoline Euphoria
B2P 1-benzylpiperazine B2P

ANTICHOLINERGICS
Belladonna,
henbane,mandrake,
datura Gimson Atropine,
scopolamine,
hyoscyamine Dead
ly nightshade,
dwale,divale,devil'sherb,blackcherry,stinkweed,
weed,thornapple),
wolfbane(ScheduleI) angel's
trumpet
Ariane
® Trihexyphenidyl
Cogentin
® Benztropine
Asmador®
cigarettes Belladonna
alkaloids

OTHER
PSYCHED
ELICS
Ketamine
(Schedule
Ill) Ketaset,
®Ketalar,
®Ketanest
® K,K,vitaminK,super
Special -K
PCP(Schedule
II) Phencyclidine
hydrochloride joint,KJ,blackweed,loveboa~
Angeldust,ho&peacepill, krystal
ozone,Sherms,Shermans
Nutmegandmace Myristicin
Amanitamushrooms lbotenicacid,muscimole Soma
Salvia
divinarum Salvinorin
A Diviner's
sage,sage,Sally-D,salvia
DMin Romilar,
®Coricidin® Dextrometho
rphan DXM,robo,reddevils,skittles,
dex.syrup,zurp
Leonotis
leonurus
0ion'stail,wilddagga) Marijuana
substitute Dip
Bromo-d
ragonF
LY(2C-F
LY,2C-B-F
LY,3C-F
LY) Bromo-benzodifuranyl-isopropylamine B-FLY,
FLY
Leonatis
/eonurus
(lion'stail,wilddagga) Leonarine Dip
Sustiva
®(HIV/AIDSmedication) Efavirenz
 All Arounders 6.5

AllArounders
(~chedelics)continued
COMMON
NAME ACTIVE
INGREDIENTS STREET
NAMES
CANNABINOIDS
Marijuana
(Schedule
I) D-9-tetrahydroamnabinol
(THC) Grass,
po~weed,nugget,bud,trees,herb
Sinsemilla
(Schedule
I) High-potency
THC Sens,
skunkweed,ganja,
MaryJane
Hashish,
hashoil (Schedule
I) High-potency
THC Hash,butanehash,hashoil,wax,"dabbing,"
BHO
Synthetic
& semisynthetic
THC(Marinol,
® Dronabinol
Cesamet,®Sativex,
®Cannador, ®and
nabilonearelegalprescription
THCs)
Synthetic
cannabinoids JWH--015,
JWH-018, JWH--073, CP47/497, Spice,K2,Mojo,Smoke,
Skunk,
stealthmarijuana,
superkush,green
(legalnon-Rx,
soldasincense) HU-210
(nowmorethan100synthetic grenade,dank
cannabinoids
of sixdistinctchemical
families)

Illusions,Delusions,and Hallucinations "Mushroomsare reallqdifferent me. for

"It was as though the entireuniversewas breathingin and out,
and when I lookedat the skf the skq was something a of
vascularsqstem, qou know, arteriesand veinsand things."
24-year-old female psychedelic user
Theq are much more earthq. I tend to see reallqvivid
hallucinationslikeseeingfairiesin the forest."
33 -year-old magic mushroom user

An illusion is a mistaken perception of an external stimulus . LSD,PsilocybinMushrooms,

A rope can be misinterpreted as a snake . A bush can be and Other lndole Psychedelics

I
misperceived as a threatening animal.
Indole psychedelics exert many of their effects through
"I'vehad illusions,not hallucinations,but just wheredifferent
interactions with serotonin receptors, particularly those
colorsstand out, things move, differentobjects,just little things
designated 5HT 2 A. The strength of most psychedelics is
of
qou neverreallqthink twice about. It's just part qour high, I
directly related to their influence on the 5HT 2A receptors .
guess, but as qou becomemore immuneto it, not as much like
Besides affecting mood, sleep, and anxiety, serotonin influ-
that happens."
ences areas of the brain that are the most likely to generate
19-year-old male marijuana smoker
hallucinations and illusions ( the medial prefrontal cortex
and the anterior cingulate cortex)_ll The down regulation of
A delusion is a mistaken idea or belief that is not swayed by
5HT 2A receptors is believed to be responsible for the rapid
reason or other contradictory evidence. Someone who
development of tolerance in those who overuse LSD and
thinks he can fly or a person seeing herself as overweight
other indole psychedelics .12 •13 Some newer research addition-
when she is actually very thin are two examples.
ally suggests the involvement of 5HT 1A receptors in produc-
ing hallucinogenic activity. 14 -15
"I have strangethoughts. I have a tunnel visioneffect.
I feel unified. I feel verqasexual,likesex would be besidethe
point becauseI feel unifiedwith everqthing."
LysergicAcid Diethylamide (LSD)
38-year-old psychedelic user
"Pictureqourselfin a boat on a river
With tangerinetreesand marmaladeskies
A hallucination is a sensory experience that does not come
Somebodq calls qou, qou answerquite slowlq
from external stimuli, such as seeing a creature or hearing a
A girl with kaleidoscopeeqes
sound that doesn 't exist.
Lucqin the Skq with Diamonds
"Yougo to places that qou could neverreachbeforeto whereqou Lucqin the Skq with Diamonds
werenevercoming back, and then out ofa dream, and qou step Lucqin the Skq with Diamonds
up back into qour bodq and come back to qour sensesand come Aaaaahhhhh. "
back to realitq." © 1967 John Lennon and Paul McCartney
16-year-old psychedelic user
Although John Lennon claimed that "Lucy in the Sky with
Illusions and delusions are the primary experiences created Diamonds" was inspired by a picture his son Julian drew,
by LSD and most psychedelics . Mescaline, psilocybin, and everyone else, including Paul McCartney , knew it was about
PCP cause hallucinations. LSD.
 6.6 CHAPTER 6
History
Acid, blotter, tab, Owsley's, sacrament, barrels, orange sun-
shine, illusion, and window panes are just some of the street
names for LSD (lysergic acid diethylamide), a semisynthetic
form of an ergot fungus toxin that infects rye and other
cereal grasses. The brownish purple fungus, Claviceps pur-
purea, was responsible for many outbreaks of ergot poisoning
(ergotism) and thousands of deaths over the centuries after
farmers and townsfolk accidentally ate the infected grain
(most ly rye) . Areas of France, Belgium, eastern Europe, and
Russia, were affected, although written references date back
more than 2,000 years to a description by the Roman poet
Lucretius (94-55 B.C.), who described a disease that was
likely ergotism. 4
'The entire bodq was reddened bq burnin9sores, as when the
sacred firespreadoverthe limbs.Throu9hout the inside of
a person,so that it burnedall the waq down to the bones.
Completelqconfusedcondition with fearand melancholia,
darkenedbrow, and a sharp evenanarqlook in the eqes.
Moreover,a fearfullqexcited hearin9and buzzin9in the ears."
Lucretius, On Nature, 50 B.C.
There are two types of ergotism: gangrenous and convulsive.
Gangrenous ergotism, also known as "Saint Anthony's Fire,"
I
is marked by feverish hallucinations and a rotting away of
Claviceps purpurea is an e,got
Ji.mgusthat grows on certain grains,
particularly ears of rye. It seems to
appear when the winter has been
extremely cold and the spring is
very rainy.
© Biosphoto. Permission bySuperstoc
k.
gangrenous extremities of the body. The gangrene is caused
by the extreme vasoconstriction of small blood vessels that
causes the unnourished tissues to die. The second type, con-
vulsive ergotism , is marked by visual and auditory halluci-
nations , painful muscular contractions, vomiting, diarrhea,
headaches, disturbances in sensation, mania, psychosis,
delirium, and convulsions. 1 There is speculation that smaller
doses of Clavicepspurpurea were used for witching and magic
ceremonies during the Midd le Ages in Europe . Ancient prep-
arations of soma in India involved the fungus , as did the Greek
drink kykeon (mentioned in The Iliad).
Knowledge of the hallucinogenic properties of ergot was hid-
den until LSD was extracted in 1938 by Dr. Albert Hoffman
at the Sandoz pharmaceutical company He and Dr. Arthur
Stoll were investigating the alkaloids of Claviceps purpurea,
looking for a circulatory and respiratory stimulant (analep-
tic). LSD (technically LSD-25) was the twenty-fifth derivative
the doctors tried. Five years later Dr. Hoffman discovered the
hallucinogenic properties of the new drug when he acciden-
tally absorbed a dose of LSD through his fingertips while
developing a new method to synthesize the substance.
"I suddenlq becamestran9elqinebriated.The externalworld
becamechan9ed as in a dream. Objects appearedto 9ain in
relief;theq assumed unusualdimensions, and colorsbecame
more9lowin9. Even self-perceptionand the sense time were of
of
chan9ed. [Another time] I lost all control time; space and
time becamemore and more disor9anized,and I was overcome
with fearsthat I was9oin9 crazq."
Dr. Albert Hoffman in 1943 , describing one of his experiences with LSD16
LSD was considered a therapy for mental illnesses and
alcoholism and a key to investigating thought processes."
In the 1950s it was sold as Delysid®(the trade name for LSD)
and prescribed to enhance psycho logical insight in psycho-
therapy It was also used by the CIA in experiments to find a
truth drug or mind-control drug as pan of a program code-
named MK-ULTRA. The experiments have been linked to
suicides and deaths, and by the mid-1960s the program was
discontinued. 18 •19
of
"Backin the fi~ieswe had 9allon jars LSD in our lab. Mq
experimentswith primatesrelatedto eqe movements, but the
bi9 picturewas theq weretrqin9to fi9ureout how to use it on
the battlefieldand aerosolizeit or 9et the wind to disperseit to
disorienttroops.Mq supervisorkept trqin9to 9et me to take it
but I neverdid."
Col. Richard Munger, M.D., LSD researcher in U.S. Army
LSD experiments in 1952
LSD-25 was popularized by Harvard psychologists Drs.
Timothy Leary and Richard Alpert (among others), who
conducted psilocybin and LSD research in the 1960s as a way
to explore consciousness and feelings . Dr. Leary's first experi-
ence with a large dose of LSD left him "unab le to speak for
five days. " He wrote that he never recovered from that mind-
shattering experience. He founded a religion called the
"League for Spiritual Discovery "20
 All Arounders 6.7

sified as a Schedule I drug in 1970, and in 1974 the National

Institute of Mental Health concluded that LSD had no thera-
"TELUGENCEMEMORANDUM
!,CIENTlfiC l" peutic use. 22 Psychedelic use continued to decline in the
1980s, but in the 1990s there was a modest resurgence of
coNVENTIONAL
_,,..., • t m:W AGEN1' FOR UN experimentation, social use, and habitual use. Over the past
p()l!SJ."~ WARFARE few years, however, use among students and the general
l)'M"fllCMlol~:)
{N, 1'1-~'°
public has dropped dramatically 8
Scientific research ceased in the early 1970s, but recently
research on LSD, psilocybin mushrooms, peyote, aya-
huasca, marijuana, ecstasy, and a few other psychedelics
has been renewed . The Multidisciplinary Association for
Psychedelic Studies (MAPS) notes studies worldwide that
aim to treat illnesses such as depression in cancer patients ,
obsessive-compulsive disorder , end-of-life anxiety, post-
traumatic stress disorder (PTSD), and addiction.

Manufactureof LSD
NTELLIGENCE AGENCY
CENTRAL I
OfflCE Of SCIEHTIFIC1t-1'TE.LUGfNC
£ "We had PaloAlto Owsleqstuff [Au9ustusOwsleqStanleq].
He ranthe soundfor the GratefulDead for qears. Supposedlq,
he madepureLSD with no additivesor bad chemistrq.I started
with200 mies[microarams],then up to 400. The bestdose
was100 to 150. If we wereout of doors,we wouldonlqtake
This CIA memorandum referredto LSD as a potential truth drug. 50 so we'dstill be ableto navi9ate.Backin 1969and the earlq
The U.S. Army consideredusing it as an airborne agent to confuse '70s, it cost about $1 to $3 a hit."

I
enemy troops.
52-year-old former LSD user

In the 1960s most LSD was manufactured in the San

'We saw ourselvesas anthropolo9ists
fromthe twentq-prstcen- Francisco Bay Area. LSD street chemists continue to operate
turtjinhabitin9a timemoduleset somewherein the darka9esof
the 1960s. On thisspacecolonqwe wereattemptin9to createa
newpa9anismand a newdedicationto lifeas art."
Timothy Leary,Ph.D., advocate of LSD

Dr. Leary's mantra, "Turn on, tune in, and drop out," served
as the rallying cry for the youth of the 1960s and 1970s. It was
used endlessly in newspaper articles, movies, and TV news
shows, leading to the accusation that the media was as respon-
sible for the rise and the fall of LSD as was its identification
and subsequent vilification as the drug of the hippie genera-
tion. Ken Kesey, author of One Flew over the Cuckoo~Nest,
was a subject of early LSD experiments. He was one of the
founders of the Merry Pranksters , a group of counterculture
advocates who traveled the country in the mid-sixties in a
converted school bus (The Magic Bus), popularizing psyche-
delics, particularly LSD.

"I believethat with the adventof acid, we discovereda newwaq

to thinkand it has to do withpiecin9to9ethernew thou9htsin
qourmind.Whq is it that peoplethinkit'sso evil?What is it
about it that scarespeopleso deeplq, eventhe 9uq that invented
it, becausetheq'reafraidthat there's moreto realitqthan theq This blotter artwork f eatures the psychedelicpioneers of the era:
haveconfronted?" psychologist Timothy Leary, who invited everyone to "Tum on, tune
in, and drop out"; Ken Kesey, leader of the Merry Pranksters;Gonzo
Ken Kesey,from the 1987 BBC documentaryThe BeyondWithin:
journalist and practitioner of living life while loaded Hunter S.
The Rise and Fall of !SD
Thompson; Albert Hoffman, the man who discovered LSD; and
Owsley Stanley, prolificmanufacturer and supplier of LSD.
LSD was made illegal on February 1, 1966 , under provisions
© Hany Herd/Getty
of the federal Drug Abuse Control Amendments. It was clas-
 6.8 CHAPTER 6
LSD starts out as a liquid and is then convertedto a number offorms
for ingestion. Putting a drop on blotter paper is the most common.
Each pane of the blotter contains about 50 microgramsof LSD. It can
also be droppedon sugar cubes and candy.
I
in the Pacific Northwest and more recently the Midwest. The
labs are hard to find because the quantities of raw materials
needed to make the drug are very small; the entire U.S. sup-
ply for one year (11 lbs.) could be carried in a backpack. It
takes 60 lbs. of ergotamine tartrate-the basic synthetic raw
ingredient for LSD-to produce those 11 lbs. 17 LSD can also
be synthesized from morning glory plants, which contain
lysergic acid amide.
Producing LSD is tedious and involves volatile and danger-
ous chemicals. The end product of the initial synthesis, crys-
talline LSD, is dissolved in alcohol and dropped onto
blotter paper; each 1 centimeter (cm) square of blotter paper
is impregnated with an average of 50 micrograms (20 to
80 micrograms [µg, or "mies"]) of liquid LSD. The squares
are chewed or swallowed_23The blotter paper is often printed
with images of recognizable icons like Mickey Mouse, Bart
Simpson, the Cheshire Cat, Scooby-Doo, Jimmy Neutron,
and other characters that appeal to younger users. It has also
been put into tiny squares of gelatin and eaten or absorbed
through mucous membranes (gums and tongue).
Epidemiology
The "acidheads" of the 1960s and 1970s were usually in their
early twenties. Besides the standard reasons for using (exper-
imentation, peer pressure, availability, and curiosity), many
were searching for psychological insight or a quasi-religious
experience. In the 1990s and 2000s, most users were young
teenagers who just wanted to get high or augment the effects
of ecstasy, GHB, or ketamine at house parties, rave clubs,
festivals, and concerts . More recently, the development of
psychostimulants and other new street creations has
expanded the choices for "psychonauts" who will try any-
thing to change their reality 27 Another reason for the brief
resurgence in use is that standard drug testing usually does
not test for LSD, and when it is tested for, the effective dose
is so small that it is extremely difficult to detect.
Federal efforts to restrict the manufacture of LSD by limiting
the availability of precursors, such as ergocristine, have
reduced the supply in the United States by 95%.24A bust in
rural Kansas years ago uncovered the largest LSD laboratory
ever found; 91 lbs . of precursor chemicals and LSD were
seized. 25 Because the demand remained steady but the sup-
ply dropped drastically, the price of a single hit jumped
from $1 to $5 to as much as $50 to $80 at rave parties.
Purchased in bulk, a vial that contains enough liquid to make
100 hits costs $500 to $1,000, or $5 to $10 per hit.
Pharmacology
LSD ( C20 H 25 N3 0) is remarkable for its potency Doses as low
as 25 µg, or 25 millionths of a gram (25 mies), can cause
stimulatory effects along with mental changes (spaced-out,
decreased perception of time, and mild euphoria). Effects
appear 15 to 60 minutes after ingestion, peak at 2 to
4 hours, and last 6 to 8 hours overall. The user returns to
the predrug state 10 to 12 hours after ingestion. 26 The usual
psychedelic dose of 150 to 300 µg can induce hallucinations,
delusions, and illusions. 28 The U.S. Drug Enforcement
Administration (DEA) reports that the current strength of
LSD street samples ranges from 20 to 80 µg. In the late 1960s
and the 1970s, samples ranged from 100 to 200 µg or more.
Tolerance develops very rapidly to the psychedelic effects of
LSD. Within a few days of daily use, a person can tolerate a
300 µg dose without experiencing any major psychedelic
effects. Tolerance disappears after cessation of use-usually
within a few days. Down regulation of the 5HT 2A receptors
is believed to be the main cause of the development of toler-
ance. Some cross-tolerance to the effects of mescaline and
psilocybin can develop, but there is little cross-tolerance
between LSD and DMT (dimethyltryptamine), another
indole psychedelic. 15 Withdrawal from LSD is usually more
mental and emotional than physical-a psychedelic hang-
over as one attempts to integrate their bizarre experience
into normal life .
"Withdrawalwas like the next daf the Germanscall it
'Katzenjammer,'which is likea chemicaldepletionof mind
and bod~, similarto a reall~bad hangover.You'restill
ps~chedelicall~spaced the next da~,and ~ou'redealingwith
all the revelations.Dependencewas more of a social urge
to do it rather than a privateurge."
24-year-old male former LSD user
PhysicalEffects
LSD can cause a rise in heart rate and blood pressure, a
higher body temperature, dizziness, dilated pupils, reduced
appetite, and sweating, much like amphetamines. Other,
less common effects include nausea, high blood sugar, jaw
clenching, and tremors. Users report seeing light trails, like
the after-images on cheap televisions; this effect is known as
the "trailing phenomenon."
 All Arounders 6.9

Mental Effects

"In a real stron9 acid, qou'IIsee the walls meltf·n likecandles

and water runnin9down the wall. That kind o distortionis not
a complete hallucinationor anqthin9real soli , like, there's a
bottle where qou wonder whether it's there or not. The thin9
that 9ot me reallqcrazq was hearin9a do9 or an airplaneor a
passen9ercar milesawaq, and I didn't know whether that was
real or an illusion."
38-year-old recovering LSD and marijuana user

LSD overloads the brainstem, the mind 's sensory switch-

board , causing sensory distortions-seeing sounds, feeling
smells , hearing colors (synesthesia), dreaminess, deper-
sonalization , altered mood, and impaired concentration
and motivation. The locus coeruleus is activated to release
extra amounts of norepinephrine , which greatly enhances
alertness. This heightened awareness of the senses explains
the introspection and awareness of the inner self that is com-
mon with LSD use. 29 Verbal expression is difficult while on
LSD. Single-word answers and seemingly unassociated com-
ments (non sequiturs) are common. A user might experience This bus, a 1939 InternationalHarvesterschoolbus purchasedby Ken
intense sensations and emotions but find it difficult to tell Kesey,authorof One Flew over the Cuckoo'sNest, becamea symbol
for thepsychedelicgenerationof the 1960s.Travelingcoastto coast
others what he or she is feeling. on variousmissions,Kesey!;group,the Meny Pranksters,would hold
"acidtests," whereLSD wouldbe passedout to the assembled
"It is fake, ersatz, instant mqsticism.There's no wisdom there. partygoersto increasetheir consciousnessor simply to get high.

I
I solved the secret of the universelast ni9ht, but this mornin9 © 2009 Haray Herd. Permissionby Getty Images.
I for9ot what it was."
Arthur Koest1er, writer, LSDuser

One of the greatest dangers of taking LSD is the impaired
reasoning and the loss of judgment . This coupled with
slowed reaction time and visual distortion can make driving
a car a recipe for disaster .
"I stuck mq hand in this name and then I went, 'Uh-oh, mq
hand is in the name,' and I pulled it out and I thou9ht it didn't
burn, but later that ni9ht mq hand started blisterin9,and I'm
aoin9, 'Oh, no, I 9ot burned."'
43-year-old male former LSD user
Because LSD affects the emotional center in the brain and
distorts reality, some users , particularly first-time users who
take it without supportive experienced users around them,
are subject to the extremes of euphoria and panic.
Depersonalization and the lack of a stable environment and
supportive friends or trippers can trigger acute anxiety, para-
noia, fear over loss of control, and delusions of persecution
or feelings of grandeur , leading to dangerous behavior.
Mental Illnessand LSD
Proponents of psychotherapeutic use claim that drug-

>
Effectsappear 15 to 60 minutesafter
ingestion,peak at 2 to 4 hours,and
last 6 to 8 hoursoverall.
Bad Trips(acute anxietyreactions-aka "bum trip")
The effects of LSD vary from person to person and depend
upon the user's experience with the drug, the environment in
which the drug is used (setting), the user's state of mind (set),
and the strength of the dose.
"One thin9 theq don't talk about with LSD is the tremendous
anxietqqou feel even if qou are an experienceduser: feelin9sof
impendin9doom, extremeworrq, rdaetin9, fee/in~likeqou 9ot
to move. But it's not the paranoia a speed freak feels;all the
nervesare tin9lin9."
33-year-old male LSD user
stimulated insights afford some users a shortcut through the
extended process of psychotherapy, which involves uncov-
ering traumas and conflicts from the subconscious to help
the patient heal. Others believe that self-experimentation by
mental health professionals could give them an understand-
ing of the schizophrenic mind and help them provide more-
effective therapy for a variety of menta l illnesses. 30 Opponents
of this kind of therapy say that the dangerous side effects of
LSD more than outweigh any perceived benefits.
The popular scenario of someone using LSD just once and
becoming permanently psychotic or schizophrenic is mostly
myth. However, users with a preexisting mental illness or
instability can aggravate those conditions with LSD, caus-
ing more-severe mental disturbances. Use can also cause
some people to experience their mental illness at an earlier
age, or it may provoke a relapse in someone who has previ-
ously suffered a psychotic disorder, a major depression, or a
bipolar disorder.
 6.10 CHAPTER 6
'The wholethin9startedwith mq schizophrenia . That alwaqs
plaqsa part. And anqtimeI 9et too involvedin the musicscene,
the acid startsto tri89€rthe schizophrenia,like~ashbacks, and
sometimesit makesme want to use. But I'm drawnto it likea
moth to a li9ht."
Recovering LSD user with schizophrenia, form er Deadh ead
(fan of the Grat eful Dead)
Some otherwise normal users can be thrown into a tempo-
rary but prolonged psychotic reaction or severe depression
that requires extended treatment. Prolonged trips (extended
LSD effects) devoid of other psychiatric symptoms have also
occurred. Though very rare, these reactions can be emotion-
ally crippling and may last for years.
Flashbacksand HallucinogenPersistingPerception
Disorder(HPPD)
Some users experience mental flashbacks or sensations of
a trip they had while under the influence of LSD or another
psychedelic months or years later . The flashbacks-which
can be triggered by stress, the use of another psychoactive
drug, a sensory stimulus (sight, smell, or odor) , or exercise-
re-create the original experience. The flashback can also
cause anxiety and panic because it is unexpected and the user
seems to have little control over its recurrence.
I
Although the DSM-5 does not specifically differentiate
between individual flashbacks and HPPD ,32 the authors
define HPPD as intermittently experiencing hallucinogenic-
like visual and perceptual disturbances (flashbacks) which
may persist for months, years , or a lifetime . Those affected
by HPPD can experience high levels of stress, social impair-
ment, occupational problems, and difficulty in other areas of
life. Visual disturbances are the most common ; symptoms
include visual after-images (trails) and halos around objects,
confused or intensified colors, illusions of movement , geo-
metric pseudo-hallucinations, flashes of color, imagined
images, objects appearing abnormally large (macropsia) or
small (micropsia),static vision, "floaters" (small bacteria-like
illusionary objects) in their field of vision , and reading or
memory problems. 32 .J3 •34
A number of psychedelics have the capacity to cause HPPD
(e.g., LSD, marijuana, MDMA, MDA, mescaline , DMT, PCP,
bath salts , Spice,® and psilocybin), though LSD and mari-
juana are the most common causes. It is estimated that flash-
backs (of widely varying intensities) occur in 23% to 64% of
regular LSD users. 35 •36 •37•38 Because an LSD flashback appears
to be similar to post-traumatic stress disorder , research sug-
gests that medications used for treating PTSD, such as sertra-
line, clonidine , and clonazepam, may be useful in treating
HPPD.39 ,40 Another drug that has been tried with some suc-
cess is the antiepileptic lamotrigine. 41
Dependence
Because LSD does not generally produce compulsive drug-
seeking behavior , it is not considered addictive . The 500 or
more LSD trips reportedly taken by a number of users were
likely initiated by a psychological dependence rather than a
physical dependence, even though tolerance does develop
rapidly. Frequent and repeated use of low-dose LSD for its
mild stimulant rather than its psychedelic effects is an exam-
ple of this psychological dependence.
"LSD wasverqcolorful.a superrush,ma9ical,trippq, 9i9Blq ,
sometimesscarq.I wascalledthe 'Kin9of Acid' becauseI
alwaqshad a verq900d trip, unlikesome friendswho took it
everqdaq. I waitedat leastthreeor fourdaqs in betweentrips
becauseqourbodqneedssometime to recover.Mq friendswho
used it dailq,theq9ot prettqburntout with insomnia,9rindin9
teeth, and exhaustionbecauseof the total nerveaction."
Aging accountant , former Deadhead (fan of the Gratefu l Dead)
MagicMushrooms(Psilocybinand Psilocin)
The other major group of indole psychedelics is psyche-
delic mushrooms ("shrooms"), whose active ingredients
are psilocybin and psilocin. These "magic mushrooms" are
found in the United States, South America, Southeast Asia,
Europe , and especially Mexico, which has the world's richest
mycoflora of Psilocybecubensismushrooms. 42
Originally called teonanacatl("divine flesh") by the Aztecs,
these fungi were especially important to Indian cultures in
Mexico and in pre-Columbian America. Their sacramental
use dates back 6,000 or 7,000 years, but serious use in mush-
room cults goes back about 3,000 years." More than 200
stone sculptures of mushrooms have been found in El
Salvador, Guatemala , and parts of Mexico. Evidence of a
mushroom cult that flourished from 100 B.C. to A.D. 400 was
found in northwestern Mexico.44
About 1,000 years later, the Aztecs used the Psilocybemush-
rooms for spiritual rites. Persecution by the Spaniards, who
conquered much of Central and South America in the six-
teenth and seventeenth centuries, drove the ceremonial use
of mushrooms underground for hundreds of years, but
mushroom use persists to this day. It was not until the 1950s
that much was known about the ceremonies conducted by
Mazatec, Ch'ol, and Lacand6n Mayan shamans, or by curan-
deros (medicine women or men). Participants ate or drank
the extracted psychedelic substances to become intoxicated ,
then spent hours chanting to induce visions to help treat
illnesses, solve problems , or connect with the spirit wor ld .
The famous Mazatec shaman Maria Sabina wrote:
'The sacredmushroomtakesme bq the hand and brin9sme
to the worldwhereeverqthin9is known.It is theq, the sacred
mushrooms,that speakin a waq I can understand.When I
returnfromthe trip that I havetakenwith them, I tell what theq
havetold me and what theq haveshownme."44
After mushroom researcher R. Gordon Wasson's article
"Seeking the Magic Mushroom " appeared in Life magazine in
1957, millions of Americans became aware of psychedelic
fungi and began experimenting. 42
Pharmacology
In 1956 the active psychedelic ingredients psilocybin and
psilocin were isolated by mycologist (mushroom expert)
Ma, IOs.b,.., (l !l'H-
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Roger Heim a nd r=n:h<r Dr. Albtn Hoffman . th< <Cienti>t Th< p,ych<d, lic dI«a includ e vi!iCer.d sens.otions;
1;:::~~;
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chemical otructune of psilocy-
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panicthanl.5D, and prolongedp,ychoticraction,•rer.tre
Psilocybi n and psilocin • re found in mor< thon IOOdiffe ,..
Ev,ryu,eraperienc e, these effectsdiff<=i tly, dq,,nd ingon
ent speck,ofmu,hroomfromvariousgeneni, including:
th< 0<ttinginwh ich th< drugistak<n . Mushrooms . L.5D. and
l's iloq be (mor< than 80 •ped <S), Pana,olos (at kut ll ,pe -
otherindol e p,yched d icscau0<p, ychedd ic ,ff«abydi<rupt •
ci<>), and a dozen or more minor genera--G ymnop ilos
ingther.ruro tr:msm ittusoerotoninanddopamir.< andge ner-
(3 •p,cia), lnoqbe (i , p,ci,s ). Plu,n1, (1 •peci <>), and
•ti ng th< !iUdd <n r, l<a« ofnor,pir.ephrir.< , • •timul alory
Conocyh<(l , p,ci<>) .'' Filt«nsp,ci e,h.o v, b« n iden tifi«l
r.rurotrammitterthatin trnsili<s,eraory pen:q,tions. "
~ ~:l .~~o~t:."mush!n ., ; ., "ngrci "entscon ti tute
3 R«<n l = • rch unro, ., m:! a grn1 , imiloritybrtwttn a
psilocybin-induced •piritu.ol txp<rienc,c • nd drug -fr<<
Bothwildandculth,.tedmushroomsvarygr,atlyinstttngth,
,nddrnmy'1ic:altxperience, . Dr.Rich.ordGr!ffi ths•n d his
soa,inglepotrn t mushroommigh t h.ove H m nchp•ilocy-
colle:,guts al JohnsHopkin ,V niversity•dmin ist<r<dcitha
bin H JO wn.ktr mush room,. Onc e• cap or ,tern i> inge, ted,
p,ilocybin,R ial in,• or•nothersu hstanceto a groupofJ6
citherfr e shordri«l .t h<p,il ocyb in i,convmed top,i!o d n,
rolunteerswhowueinrolved !nreligious acti,it i<S.Fourt< en
whichi>onlylwf H potent . P>il ocybincr = th, blood -
month,lat<r• bou t half ol thos< whohadalcenthe p, ilocy-
bnii nbarriamore e.a,ily P,ychiceff«aareoba inedfrom
binreporttdc ontinuingto<xp<ri<nct spi<itu• l changes • nd
d= of l0 to 60 mill igr,,m,;(mg)of actfreingred iena (th<
in,igh a ."
:u::'.:1of= mtl mushrooms ) a ndgrne ra llylutthr< < to
Ther<eis• m a llm:trk<t lormail-order kil5conaining p, y-
ched,l icmushroom •por ,stho twi ll growinto fungi in a

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d "" tor basem<nt. Som<= 0<an:hfor<0ts . look in gf or•
Traditionally,.psychede!ic.m<Jsh_roo.=.
tomd11cevr.;,on,tohelptreatillnesse5,ro!ve Cffl>in,peci <0. Th<po tentiilh.uardof ", hroom " horvu t-
problem,,orconnedwtththe,pmtworld ingi, m i'1 • ldngpoisonou,mu,hroom,fortho,.econain -
ing p,ilocybin . In e,;e ry region of th, world. po isonon •
mushroom, greatly outnumba p,ilocybin sp,ci<S . Some poi-
50nou, mushroom, (<.g., Aman ita pN:dloiJ<, ) cm caust
dt:athorpenn :rn entliverdama ge with inhourso l inge, tion
Step, to counter the toxinsmu,t be tak<n imm«lialdy .'"
Commongroceryotoremu,hrooms u e !iOm<time,lactd with
L.5Dor PCP and !iOld to 1h00< .., king• •~c mushroom "

Othe r lndolePsychedelics
lboga ine
Most mushrooms con tain ing p,ilocybin ,, .. 1.,
n:ou..a and Productd by the African Tabunanl ~< ibo):o shrub •nd oth<r
other p hy, ical,ymptom>bdoreth<p,ychede lic effectstak< pWl<>,ibogainein lowdo,.e,octs H aot imnl•nt:inhigha
dos,,itproduceolong-act ini;p•ychedelkeffectoand•Klf - yopo , oohoba,vi lca.e<bil.or<p<n.1.. Th,yblowiti nto u ch
d<tennin<da,.tonicrnction thatcanb<main,_in<d/orup othdsnose,through•hollowr<ed>ndthrndance,halluci -
totwodays.ltiorore lylound inth<VnitedS,.,,. , a!though """ · •nd•ing . Th<,ynth<ticformcanb<made in••imp l<
it has been •ynth« illd in W>oratori<>. la°"' is grnaa!ly basement l•bor.uory. "

~~Bwiti t;il,. or\ •.,.,~,,Hr.r

Africacdtrib< m~~,,;u.,
Wh<ninruiledDMTcau0<,intoxkation
lucinotion , . • nd•los•ofawor<n<0•0f
. in1<ns<visualruil -
, urround ing,Wting
lorreligioo,;ritoal, a ndto, ,ay a l<nandmotionl<.,whil<
u litt1, .. 10 minule5orup tom hour . Th< shOTt duration
~~7~~nd!:',t~~o,~~~°; , ~h.::e..:i~ •~ ;c,::;i.::: ohctiong ,s<ri«to th<cat chphr:o, e ·bus in<mn.onhp,c i•I"
b<cou« whit<-collor worker, can get high at lunch rnd
b<vcpai<I>ttdwithth<<y<>op<nOTd<»<d.Som<propl<
quickly>Ober up by th< time thcyrrtum to work . Som,
whous«lth e drugd<<erib<mo,i<lik<recollectionsofearli<r
prop l<<V<nr<ponup<rirncinggodlik<entitinand a lirn
lif<<xp<ri<nc«,rnd50meloundth <ms<l\,e, indttp intro-
WOTldswhil<high
•p<ctiv<•to1<> . Th<><<lf<cto hav,prompl«lr<<Urch<r,to
ap lor<th<drug'sth<np,uticpotrntiol Newspap<rreporu,.,,n,ation.alized a v.triantofD).!Tcall<d
bulot<nin<(~ .).f,0 .DMT ), whichisth<vrnomofth,Sonora
Theoseofibogain<totr<atalrohol,rocain<,andp>.niculorly
De><I"tOTColorado Rhu tom . Con tmy to ,.r,. of propl <
opioidaddictionront inu«tob<studied.On<animolotudy
lickingthet oadtog<thigh.the,ubs,.nceis<crap<donto
found lm t a ,ynthe ticd<th .. tiv,ofibogain< reduced th<
animols'withdrawal,ymplom,andth<iT><lf -• dminiotr:,tion cig:uet1<S. dri<d . •ndth en,mok<d. "
ofmorphin , ."'.,A nimolstudi«alsoind ie11<lmtcer<b<llum Ayahua= (yag~)
nrurotoxicitycan=ultlromibogain<O><C . Vnti l =:<ntly.
Ay•h=i , modefromth<l u ve,,ba rk,andvinesof
the«concumdfectivelylimit<d~rchintoibog•in< •• &utll1<riop,isrnapi a nd8anis1<riop,i,in<brian,,foundinth<
a m«lic •I tratmrn t lor huoind<p<ndrnce. "'-'' Anecdo!al
Amuonjungle.Drinkingth i,pr<pamioncau0<,int<nse
reporurndlimit<dstud i<>cb imthatjustafewtrutm<nl5
vomitinJ!anddiorrhealollow,dbyadrttmlik<rondition
<limiruot<d both withdrawa l ,ymptom, and craving lor
tha t lHt> npto l Ohoun
opioids . although«, ·eraldathsha,,eb<enlink<dto•dmin -
iot<ringibogain, ." Th,Chama,Tukanoan,rndZ:iparolndionsolP<ru,Br.u il
andEcuadoruseitforprophecy.dhin:ttion,sorc<ry,rnd
MomingGlorySeeds(ololiuqui) 1
S«ds from th< morning glory plrnt (lpomoca nirnlOT) or th<
:::, ::i"::.;,
~l~~:i":u:'.:: f:•;.,~m:~~::
Ha,. .. iirnwoodros<(A'l:)·r<iaorrvosa)oont>in.,v,r.,JLSD- with•nc<>tOB . UKnb<li<>'e t hat !twill•lsoindue<lnnc<
lik<,ubst2neeo.p • rtiruLulylyKrgicacid • mid< . whichi, slates lorprophecy . curemen!alilln<.,,rnd !xili tot<,ocial
abouton<-tenth .. pot<nt .. LSD. Th<ty,,,gicocid•mid<
:::::~:: :~., t~~~ ": ::"::t,:o:;,.,~n ~•~n~t
e1nb<us«ltorruok<l~aciddi<thylamide(LSD) . B,c,u«
it lak<, ing,.ting ><V<nl hundred «fflS to <irp<ri<ne< LSD- Currently,mE1yu., t h<j>T<parotioninritesthotf acili1>1<
like dfeca, th< drug', n.au,ating prop<n~ >r< nttgnifi<d ><lf-undus,andi ngandtoe,q,and con.ciou,ness . W<>l<m<f'.5
whichdiminish<>th<pWlt'spopulari tyamongtho><whou K who tried thedrugmor< thrnoncerepon«lexp<ri<ncing
psychede lics. Along with Knsory disturbanc es and mood altued,piritn• l• '"'" -"
change,oom,nau<U . vomiting . drowsin<M .h adache,rnd Theactiv<ingrcii<ntinayalmascai,th<indole•lk>loid
chills . Eff«toWtupto,ixhoun,rndLSD -lik,ft..hbacks•re harmoline.Nath,ecu ltu=oft<nmix) .. g<withD).!Tplont
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ha v<nlyblue.flyingsauc<n ,rn dpurlyg>l<>

DMT(dimethyltryptamine)
Fim,yn th<sizedin 1931, dimethy ltryptomine (DMT)i,
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mushrooms(e.g,,yopotr«Keds)>ndi, a lso,ynth<0iud ln2009•federaldistrictcourtrul<dthatth<Holylightof
byOlr«tch<m im . DMTi, • p,ych<d,lic ,ub<Wle< ,imilorin the Qu«n Church !n Ashwid . Ougon (• bnnch of th<
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ch«l,licpbna , ,uch u lh<O,in<><h<rb>)~Wlru<)inm rourtrul<din &vorolOr<gon 's HolyLightofth<Qu<rn
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Th<><etwopsychtdtlictrypwni n esapp,attdon the otrttt in
isu..don ly forneligiou•pofJ>O"'
th,eulylOOO. . bdor,thcyw<t< list<da,;!iCh<dultddrugs
Ovuth,pastf<Wy<ars,~nr.t l neligiom . includingUniJodo undu the Compr,chensh,e DrugAbus< Pr<=<ion ,nd Control
Veg<Ul (9,000m<mbu>)mdSantoDaim,,u,ing ayahua.,.ai Actofl970(th<Con<roll<d5uh,w,ce,Act),yrtuS<Bhav,
a,;thefocusofth<i r e<r<monie,ha,.,,prungupinBnuil and b«nprOS<Cul<dunderth<ftd<T>ldrugmalogu,,tatut< . Law
,ner<cogniudby th<Bnu iliongovemm<nt.UniJodo\'egetal rnfon:rment ,grnci<s ha,., s<i=l ,amp !<> in a number ol
u,u ·tonly ·nne lig"ou,c:,r<mon ·es 1 ·«•montl' ' r ,tat<>,butlh<drug,areu«donlyOCCil5ioruollyatrovnin
hours Ol>lim , .Adula .. w<ll "' adole«enadrink t h<>,,. · Arizono.C..lifomi , . F!orida,mdNewYork.Th<T<hav,b«n
hu= > te,b<caus < theyb ,Jie,.'<ilispsychologic • llybrndi - f,w,r •nd fcwu mrntiom of th< drug, !n r<ern l )ttr!I
::~; :,:~~~:: Th, u., ,pncad Elfecl>indud, illusiom,formica tion(int<m,i tching),pn,. -
no i.o, rnd<mo lion.ald ist= .'" Th<drugscan•lsocaus,
The DEA ha,d<t<rmin<d that D).IT, psilocybin mushroom,, """""• romiting . and di,rrh<>. The effect, lrom 10 mg
m<SC>lin,(pcyot<cactu, ),ha rmolin<(>,,.h= ), and a few th'.::;':drug can 1.. , 12 to H hour,; ,m.all,r d= lrn J 10
otherSch<dul,lp,ych,d,licsdonotc•US<Cphys ical d,p,n-
drnc, ." Th, Am,ric•n Indian R<ligious Fn,dom Act of
1978provid,s/o r th<c:<r<monia l us,ofth<halludoogrnic
drugstho1 Americ • nlndi.m,ha,., includ<dinth <iTneligiou, Peyote,MDMA, and Other
,acnmrntsfore<nturi<>. Thi, actwa>orig!n,llywrittenfor
th<e<ncmon· , 1u.,ofth,qo1<cactu, PhenylalkylaminePsychedelics

>
Psyd,edelK5suchupeyott,,psyched elic Althoughthi,ct. .. ofpsychedelic,isch<mically"'t.1<dto
,d,-,ru,lineandamph<umin< . m.onyolthe,ffectsarequit<
mu.t,,rooms,andayahuaSCAdonotaius e
physiaildependence . differ<nl . Theeffecaol,mph<"'-mine,pukwithin• half
hour(muchsooner il ,mok<d);ma nyoltheph<nyWkyl-
•min<>takes,v,ndhom~ t or<ochth<irpuk.Thisct. .. of
Foxy(5-methoxy-N, N--diisopropyltryptamine psyched elic, include,ruotura l ,oun:es,uch.,th<pcyot<
(5-Me-DIPT])and AMT(alpha-methyltryptamine) cactus•nd•numb<rof,ynth<ticrompounds,ucha,;MD).IA
Al,oknown.,••pira l, ," trypumin<i, • psycl>o-stimulant (ec, "'->y). Th<.,•neknowna,;p,ycho-e;timub.na
th.otwuoriginolly duign<d"-'E>E>t idepne,;unt(lndopm .e
).\oruos<").hwa,; al,o occa,ion.al ly a bustdonth<strtttdu, Peyote(mescaline)
toil>psychtdeliceffeca . Theeffecacanbstuptollhours. Mesca line is the active component ofth<pcyol<cactus
Sid,,/feruinclud e •nxi<ty,mu«l<l<mion,ne, ti,.,n,.. ,j• w (Loplwphorawilliam,;i) and t h< San hdro c"-Ctus

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0
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,:\:1u~~~;,:11;3 i~
(Trit:hocrm<>pachanai).SanP<drocact
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thep,yot< cacti ,trrtche,back,v<n
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"'-1 Peru . The u., of
further -3 ,700yurs
 6.14 CHAPTER 6
ago to 3700 B.C.13 Over the centuries the Aztecs, Toltecs,
Chichimecas, and several Meso-American cultures included
peyote in their rituals. When they invaded the New World,
the Spanish conquistadors regarded peyote as evil and the
hallucinations as an invitation from the devil. They tried
unsuccessfully to abolish its use. In the 1800s use spread
north to the Mescalero Apache and other tribes of the
American Southwest. Close to 50 North American tribes
(e.g.,Apache, Navaho) were using peyote in the early 1900s. 4 3
The search for connections to the inner self and the outer spiri-
tual worlds prompted many cultures to experiment with hallu-
cinogenic plants. In the late-nineteenth and early-twentieth
centuries, interest in the inner workings of the mind, as delin-
eated in the writings of Drs. Sigmund Freud, Alfred Adler, and
Carl Jung, among others, led many to search for the philoso-
pher's stone (plant) that would chemically aid them to a deeper
understanding of themselves. Aldous Huxley, one of the earliest
writer-philosophers of the twentieth century, used mescaline
from the peyote cactus to examine this connection .
'The urge to transcendself-consciousselfhood is, as I have said,
a principalappetite of the soul. When, for whateverreason,
men and women fail to transcendthemselvesb~ means of
worship,good works,and spiritualexercises,the~ are apt to
resortto religion'schemicalsurrogates-alcohol and 'goof pills'
I
in the modem West, alcohol and opium in the East, hashish
in the Mohammedan world, alcohol and marijuanain
Central America, alcohol and coca in the Andes."
Aldous Huxley, The Doors of Perception, 1954
The legality of using psychedelic substances for religious
ceremonies has been challenged for decades. In 1996 the
U .S. Supreme Court ruled that the use of peyote during
religious ceremonies by American Indians is protected by
the Constitution and that individual states cannot ban its
use. Peyote is used ceremonially by the Native American
Church of North America (with a claimed membership of
250,000) based on the belief that it builds spirituality and
community.
A peyote ceremony might consist of ingesting peyote but-
tons, then singing, drumming, and chanting hymns to better
understand the psychedelic visions or to have a spiritual
experience . Many participants have hallucinatory visions of
a deity or spiritual leader with whom they are able to con-
verse for guidance and understanding. 43
In the 1950s and 1960s, peyote cacti crowns (called "but-
tons") were available by mail order . Today customers must
file documentation of membership in the Native American
Church to purchase them. There are nine licensed distribu-
tors of peyote in the United States. 17 -60 About 2 million but-
tons are harvested in Texas each year, leading the Texas
legislature to place the cactus on the endangered species list.
Heavy users might consume up to 1,000 buttons a year.
Peyote cacti are still eaten in spiritual ceremonies by tribes
in northern Mexico (Huichol, Tarahumara, and Cora Indians)
and by the Southwest Plains Indian tribes ( Comanche, Kiowa,
and Ute).
lndolealkylamine Phenylalkylamine
Psychedelics Psychedelics
Psilocybin
mushroom
o- "\H
HO,p" +N-
cf 'O
Mescaline MDMA
H C,,.O NH2 H
N
<
3
H3 C,
0 #
0
H3 C,,.
These structural fonnulas show the method of designation for
psychedelics that is used in this chapter. Notice that the
indolealkylamine core is the same for all indole psychedelics and
the phenylalkylamine core is the same for all phenylalkylamine
psychedelics. Similar cores usually deliver similar effects.
© 2014 CNSProductions,lnc.
Effects
The gray-green crowns of the peyote cactus are cut at ground
level or uprooted and can be used fresh or dried. The bitter,
nauseating substance is either eaten (seven to eight buttons
is an average dose) or boiled and consumed as a tea. It can
also be ground and eaten as a powder. 4 •44 Mescaline was
extracted and isolated in 1896 and synthesized in 1919. The
synthetic form consists of thin, needlelike crystals that are
sold in capsules. The effects of mescaline last approximately
12 hours and are very similar to those from LSD with an
emphasis on colorful visions and hallucinations . Although
some users refer to it as the "mellow LSD," hallucinations are
more common with mescaline than with LSD. Each use of
peyote is usually accompanied by a severe episode of nausea
and vomiting, although some users develop a tolerance to
these side effects. As with most psychedelics, tolerance to the
mental effects can also develop rapidly. 61
"When ~ou get fresh buttons, the~ go down easier.No doubt
about it, pe~ote is the worst taste I'veeverexperienced.
WheneverI took it, I got into projectilevomiting. It would
happen as I was coming on to it. M~ reactionwas intense/~
visual,but it was different than LSD in that I could have a
conversationdespite the hallucinations."
64-year-old male former psychedelic user

This mature peyote cacrus (Lophophora williamsii) , held by a
Navaho medicine man, is used in many spiritual ceremonies. Each
butron (the top of the cactus) contains about 50 mg of mescaline.
It can rake two ro 10 butrons roget high.
0 Ira Block. Reprinted with permission.
People's reaction to many psychedelics depends on their
mind-set and the setting as well as the actual properties of the
drug, so the use of a mind-altering substance in a structured
ceremonial setting can induce more-spiritual feelings than
use at a rock concert. Peyote 's connection to spiritual matters
limits abuse. A study of long-term peyote users, 61 members
of the Navaho Native American Church, found no significant
psychological or cognitive deficits when it was used in a reli-
gious setting. 61,62
Psycho-Stimulants (MDA, MDMA, 2C-B,
2C-T-7, 2C-T-2, PMA)and Club Drugs
"There is a wealth of infonnation built into us, tucked away
in the genetic material in every one of our cells. Without
some means of access, there is no way even to begin to guess
at the extent and quality of what is there. The psychedelic
drugs allow exploration of this interior world and insights
into its nature."
Alexander Shulgin , Ph.D., psychophannaco logist and chemis t
Designer psychedelics or psycho-stimulants were one of the
first groups of synthetic drugs used for mental exploration
and later for recreation. Chemically defined as phenethyl-
amine derivatives, this group is chemically similar to mes-
caline. Some phenylethylamines are naturally occurring
compounds found in the human brain. 59
All Arounders 6.15
MDMA(ecstasy)
In the early 2000s, ecstasy (MDMA) was the psychoactive
drug with the highest public profile. When government
agencies focus on a certain drug, media interest skyrockets;
and when the interest dies down or another drug takes the
spotlight, media coverage and governmental concern dimin-
ish. Ecstasy followed that pattern. Use among high-school
seniors and young adults peaked from 2001 to 2003 but has
declined to about half of peak levels since then, although
recently use by high-school seniors has started to creep up
again while young adult use remains constant . Part of the
current interest is for "Molly," a refined , often-crystalline
form of MDMA, sold in capsules, which seems to users to
be stronger than the old ecstasy pills but only because it is
a more concentrated and purer form of one of the most mis-
represented drugs.
The psycho-stimulant MDMA, chemical name 3,4-methyl-
enedioxy-methamphetamine, is shorter acting than MDA
(4 to 6 hours vs. 10 to 12). It has numerous street names,
including "E," ecstasy, XTC, X, Adam , and, most recently,
"Molly." MOMA can be swallo wed, snorted, or injected,
much like methamphetamine , though it is usually sold as a
capsule, tablet, or powder. MDMA is used at parties , raves,
and music clubs; users claim it creates a strong desire to move
I
about , dance , and interact with other people.
"Wea have'E' parties;a bunchof peoplewouldtake 'E' and,
like,it 's real/~likea friend/~dru9.Youtake it and then~oufeel
happ~, so ~outalkto ~ourfriendsa lot, ~outalk to stran9ers,
and ~ou find thin9s in common, and. ever~one is like ~our best
friend; but when~oucome downoff the dru9,it's likea total/~
different experience- it's like a downer."
17-year-old ecstas y user
History The German pharmaceutical company Merck first
disco vered MOMA in 1914 as an intermediate chemical step
in the synthesis of MDA. It did not surface again until 1953,
when the U.S. Army carried out psychological warfare/
brainwashing experiments on animals and humans with a
number of other psychedelic compounds (as well as MDA
and MDMA), including:
• MDPEA (methylenedioxyphenethylamine)
• BDB (1,2-benzodioxolyl-butanamine)
• DMA (dimethoxyamphetamine)
• TMA (trimethox yamphetamine)
After a test subject died due to MDA, testing ceased and it
was another 16 years before the first published human study
of MDMA appeared, written by Dr. Alexander Shulgin (a
chemist and psychopharmacologist) and his colleague Dave
Nichols. 63 They described the level of personal insight a
patient using th e drug was able to achie ve and recommended
its use to a number of therapists to help their patients tap
their emotions and repressed memories. Dr. Ann Shulgin , a
psychotherapist ( who , along with her husband, Alexander,
developed more than 150 amphetamine analogues, many
for the DEA), estimated that as many as 4 ,000 therapists
 6.16 CHAPTER 6
experimented with MOMA in the late 1970s and 1980s as a
way to create a deeper empathy for the feelings and the fears
of their clients .59 •64 •65
MOMA was designated a Schedule I drug in 1988, making
it illegal in the United States. This made it very difficult to
continue psychotherapeutic experimentation. It is human
nature to want what is suddenly unavailable, so the drug
became more desirable.
"I had no inhibitions.I mean,it waslikewhateversexualcom-
promiseor, qou know,touchin9or conversation that I would
havenormallqhad boundariesfor, I didn't when I tookecstasf"
28-year-old ecstasy user
Ecstasyseemsto createa deeper empathy
in usersand has been used by a number
of therapiststo work on repressedmemories
and emotions.
When ecstasy was legal, the main manufacturer sold up to
50,000 tablets per week. In 2006 a single Dutch trafficker was
sentenced to 20 years in prison for importing 1.7 million
ecstasy tablets into the United States. Since then seizures
I
have decreased. Most of the MOMA used in the United States
was smuggled in by western European, Russian , and Israeli
drug-trafficking syndicates. 66 Significant numbers of "E" tabs
are now manufactured by clandestine laboratories in Canada
and the United States.
Use and Cost Ecstasy use is often called "rolling," a Genera-
tion X term derived from the practice of concealing an "E"
tablet in a Tootsie Roll.®Vicks®inhalants and other pungent
substances are reported to be pleasingly enhanced after tak-
ing "E" and are used at rave clubs. Waving glow or light sticks
in front of someone who is rolling, to produce mesmerizing
effects, is a common activity at rave and music events.
The average cost of a capsule, a tablet, or an equivalent pow-
der packet (75 to 125 mg) is $25 but can be as high as $70.
The cost of producing a tablet ranges from 50¢ to $2; do the
math-the profit margin is huge. Wholesale prices for quan-
tities of 1,000 vary from $10,000 in the United States ($10
per pill) to $5,000 in Canada and $15 ,000 in Brazil.67 Tablets
are stamped with a variety of designs and come in almost
every color; white or light tan is the most common.
An early DEA report found that 30% to 50% of tablets sold
as MOMAat raves actually contained no MOMAbut rather
other illicit drugs, such as PCP, methamphetamine , PMA, or
MDA. Of those actually containing MOMA, only 24% were
straight MOMA; the remaining 76% contained other psycho-
active drugs .60 ,66 Not much has changed . The drop in sales,
however, suggests that the explosion of bath salts, synthetic
marijuana , and other designer drugs has taken part of the
traditional market. Unfortunately, because many of the new
drugs are undetectable, accurate figures for ecstasy-like-
drug use are hard to come by.
"In Florida,the fakeecstasq, calledPMAor para-methoxqam-
phetamine,and PMMA,or para-methoxqmethamphetamine,
is killin9qoun9peoplebq raisin9theirbodqtemperatures to
as hi9has 108 dearees. The pillsbein9sold in centralFlorida
arebelievedto be morelethalthan ecstasq,whichis madeof
MOMAor methqlenedioxq-methamphetamine. The pillsare
similar,and medicalexpertssaq it is virtuallqimpossibleto tell
themapart unlesstheq aretestedin a laboratorq."
ABC News, September 30, 2013~
Physical Effects MDMA's stimulant effects are similar to
those of amphetamines , such as increased heart rate and
respiration, excess energy, fainting , sweating, hyperthermal
increased body temperature , chills , and hyperactivity. The
more MOMA a person takes, the greater the physical effects.
The effects of "E" appear about 30 minutes after ingestion
(the usual route of administration) . The onset consists of
tightness in muscles with generalized spasms. Tiger Balm®
or rubbing oils are used to offset the muscle tightness caused
by the drug. Trismus (jaw muscle spasm) and bruxism
(clenching of the teeth) occur just before most of the psy-
chic effects begin.
'The firsttime I did what I thou9htwas 'E,' I chewedthe
bottomof mq lip openbecause therewasso muchspeedin it.
I wokeup the next mornin9and mq stomachwas,like,
completelqhollow.I felt liketherewasnothin9in mq stomach
at all. Mq le9swere9Din9 ; I was bouncin9mq le9s, and theq
werevibratin9;theq were9oin9so fast. It was so weird.
Mq eqeswerepoppin9out of theirsockets."
17-year-old ecstasy user
A variety of paraphernalia is associated with MOMA, includ-
ing baby pacifiers and lollipops, used to avoid damage to the
user's teeth. Though some users report more-heightened
sexual sensations, prolonged use decreases arousal in women
and orgasm in men .69 •70 MOMA releases less adrenaline than
most methamphetamines , so a user does not receive quite as
much sympathetic nervous system stimulation of heart rate
and blood pressure . For occasional users oflow or moderate
amounts, most of the physical effects are relatively benign;
however , tolerance to its mental effects develops rapidly,
so user s increase doses, often causing greater physical
liability.
The more serious MOMA effects can include:
• water toxicity and electrolyte imbalances as well as dehy-
dration
• pupil dilatation, blurred vision, and twitching eyelids
• headaches, agitation , nausea , and anorexia
• serotonergic axon apoptosis (cell death caused by do-
pamine uptake in serotonergic cells and the subsequent
production of hydrogen peroxide), resulting in thought
and memory impairment 71
• rapid and potentially dangerous heart rhythm activity
• seizure activity, stroke , cardiovascular failure, and coma

• malignant hyperthermia (high body temperature) that
can result in rhabdomyolysis (muscle damage) and renal
(kidney) failure; extreme body heat can even coagu late
the blood
"At ravesecstas~can cause the natural thermostat in ~our bod~
to 90 ha~wire,so there'sa lot of heat becausepeople are ver~
active. It's a stimulant, so people are dancin9, for9et to drink
water, for9et to h~drate;and these places are most/~ hot, and
we'veseen people with extended bod~ temperatures."
Glen Razwick, former director, Rock Medicine Program,
Haight Ashbury Free Clinics
Very high-dose use can result in high blood pressure and
seizure activity similar to what occurs in amphetamine over-
dose. In experiments with rats and monkeys, researchers
found that MDMA damaged serotonin-producing neurons in
the animals' brains and lasted for 12 to 18 months or more
after use. In tests of people who attended parties and/or raves,
methamphetamine was often found in the blood along with
MDMA, thus amplifying the danger of serotonin damage_72
Mental and Emotional Effects Twenty to 60 minutes after
ingestion and continuing for 3 to 4 more hours, MOMA
induces feelings of happiness, clarity, peace, pleasure, and
altered sensory perceptions without causing any deperson-
alization or detachment of the users from the realities of their
environment. Users report experiencing an increased non-
sexual empathy for others, more self-awareness, and
heightened self-esteem, open mindedness, acceptance, and
intimacy, which are reasons why it is called a "hug drug"
rather than a "love drug" like MDA.
Many of the psychic effects are probably due to serotonergic
activity, though the drug does not give the visual illusions
most often associated with psychedelics. 29 For the first few
hours of use, ecstasy overwhelms the synaptic vesicles and
forces them to discharge their reservoirs of serotonin into
the synaptic gap, thus continuing to dramatically amplify the
brain's response to its internal and external environment.
All Arounders 6. 17
These pills of ecstasy were interceptedby the DEA. Much of the
smuggling was done by Canadian-basedChinese gangs. Currently,
a capsule of the powderedform of ecstasy (above) called "Molly" is
the ecstasy of choice,but both tablet and capsuleforms often contain
some other chemical, rangingfrom methamphetamine and ephedrine
to MDA, PCP,and PMA.
Courtesyof the U.S. Drug EnforcementAdministration
After about three hours, ecstasy continues to prompt the vesi-
cles to release more serotonin, but by then the supplies have
been depleted. If more ecstasy is taken at the point of deple-
tion, the effects are proportionately diminished, so the drug is
often taken with other drugs like LSD or amphetamines to
prolong the feelings. It can take up to a week or more to
produce a sufficient amount of serotonin to re-experience the
I
same feelings originally produced by the drug.
Due to this excessive stimulation, serotonin receptors
retreat into the cell membrane to avoid damage . This pro-
cess, called "down regulation," leads to more long -lasting
mood changes because there are fewer receptors to respond
to the serotonin.
'The next da~ ~ou wake up and it's what ~ou call
'E-tarded.' You feel retarded but ~ou'recomin9 off of 'E'
so ~ou're'E-tarded' and ~ou'rejust, ~ou know, total/~ tired
and just, ~ou know, just, 'Duh, what's 9oin9 on?' You are
real/~slow in ~our thinkin9."
17-year-old ecstasy user
Following an ecstasy experience, some users become
extremely depressed and suicidal. High-dose use can result
in an acute anxiety reaction and can cause flashbacks after
cessation of use. 63
Physical dependency rarely occurs, but psycho logical depen-
dence can cause compu lsive use; tolerance develops rather
quickly if the drug is used daily.26
Ecstasy is often ingested simul-
MDMA Polydrug Combinations
taneously with a number of other illicit and prescription
drugs.
• LSD with ecstasy, known as candy flipping, flip flop-
ping, X and Ls, and candy snaps, is said to intensify the
effects of both drugs and increase the duration of action
ofMDMA.
• Hydrocodone/OxyContin ®/codeine/heroin with ecstasy
is a Generation X speedball combination that can en-
hance the euphoric feelings of both drugs.
 6.18 CHAPTER 6
• Nitrous oxide with ecstasy is used to intensify the inhal-
ant rush, sometimes resulting in traumatic injuries from
passing out.
• Prozac® (fluoxetine) with ecstasy is thought to protect
serotonin brain cells from the neurotoxic effects of ec-
stasy. Recent animal studies indicate that Prozac ® may
actually neutralize the effects of MOMA when both are
taken together. Savvy users take Prozac ® after the effects
of ecstasy have worn off.
• MOMA with Viagra® is used to enhance sexuality, called
"sextacy. "
"I smokeda 'blunt'that had abouta gramof cokein it and five
pillsof ecstas~.And the ecstas~,I hadgotten, I had abouta
thousandpills, I wasdoingit a lot. It wasbad; it wasa bad
dose.And it put me in the hospitalfor abouta month; attacked
m~heart.The doctorssuggestedthat I'm goingto needa heart
transplantbeforeI am 25 ~earsold."
22-year-old recovering addict
Parties,Festivals,Raves,and MusicClubs
The term rave was coined in England in the late 1960s to
describe a large dance party. The collapse of the textile indus-
I
try made many large warehouses and spaces available for this
purpose. Drugs were often available as they are today. Today
raves have evolved into gatherings where loud computer-
generated techno or electronic dance music (EDM) is played
by increasingly famous disc jockeys (e.g., Dutch DJs Armin
van Buuren and Hardwell, and American DJs/musicians
Calvin Harris and Filo & Peri). These often elaborate presen-
tations, with anywhere from 100 to 50,000 attendees,
accompany the EDM with laser lightshows and elaborate
stage sets somewhat like a psychedelic carnival. The music is
often original, sometimes composed right at the rave .73 -74 ,75
Today most raves occur legally at stationary locations, even
stadiums. They have become very big business, with revenues
that can reach into the millions of dollars.
Drugs found at these gatherings include 2C-B, 2C-C
(C-boom), nitrous oxide ("laughing gas"), nitrites (pop-
pers), GHB or GBL, ketamine, PCP, nexus (2C-B), mari-
juana, and of course ecstasy ("Molly "). At some raves a
product called Mollywatr is sold. Capsules of "Molly " can go
for anywhere from $8 to $40 . Overdoses attributed to "Molly"
have increased significantly .78 Gamma-hydroxybutyrate
(GHB) and gamma-butrolactone (GBL) are actually more
like downers than psychedelics.
"Purple drank " (sizzurp , "syrup ," lean , purp, Texas tea,
purple jelly, barre) is a concoction that has achieved increas-
ing notoriety due to its association with the hip-hop music
community (e.g., Lil Wayne, DJ Screw) . "Purple drank" is
cough syrup containing codeine and promethazine (an anti-
histamine) mixed with Sprite® and a handful of Jolly
Rancher®candies, which dissolve in the soft drink. Although
the concoction was consumed in the 1960s and 1970s (usu-
ally with beer and not a soft drink), it became popular out-
side of Texas in 2000 due to its increasing mention in hip-hop
music. Although it acts more like a downer, the prometha-
zine gives it a spacey effect. Most of the overdose problems
come from the depressing effects of the promethazine and
codeine on the central nervous system (CNS).
Alcohol is available at raves if you "bring your own, " along
with various prescription opioids such as OxyContin ® and
Vicodin ® and prescription stimulants (Ritalin ® and
Adderall ®) . In the past dozen years, synthetic marijuana,
bath salts, and other new methcathinone compounds are on
the increase. The bath salts are stimulants with the potency
of methamphetamine or cocaine, such as:
• mephedrone (4-methylmethcathinone or 4-MMC)
• 2C-P (2,5-dimethoxy-4-n-propylphenethylamine)
• MOPY (methylenedioxypyrovalerone)
Unfortunately , because their composition is unknown , their
side effects can include stimulant cardiac effects as well as
just flipping out.
In a study of underground raves where drugs are more plen-
tiful , the average attendee used five different drugs, mainly
tobacco, alcohol , marijuana , ecstasy, and amphetamine ."
Most attendees simply enjoy the music, dance, and socialize
without suffering any adverse effects. When problems occur
they include harmful physical reactions to drugs, negative
psychedelic experiences, mental destabilization, overheat-
ing, and injuries caused by falling (often caused by nitrous
oxide). Most trips to the emergency room are due (in order of
frequency) to alcohol, cocaine, marijuana, heroin, metham-
phetamine, nitrous oxide , PCP, MOMA, LSD, GHB, and ket-
amine abuse .75 At a rave festival attended by an estimated
16,500 at San Francisco's Cow Palace over Memorial Day
Weekend in 2010, one death and five critical hospital admis-
sions thought to be due to ecstasy were recorded. 76
The most common drugsat ravesare ecstasy
("Molly''),marijuana,"purpledrank,"nitrous
oxide,occasionalbath salts,methamphetamine,
syntheticmarijuana,and alcohol (often drunk
before the party-known as front-loading.)
6-(2-aminopropyl)benzofuranor 6-APB (Benzofury)
Benzofury is an entactogenic compound (a substance that
produces emotional and physical effects similar to ecstasy).
It begins to work in 45 minutes to an hour, inducing a sense
of overwhelming euphoria and a surge of energy, and lasts
up to 10 hours. It induces strong empathy toward others .
Its sale is banned in Britain. In the United States it is not
approved for human consumption, but it is still available,
though availability is limited. With long-term use, it can
become toxic to the heart and cardiovascular system.
2C-T-7 and 2C-T-2
Two other phenethylamines, originally developed by Dr.
Alexander Shulgin and mentioned in his 1991 book , PiHKAL:
A Chemical Love Story, have recently surfaced in the psyche-
delic drug-taking subculture. The common effects shared by

these two phenethylamine psycho-stimulant drugs are the
ability to induce delirium, heighten sensitivity, and increase
awareness in the user. 59 They can also cause dangerous
cardiovascular effects or death when taken in high doses.
Known by its Netherlands trade name "Blue Mystic," 2C-T-7
(2,5 dimethoxy-4-propyl-thiophenethylamine) was first syn-
thesized in January 1986. By 2000 "smart shops" were selling
the psycho-stimulant under the brand names Tripstacy, 7th
Heaven, "7-Up," Lucky 7, and Beautiful. 77 "Smart shops,"
descendants of "head shops," are boutiques that promote and
sell New Age psychedelic substances, paraphernalia, litera-
ture, and fashion accessories that promote drug use. There
are more than 200 in the Netherlands; most sell fresh and
dried varieties of magic mushrooms, herbal ecstasy (with
trade names like Cloud 9,® Ultimate Xphoria,® and Herbal
Ecstasy® containing caffeine and/or ephedrine), guarana,
other herbal stimulants, psychoactive herbs, Cannabis seeds,
and grow kits.
The abuse of a similar drug, 2C-T-2 (2,5-dimethoxy-4-ethyl-
thiophenethylamine), spread through "smart shops" in the
Netherlands, Sweden, Germany, andJapan, leading to its ban
in the Netherlands in 1999. The high, according to some
users, comes with unpleasant physical effects (nausea, vom-
iting, and muscle tension) and does not deliver the satisfying
mental effects that 2C-T-7 does."
Nexus (2C-B [CBR]or 4-bromo-2,5-dimethoxy-
phenylethylamine)
"I foundonlqmildvisualand emotionaleffectsat the 20 mg
dose,so I tookthe remaining44 mg. I waspropelledinto
somethingnot ofmqchoosing.Everqthing that wasalivewas
completelqfearsome.Mq gazemovedto the rightand caughta
bushgrowingoutsidethe window,and I waspetrified.It wasa
lifeformI couldnot understand."
40-year-old physician 59
All Arounders 6.19
More than 50,000 people
assemblefor the week-long
Burning Man Festival every year
in the Black Rock Desert in
northern Nevada. Although it is
describedas an experiment in
community,art, self-expression,
and self-reliance,there are ample
electronicdance music gatherings
and sufficient alcohol and drug
use that qualify as mini-raves.
© 2013 AlexanderVo
lkov
This rarely used amphetamine-like chemical was synthesized
by Dr. Alexander Shulgin. Like with many of the psycho-
stimulants, the effects of 2C-B depend on the amount taken:
I
mild stimulation at low doses and intense psychedelic
experiences at high doses.
A number of users combine 2C-B and MDMA to intensify the
effects. Experienced psychedelic users will experiment with
whatever drug is available, but they learn to control their
reactions to various substances and can credibly report on
the subtleties between one psycho-stimulant and another.
25C-NBOMe or "C-boom"
There has been a recent surge in the use of "C-boom" or
25C-NBOMe,derived from phenethylamine. It is very potent
when snorted as a liquid, even more than LSD, especially
at doses above 350 µg. By boosting serotonin, "C-boom"
causes vibrant coloring, sound distortion, a body high, ego
loss, an inability to act normally, and a loss of being, time,
and space.
2C-I (2,5 dimethoxy-4-iodophenethylamine) is another
psycho-stimulant that is part of this family of designer club
drugs that is gaining some recent popularity and has effects
similar to 2C-B and 25B-NBOMe ("C-boom").
The creationof new designerdrugs
("C-boom,"bath salts) or renewed popularity
of older ones (2C-B, "Molly'') makes it hard
for the DEAto restrictthese substances.
PMA (4-MA or para-methoxyamphetamine)
PMA has been found in pills purporting to be ecstasy . After
an hour this short-acting drug causes a sudden rise in blood
pressure, distinct after-images, and a pins-and-needles tingly
feeling resembling goose bumps or hair standing on end.
 6.20 CHAPTER 6

This hallucinogen can negatively surprise the unaware user,

causing severe sympathetic nervous system stimulation (sei-
zures), hyperthermia, coagulation of blood, and muscle dam-
age. PMA became popular after street lore touted its effects
as being similar to LSD (not true). Most of the reported
deaths were caused by overdosing . At one time it was sold in
the United States and Canada as "death," chicken power, and
chicken yellow.

STP(DOM) (2,5-dirnethoxy-4-rnethylarnphetarnine)
STP-also called the serenity, tranquility, or peace pill-is
similar to MDA. It causes a 12-hour intoxication character-
ized by int ense stimulation and several mild psychedelic
reactions. It was used in the 1960s and 1970s but is rarely
seen today because of the high incidence of bad trips.

Anticholinergic
Psychedelics
(belladonna,henbane,mandrake,and
daturaOimsonweed, thornapple])
The differencebetween a dose ofjimson weed that is used to relieve
"Double,double,toiland trouble; asthma symptoms vs. a dose that is used as a hallucinogenand a
Fire bum and cauldronbubble; deliriant vs. a dose that can kill is not very great. It supposedly
Filletofa fenn~snake; originated in the Americas but is now found around the world.

I
In the cauldron,boiland bake;
E~eofnewtand toe offrof
Woolofbat and tongueof dog."
William Shakespeare, Macbeth, 1623
The witches in Shakespeare's Macbeth did not mention bel-
ladonna and other nightshade plants, such as henbane, man-
drake, and datura, but they very well could hav e because
these anticholinergic psychedelic drugs were used in magic,
sorcery, witchcraft, and religious rituals from ancient Greek
times through the Middle Ages and the Renaissance. These
plants contain the psychoactive and/or psychedelic chemi-
cals hyoscyamine, atropine, and scopolamine-all of which
could season a malevolent brew.
These plants hav e also been used to mimic insanity and as a
narcotic, a diuretic, a sedative, an antispasmodic, a poison,
and even a beauty aid by ancient Greek, Roman, and Egyptian
women because they dilate pupils and make the eyes more
striking. " It is no surprise that belladonna in Latin means
"beautiful woman."
Belladonna is a short bush (2 to 4 ft. high) with green leaves
that is widely distributed over central and southern Europe
and southwest Asia; it is cultivated in England, France, and
North America. Datura is more widely grown than bella-
donna, and references to it are found in Chinese, Indian,
Greek, and Aztec history.
One of the effects of these plants is the blockage of acetyl-
choline receptors in the CNS. Acetylcholine helps regulate
reflexes, aggression, sleep, blood pressure, heart rate, sexual
behavior, mental acuity, and attention. This disruptive effect
can cause a form of delirium, making it hard to focus. It can
also speed up the heart, cause intense thirst, and raise the
© 2013 CNSProductions, lnc.
body temperature to dangerous levels . Anticholinergics
also cause hallucinations, a separation from reality, and
deep sleep for up to 48 hours .so They are still used today by
some native tribes in Mexico and Africa .
Synthetic anticholinergic prescription drugs such as
Cogentin ® and Artane, ® which are used to treat the side
effects of antipsychotic drugs and the symptoms of Parkinson's
disease, are diverted from legal sources and abused for their
psychedelic effects . Belladonna cigarettes (Asmador®) are
used to treat asthma and have been abused by youth in search
of a cheap high. 81
Jimson weed, also known as thornapple, angel's trumpet,
Jamestown weed, mad apple, moonflower, "hell's walls," and
stinkweed, is a bristly plant with coarsely serrated green
leaves and a white flower that resembles a morning glory The
plant is indigenous to many parts of the United States and is
classified as a toxic weed. Every part of the plant is toxic to
humans and animals. Users eat the seeds, drink jimson tea,
and smoke cigarettes made from the leaves. The drug induc es
jerky movements, tachycardia, hypotension, and especially
severe hallucinations, such as of imaginary snakes, spiders,
and lizards. Not many users try the drug twice because it is
often described as a horrible experience that can last for days.
Almost 1,000 jimsonweed poisonings were reported in the
United States in 2008 .82 Impaired judgment and coordina-
tion leads to risk-taking activities, which often lands users in
the emergency room. Emergency personnel describe jimson
weed users as "Hot as a hare, blind as a bat, dry as a bone, red
as a beet, and mad as a hatter. "83

PCP,Ketamine,Salvia Divinorum,
and Other Psychedelics
There are lesser-known psychedelics whose popularity surges
as each generation discovers an obscure substance that was
used by other cultures or has recently been synthesized .
Once drugs such as Salvia divinorum, bromo-dragonFLY,
lion's tail, and even the AIDS drug Sustiva"' make headlines,
they are listed as DEA drugs of concern. When new genera-
tions rediscover older drugs, they are usually unaware of the
drugs ' negative histories. For example, PCP was popular in
the early and mid-1970s, causing problems for police, par-
ents, and schools because of the violence it engendered. PCP
became yesterday's news to the media, although emergency
room visits remained high. By 2005 and 2006 , a new genera-
tion of users started smoking "fry" or "fry daddies" (mari-
juana dipped in embalming fluid) and adding PCP. To the
younger users , it was a novelty ; but like the use of PCP in
previous decades, the drug caused unexpected effects, such
as disassociation, anger, insensitivity to pain , increased inju-
ries, arrests, and visits to the emergency room.
PCP
PCP (phencyclidine hydrochloride) was originally developed
in the 1950s as an intravenous anesthetic, but it was never
approved for human use. The frequency and the severity of
toxic and hallucinogenic effects limited its use exclusively to
veterinary medicine. 84 •85 Although the drug is fairly simple to
manufacture in a home laboratory, the pungent odor is easily
detectable. Today PCP is illegal and available only from
street gangs.
Also called angel dust, peep, KJ, Shermans , whack , rocket
fuel, and ozone, PCP is often misrepresented as THC, mes-
caline, or psilocybin. It comes in liquid, crystal, tablet, or
Both PCP and ketamine were originally developedas anestheticsbut
were eventually only used as animal tranquilizers. Ketamine is the
only one used extensively now.
© 2003 CNS Productions,Inc.
All Arounders 6.21
powdered form and is smoked, snorted, swallowed, or
injected. It is often smoked in a Nat Sherman "' cigarette or
added to a marijuana "joint" ("fry" or "fry stick").
PCP blocks the sensory messages sent to the central nervous
system, which dissolves inhibitions, deadens pain, and causes
mind/body separation. In one study almost three-fourths of
the users reported forgetfulness, difficulty concentrating,
aggressive and violent behavior, depersonalization, and/or
estrangement; a smaller percentage (about 40%) reported
hallucinations (tactile, visual, or auditory) .35 -63 ,85 The most
problematic effects of PCP-self-inflicted injuries and vio-
lent run-ins with authorities-occur because its dissociative
effects cause a numbness to pain, so users run the risk of
overstressing muscles, sinews, and flesh. Sensational news
stories often overinflate PCP's power and report altercations
involving superhuman feats of incredible strength; movies
such as The Tenninator and Death Wish II perpetuate the
misperception by featuring characters who fight like robots
and feel no pain.
"WhenI smokePCP,I feeljustlikeon top ofthe world,~ouknow.
Youdon'tfeelpain.Youdon't thinkabout~ourpast. It'sa 000d
dru9if ~ouwantto coverup ~ourfeelin9s,~ouknow?You/eellike
Superman.It'slikeacidwithoutthe mindtrip.A coupleof times,
I9ot scaredon it thou9h'causeI smokedtoo much."
I
Recovering PCP user
Because PCP is so strong, particularly for first-time users, the
range between a dose that produces a pleasant sensory-
deprivation effect and one that induces catatonia, coma,
or convulsions is very small. Low dosages (2 to 5 mg)
produce mild depression then stimulation . Moderate doses
(10 to 15 mg) produce a more intense sensory-deprived state .
Dosages above 20 mg can cause catatonia, coma , and convul-
sions . Large doses of PCP have produced seizures , respiratory
depression , rigidity of muscles, cardiovascular instability,
and kidney failure."
"I'vehad seizuresbeforeon it and ban9edm~ headreall~
hard-co ntinuaII~on hardobjects-and 9ot lotsof bumps
and eve~thin9and felt themthe nextfewda~sbut never
realizedI wasdoin9it and neverfelt hurtfromit."
RecoveringPCP user
A low dose of PCP lasts 1 to 2 hours, and a moderate dose
lasts 4 to 6 hours, but the effects of a large dose can last up
to 48 hours , much longer than the effects produced by a
comparable dose of LSD. PCP can be recirculated from the
body fat to the brain, causing an actual drug "flashback"as
opposed to a PTSD-like memory. Some have reported expe-
riencing this reaction for several months after discontinuing
use. PCP is not widely used because of its propensity to
deliver a bad trip, but it continues to be misrepresented as
other, more popular drugs like THC or mescaline and is
accidentally used by unsuspecting consumers .
When the psychedelic effects kick in, first-time or unaware
users can have a bad trip and often do not remember what
happened. This type of amnesia is called anterogradeamnesia.
 6.22 CHAPTER 6
There is also some memory loss of events that occurred
shortly before the drug was taken; this type is called retro-
grade amnesia. Both types of memory loss are frequently
associated with date-rape drugs like Rohypnol ® or GHB and
with alcohol (blackouts). Long-term , die-hard users experi-
ment to arrive at a personal dose for these drugs that does not
result in radical side effects .
PCPand ketamine are classifiedas dissociative
anestheticsand are also used as animal
tranquilizers.They can act as a sedativeand a
hallucinogen.
Ketamine
Although interest in club drugs has declined, they are still
found in nightclubs and at raves . Ketamine is a dissociative
general anesthetic used in human and veterinary medical
procedures; it produces effects very similar to those of PCP,
its close chemical relative and predecessor. Both share the
same receptor sites in the brain, although each has a different
duration of action-PCP lasts longer than ketamine. First
synthesized in 1962, ketamine was the most frequently used
anesthetic in the Vietnam War and continued to be widely
used on humans until reports of its side effect-unwanted
I
visions-stopped its use on humans . It is now used most
often as an animal tranquilizer . It was not rated as a sched-
uled substance (depressant-Schedule III) until 1999.
Because ketamine is more difficult to synthesize than PCP,
most of it is diverted from legitimate suppliers and users.
Intravenous solutions ofketamine are diverted from medical
and dental supply sources and crystallized by heating in a
microwave oven. The crystals are usually snorted but can
also be smoked in a crack pipe . Occasionally, the drug is
taken orally or injected . Ketamine is sold under the trade
names Ketanest, ®Ketaset, ®and Ketalar ®and is known on the
streets as special K, vitamin K, and kit kat. It is also available
in Mexico as an over-the-counter anesthetic gel for horses.
Effects
"K-heads " (ketamine abusers) often use a micro-spoon, pile
about 20 mg of powder as a "line " on a mirror, or take a
"bump " from a plastic snorting device called a "bullet " and
snort up each nostril two to five times until the desired effects
are achieved. A "K-land" dose of 100 to 200 mg causes a
mild, dreamlike intoxication, sensations of mind/body sepa-
ration, dizziness, free-floating giddiness, slurred speech, and
impaired muscular coordination. 87
"Youdon't care about an~thingwhatsoever.You are distant from
whateverit is. Whether someoneis talkingto ~ou, whetherthere
is an argumentgoing on right next to ~ou, ~ou don't know it.
You are in ~ourown little place. Nothing around ~ou is con-
nected to ~ou."
43-year-old former psychedelic user
It takes a 300 to 500 mg dose ofketamine to produce the full
psychedelic experience. "Being in a K-hole" is described as
an out-of-body near-death encounter with depersonaliza-
tion, hallucinations, delirium , and occasionally bizarre or
mystical experiences .88 Users also become anesthetized to
pain and feel nothing when injured due to rough activities,
fights, or strolling through a hostile landscape.
"/ walkedinto a cactus garden duringa part~. I just walked right
through, walkedright out. The next da~ m~ feet wereall blood~
and I was pullingstickersout and stuff, but at the time there
wasn't an~thingto it."
43 -year-old former psychedelic user
The toxic side effects from a K-hole dose or a full-on over-
dose include respiratory depression, increased heart rate
and blood pressure, combative or belligerent behavior,
convulsions, and, in a few cases, coma.
Veterinarians pay about $7 for a legal vial of ketamine, mid-
level street dealers pay $30 to $45 per vial, and users may pay
$60 to $200 per vial , or $20 to $25 per dose . A vial contains
about 1 gram (gm) of liquid ketamine (five to 10 doses). 90
Several researchers have used ketamine to treat alcoholism in
a technique known as ketamine-assisted psychotherapy.
The ketamine is injected intramuscularly, supposedly to
make the brain more accessible to emotions and dialogue. In
one study researchers reported that about two-thirds of the
clients receiving this treatment remained abstinent for more
than a year compared with one-fourth of a control group who
underwent conventional treatment. 91
Rapid and dramatic development of tolerance, along with a
profound psychic dependence, occurs with regular daily use
ofketamine. 92 Major effects last an hour or less, but coordina-
tion, judgment, and sensory perceptions may be affected for
18 to 24 hours after use .
Salvia Divinorum(salvinorinA)
Salvia divinorum (sage, diviner 's sage, magic mint, Sally-D)
has unique psychic effects likened to a combination of vari-
ous psychedelic drugs and is showing up more frequently at
the high-school and college level. Although it is still legal in
many states, other states have rushed to pass laws banning
the drug altogether. In California sales to minors are prohib-
ited , and Nebraska bans all sales. The DEA is deciding
whether to prohibit or simply restrict sales of Salvia. 93
At different dosages and in different settings, some have
described Salvia as LSD-like, DMT-like, ketamine-like , and
PCP-like-but falling short of replicating the effects of these
substances. Salvia divinorum was used for centuries by
Mazatec shamans and curanderos (medicine men and
women) in the Sierra Madre Oriental in northeastern Mexico;
they gave it to patients to induce a trancelike state to help
determine the cause of an illness.
Dried leaves and live cuttings of this member of the mint
family are chewed and absorbed through the buccal mem-
branes, smoked and absorbed through the lungs, or made
into a tea to drink. Salvinorin A is inactivated by the gastro-
intestinal system when ingested, so the tea is held in the
 All Arounders 6.23

The effectsof Salvia divinorum-hallucinations,

delirium,and out-of-bodysensations-usually
make the userunableto functionphysicallyor
communicate.

Australia, Belgium, Denmark, Estonia, Finland , Germany,

Italy, Norway, South Korea, Spain, and Sweden regulate the
use of Salvia divinorum.As of 2010 it was legal in the United
States but illegal to advertise its sale for human consumption .
Live cuttings of the plant are available for sale on the Internet.

Amanita Mushrooms
The Amanita muscaria (fly agaric) is a large mushroom with
an orange, tan , red , or yellow cap with whit e spots. It can
cause dreamy intoxication, hallucinations, or delirious
excitement , but its toxicity can be dangerous. Its anticho-
linergic activity can cause loss of muscle coordination, a
dangerous increase in body temperature , problems with
vision, increased heart rate, confusion, and hallucinations.
Occasionally, it can lead to seizures, coma, and death . Thirty
minutes after ingestion , the effects kick in and can last four
to eight hours. 44 The active ingredients are ibotenic acid and
the alkaloid muscimole , substances that resemble the inhibi-
tory neurotransmitter GABA.The Amanita pantherina (pan-

I
ther mushroom) contains more of the active ingredi ents than
does the Amanita muscaria, and ingesting too much of either
one can make the user sick for up to 12 hours .9
Salvia divinorum is cultivated throughoutthe United States. It grows Although many members of this family of mushrooms are
to a height of 3 ft. deadly (such as Amanita phalloides), the Amanita muscaria
«:>2006 CNSproductions,Inc. and the Amanita pantherina have been used as psychedelics

mouth for as long as possib le to allow the drug to be absorbed

through the oral mucosa . The major effects are hallucina-
tions, delirium, and out-of-body sensations along with an
inability to communicate or function physically. When
smoked, the effects last a few minutes, taper off after 7 to
10 minutes, and disappear within 30 minutes.
Salvinorin A (a kappa opioid receptor agonist) is thought
to be the key psychoactive chemical responsible for Salvia
divinorum's major psychoactive effects. It takes 3 lbs., or
about 100 to 200 leaves, to make 1 oz. of salvinorin A extract,
which is enough for four to 12 doses . It is not yet understood
how the extract works in the brain, though it is believed to
activate the opioid kappa receptor. When smoked, doses of
200 to 500 µg of salvinorin A are said to produce similar yet
more-intense psychedelic effects than 100 to 200 µg ofLSD. 94
The exper ience is quite dependent on the user's mind-set and
surroundings.

"And then there's the extractof Salvia, whichis a

wholeotherball9ame.It's similarto a DMT experience Amanita muscaria mushrooms have been used as a psychedelicfor
but withoutsuch a hard-ed13ed thin99oin9on. thousands of years, mostly in India and Russia, but they have popped
up in a number of other countries, as well. This one is from La Honda,
You dernitelq9et removedfromwhateversituation qou California.
arein at the moment."
© NancyMartinby permission
24-year-old Salvia divinorumuser
 6.24 CHAPTER 6
for centuries. Drinkable preparations are referred to as the
god Soma in sacred Indian writings (the four Vedas)dating
back to 1500 B.C.
"Comethou to our libations,drinkof Soma; Soma-drinkerthou!
The richOne's rapture9ivethkine.
So maq we be acquaintedwith thineinnermostbenevolence:
Ne9lectus not, comehitherward."
Rig-Veda, Hymn N, Indra"
Amanita was used by native tribes in Siberia, but today its use
is limited because of the unpredictability of its effects and
because it can be mistaken for more-deadly mushrooms. The
use of Amanita muscaria in ancient ritual ceremonies is still
practiced by some Ojibwe Indians in Michigan. 96
This mushroom is among the few psychedelics that are sold
legally in the United States and some other countries. Sales
are regulated by a number of state laws. Minced Amanita
mushrooms in a 25 gm packet can be purchased over the
Internet for about $25. When sold as a food or supplement ,
Amanita mushrooms are regulated by the U.S. Food and Drug
Administration.
Dextromethorphan(Robitussin
® DM, Romilar,®
and other coughsyrups)
I
Before "purple drank" became popular , dextromethorphan
cough syrups were the abusable cough syrups of choice.
Dextromethorphan (DXM) is an opioid with more-specific
activity at the cough receptors than the pain and euphoria
sites of the brain; it is an ingredient in many nonprescription
cough suppressants such as Robitussin "' OM, Romilar,"'
Coricidin, "' and more than 140 other liquids, tablets , and
capsules. Early on , users discovered that high concentra-
tions of dextromethorphan caused psychoactive and psy-
chedelic effects. Reports of DXM abuse have been around
since the early 1960s and, recently, returning U.S. soldiers
from Afghanistan have shown a high incidence of DXM abuse
due to the drug 's availability. Cough syrups are still popular
among some heavy metal fans and their bands , such as
Weedeater ; Weedeater even has an online show segment
comparing various brands of cough syrup.
Street names for the substance include orange crush , CCC,
robo, dex, and red devils. To counter abuse , in many states
over-the-counter drugs with DXM are kept behind the phar-
macy counter and require an ID for purchase .
A normal therapeutic dose is 10 to 50 mg or up to 120 mg in
a 24-hour period. An abuser seeking the drug's psychedelic
effects will take 300 to 600 mg; at this dose effects last six to
eight hours . Some will take a heavy dose (600 to 1,500 mg) in
search of even more-intense mental effects (euphoria, mind/
body separation , auditory and visual hallucinations , and a loss
of coordination) ; and someone who gets totally carried away
might take 2,500 mg or more. At those levels death can occur,
especially if used with alcohol. Many of these cough medica-
tions contain alcohol, so the effects can be similar to those of
someone who is both drunk and delirious.
"/ onlq took a capful,and it waskind of a bluishtint.
It kindaremindedme of acid sort of, wherelikewherever
I'd walk,I'd feel likethe worldwaskindarushin9towardme.
WhereverI looked,it wasjust likethe visuals,almostlike
tracers,comin9at me."
Recovering dub drug user
DXM can also dilate pupils (unlike other opioids, which con-
strict pupils), decrease orgasm, upset the stomach, and
induce nausea. Additional negative reactions include itching,
rashes, fever, and tachycardia; these toxic side effects can
cause acute anxiety and panic reactions. Tolerance to DXM
does develop , and when used in excess it can be mildly
addicting. Because DXM is an opioid, a large overdose can
result in respiratory depression and coma. Overdoses of
DXM have been successfully treated with naloxone, an opi-
oid antagonist. 97 Dextromethorphan has been studied by
researchers as a treatment for heroin and opioid addiction
and has been used by addicts for detox purposes.
Nutmeg and Mace
At the low end of the psychedelic drug spectrum are nutmeg
and mace. Both come from the nutmeg tree (Myristica fra-
grans) and can cause varied effects from a mild floating
sensation to full-blown delirium. The active chemicals in
nutmeg and mace are variants of MDA.17Huge quantities
must be consumed (about 20 gm) to gain any effects, leaving
the user with a bad hangover and a severely upset stomach .
Because this dose exposes a user to the nauseating and toxic
effects of other chemicals in nutmeg, its abuse is extremely
rare outside of prisons , where inmates use it because they
have limited access to other psychedelics.
Bromo-dragonFLY
Bromo-dragonFLY, sometimes referred to as "FLY" or
"B-FLY,"is a phenethylamine psychedelic with differences
that give it much more potent and longer-lasting effects than
most other phenethylamines. 59 It is described as a powerful
hallucinogen that causes visual distortions, muscle tension ,
memory loss, confusion , and acute anxiety reactions with
depersonification and panic .
There are reports of great discrepancies in the liquid, blotter
paper , and other dosage forms of this drug. The European
batch of the drug is purported to be much stronger than the
American version. Effects can last anywhere from six hours
to four days due to inconsistencies in production. For this
reason "FLY" is a drug that even experienced users suggest
avoiding.
"/ watchedmq feet billowin9with thicksmoke[visual
hallucination]and the TV set bled onto the ~oorwith
multicolorand 9ur9linfiblood [auditorqhallucination];
whilecomin9down I felt a roller-coastereffect, mentallq
oscillatin9betweenpeaksof ps~chedelicdru9effects
and then feelin9sof completenormalc~."
21-year-oldmale "FLY"user

LeonotisLeonurus(lion'stail, wild dagga)
This South African bush produces red , orange , yellow, or
white tubular flowers and is also known as dacha , daggha,
wild dagga, and wild hemp. When the resin from the blos-
soms is smoked (alone or mixed with tobacco) , lightheaded-
ness, giddiness, mild euphoria , reduc ed stress , and mild
hallucinogenic effects are induced. Other effects include
increased perspiration and production of gastric juices . It
acts as a mild analgesic and has been used to treat headaches,
muscular cramps, influenza, and scorpion stings. Its effects
have been likened to those of marijuana. Leonurine, a psy-
choactive alkaloid, is thought to be the active substance in
lion's tail.
Any herb sold online cannot be described as a psychedelic or
as something that will enhance a psychoactive substance , so
the language used in a sales pitch must be chosen very care-
fully. Consider the wording used in the following product
description for lion's tail:
"Manqtraditionaluseshavebeenrecorded.This folia9eis com-
monlqmade into a medicinaltea, whichis favoredfor the hqp-
noticfocusit 9ives.It's alsoconsidereda 'potentiator,'which,
whenmixedwith otherherbsof qourchoice,willintensifqthe
effectsof thoseherbs.This worksifqou makethe Da99ainto an
herbalsmokeor makeit into a tea. Tqpicallq , what this means
is that qoucan use far lessof anq expensiveherbsqou'reusin9,
and moreof this, but end up with the sameresult."
ShamansGarden.com (accessed October 5, 2010 )
Efavirenz(Sustiva®: HIV/AIDS medication)
Efavirenz is a protease inhibitor used to treat HIV/AIDS.
It has been abused principally in South Africa, although
HIV/AIDS medication specialists in the United States
acknowledge occasional abuse here. Smoking the drug can
cause lightheadedness, dizziness, vivid dreams, hallucina-
tions, depersonalization, relaxation , and forgetfulness. The
All Arounders 6.25
psychedelic effects occur in up to 25% of users , according to
anecdotal reports ; however, the manufacturer lists the CNS
side effects as common. Tolerance to these side effects does
occur .98 ,99 ,100
Users obtain these drugs from HIV patients who sell their
medication for profit and through diversion by unethical
health professionals. A more common way of obtaining this
medication is simply to rob patients and pharmacies of their
efavirenz supplies. The drug is cheap and readily available in
South Africa, which is one of the reasons why it is singled out
for abuse when so many other drugs are available. The drug
damages nasal passages and the lungs, but the real harm
comes from the fact that an HIV or AIDS patient is denied his
or her medication and that efavirenz abuse has the potential
to create new drug-resistant strains of the virus.
Marijuanaand Other Cannabinoids
"Coloradoresortsbracefor marijuanatourism... an in~ux
of touristsseekin9a now-le9alRockq
Mountain hi9h."
USA Today, December 23, 2013
I
"Pitfallsaboundas le9alpot salesbe9in.Coloradoand
Washin9tonState are launchin9the world's ~rstle9al
recreationalmarijuanamarkets."
Seattle Times, Dece mber 30 , 2013
"Medicalmarijuanauserswillpaq theirown waq. No insurance
healthplanswillpaq for medicalmarijuana.
"
StamfordAdvocate, Dece mber 29 , 2013
"Pot-basedmedicinesin U.S. not so far awaq."
Seattle Times, January23, 2012
Employees help customers at the crowded
sales counter inside Medicine Man
marijuana retail store. It opened as a legal
recreationalmarijuana retail outlet in
Denver, Colorado, on January 1, 2014.
First-day combinedsales at the 24 Denver
shops is estimated at more than $1 million.
© 2014 AP Photo/ Brennan Linsley
 6.26 CHAPTER6
In India the more-potentleaves and flowering tops of the Cannabis
plant are smoked in "chillums"-hollow cone-shapedpipes. The
smoker cups his hands over the opening at the bottom of the pipe and
draws the smoke in through his hands. Shivite devoteesuse Cannabis
in chillums as part of their religion.
© 2000 CNSProductions, Inc.
"175metricto~; RAND stud~shows2013 Washin9ton
man1uanause.
I
Seattlepi.com, December 17, 2013
Headlines about marijuana have focused on efforts to legalize
its medical use and, most recently, its recreational use . This
exaggerated interest emphasizes that marijuana is deeply
ingrained in most aspects of our society: the legal, medical,
social, environmental, and especially economic implica-
tions of growing, selling, and using the drug .
It seems that in almost every state election, new initiatives are
proposed to regulate its medical use or decriminalize/legalize
marijuana altogether, while chemists continue to develop
synthetic versions that are, at least temporarily, legal.
Marijuana is used most often to alter consciousness, but
the Cannabis, or hemp, plant also produces fibers to make
rope, grows edible seeds (alkenes), contains an oil that is
used as a fuel and a lubricant, and provides a number of
medicinal benefits. Due partly to its versatility, a relationship
between Cannabis and Homo sapiens has existed for at least
10,000 years.
Historyof Use
From its probable origin in China or Central Asia, Cannabis
cultivation spread to almost every country in the world.
There are unique properties found in each of the many spe-
cies of Cannabis;some plants produce stronger fiber, some
produce better food, some are more useful medicinally , and
some induce psychedelic effects. Once the plant 's usefulness
had been confirmed, people searched for ways to grow,
extract , and consume its psychedelic components.
References in early Chinese texts indicate that the plant was
used for fiber, clothing , and food; later texts contain descrip-
tions of ways to use Cannabis to produce hallucinations ,
ecstatic states, and revelatory visions, and to communicate
with spirits or see demons.
Around 1500 B.C. the Indian Vedasdescribed Cannabisas a
"divine nectar " that could deter evil, bring luck , and cleanse
man of sin . It was listed as one of the five sacred plants that
would bring about freedom from stress .100
"Wespeakto the fivekin9doms of the plantswith soma
[Amanitamushroom]the mostexcellentamon9them.
The darbha-arass,hemp,and mi9ht~barler
the~shalldeliverus fromcalamit~!"
Atharva Veda, VI 4J 9!i
Fromits probableorigin in CentralAsia,
Cannabis has spreadto almost every
countryin the world.
Cannabisis associated with a number of religions and deities
in India, especially Shiva. Shivite sects offer Cannabisto Shiva
while drinking or smoking the substance. Indian writings also
described using Cannabis medicinals to relieve headaches,
control mania , counteract insomnia, treat venereal disease,
cure whooping cough, and arrest tuberculosis .101
Over succeeding millennia Cannabiscontinued to be used in
all of its forms. Galen, the "father of modem Western medi-
cine," wrote in A.D. 200 that it was sometimes customary to
give Cannabis to guests to induce enjoyment and mirth . In
third-century Rome, ropes and sails for ships ' riggings were
made from hemp fiber.102 Medieval physicians cultivated
hemp for the treatment of jaundice and coughs and recom-
mended weedy hemp to treat cancer.
Because Cannabis was not specifically banned by the
Prophet Mohammed in the Qur'an, Islamic cultures spread
its use to Africa and Europe . Hashish, the concentrated form
of marijuana , is mentioned in certain ancient texts , some of
them originating about A.D. 1000.
'When he had earnedhis dail~wa(ie, he wouldspend a little
of it on food and the reston a sufficienc~of that hilarious
herb. He took his hashishthreetimesa dar oncein the
mornin9on an empt~stomach, once at noon, and onceat
sundown.Thus he was neverlackin9in extravaaant9aiet~."
"A Tale of Two Hashish Eaters" from A Thousandand OneArabianNights
In later centuries the use of hashish and marijuana in
Islamic countries was discouraged and finally condemned.
About 600 years ago, Africans began using marijuana in
social and religious rituals and in medicinal preparations to
treat dysentery, fevers, asthma, and the pain of childbirth. 103
The Age of Exploration spawned a need for more rope , sails,
and paper, so the newly established colonies in North America
were encouraged by the crown to grow more-fibrous variants
of Cannabis and export the hemp to England. Even George
Washington had large fields of Cannabison his plantation.
Cannabis (hemp) was widely cultivated in the Americas

Movies such as Reefer Madness (1936),
Marijuana , Weed with Roots in Hell (1936),
and Devil's Harvest (1942) exploited the
sensationalismthat surroundedpsychoactive
drugs.
until the nineteenth century, when
the abolishment of slavery made it
less profitable to harvest and process .
South America's introduction to the
psychoactive effects of smoking Can-
nabis is believed to have originated
with African slaves who were kid-
napped from Angola and brought to
plantations in northeastern Brazil.
The practice eventually spread north THE TRUTH ABOUT
to the Caribbean Islands and
Mexico. 104
MARIJUANA
. r11£ SMOKE
After World War I, migrant labor-
ers coming to the United States introduced the habit of
smoking marijuana for its psychoactive effects. Initially, its
use was confined to the poor and minority groups, but in the
1920s the use of Cannabis as a substitute for prohibited alco-
hol spread in popularity. Marijuana "tea pads, " similar to
opium dens, became popular. It is estimated that there were
more than 500 "tea pads" in New York by the early 1930s.
Many of the "tea pads " were apartments where tenants and
their friends would get together to smoke "pot. " Some of
these gatherings evolved into "rent parties "; the tenant would
charge an admission fee to help make the rent payment. 47 , 104
This unbridled use of marijuana alarmed prohibitionists, who
were left without a cause when the Eighteenth Amendment
was repealed . Adding to this prohibitionist atmosphere was
a series of articles in Hearst-owned newspapers , crusading
against the drug. The articles referred to Cannabis as
marijuana (as opposed to hemp) to make the drug sound
more foreign and menacing. The drug was made illegal in
a dozen states between 1913 and 1927. Internationally,
Cannabis was included as a drug to be limited or banned,
starting in 1909, reinforced in the 1925 Geneva Convention
under the auspices of the League of Nations but mostly at the
urging of the United States.
In some western states, particularly California, the law was
enforced to justify deporting Mexican laborers when jobs
were scarce. Nationwide the use of Cannabis (except for ster-
ilized bird seed) was banned by the Marijuana Tax Act of
1937 . Medical use was still legal, but prescriptions were
actively discouraged. Pharmaceutical manufacturers removed
Cannabis from a list of 28 medications that were widely
prescribed at the time_l05
With the advent of World War II, the fear of an interruption
in the importation of hemp fiber to the United States gener-
ated government support for locally grown hemp, yielding a
harvest that would be made into rope and fibers for the war
effort. At the same time, the Office of Strategic Services (later
All Arounders 6.27
the Central Intelligence Agency) was
working on a secret program to develop
a speech-inducing drug designed to
unseal the lips of spies during interroga-
tions . One of the drugs they came up
with was a potent extract of Cannabis
that was odorless, tasteless , and colorless,
code-named "TD," or truth drug . This
occurred in the early 1940s, only a few
years after marijuana had been banned as
"the killer weed. "
Since the end of World War II, the use of
marijuana has been illegal in most coun-
tries, although the level of enforcement
varies widely from country to country .
Currently, Italy and to a lesser extent
England and Canada are cultivating a
0FH£Ll/
fibrous variant of the Cannabis plant to
supply pulp and fiber to make paper, tex-
tiles, and rope. The Netherlands allows
patrons of Amsterdam's "coffee shops " to
light up marijuana but prohibits smoking tobacco in those
establishments due to a 2008 indoor tobacco ban . In spite of
restrictions, marijuana is used in some form by 180 million
people worldwide. 67 , 106
I
Marijuanawas made illegal in the
United Statesin 1937, and it took
77 yearsfor it to be legalizedagain
in Coloradoand Washingtonfor
recreationaluse.
Epidemiologyin the United States
"Before I tried marijuanam~self, I thou9ht that it smelled like
musk becauseever~onein the sixtiesand seventiesused musk
perfumeto hide the real marijuanasmell from the cops."
30-year-old marijuana smoker
In 1960 only 2% of U.S. citizens (3 million to 4 million) had
tried an illegal drug. By the late 1960s, the growth of the
counterculture, fueled by the Baby Boom generation, greatly
increased the use of marijuana and other illicit drugs. By
1979, 68 million people in the United States had tried mari-
juana, and 23 million used it on a monthly basis . In 1970
Congress established the National Commission on Marihuana
and Drug Abuse; and after an authoritative study, the com-
mission 's report surprised many by recommending decrimi-
nalization. Twelve states decriminalized possession of small
amounts of the drug for personal use . By the 1990s a move-
ment toward complete prohibition recriminalized the use of
"pot " in most states, greatly increasing the number of people
incarcerated for marijuana possession and use . By 1992 the
monthly rate of use had dropped to one-third of its 1979 peak
level, but recently those levels have begun to climb, particu-
larly among teenagers.
 6.28 CHAPTER 6
MarijuanaUsein PastMonth
by Youth- UnitedStates1991-2013
25%
20%
5%
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013
Year
By 2012 more than 18.9 million Americans (about 7.3% of
the population 12 and older) were using marijuana on a
monthly basis (an average of 18 joints); 4 .3 million exhibited
dependence or abuse in the past year. 7
• According to the Drug Abuse Warning Network, more
I
than 455,000 visits to an emergency department listed
marijuana as a contributing factor.
• The Arre.stee Drug Abuse Monitoring program of
the National Institute of Justice found that in 2012,
37% to 58% of adult arrestees tested positive for
marijuana. 7sJ01,1oa
''Youwantto useit all the time. Youwantto be hi9h;~auwant
to han9out withthe kidsthat arehi9hso ~au9et the samefeel-
in9 or ~ou'reat the same levelas them. Youjust want to han9
out withthem. justbe cool."
18-year-old marijuana smoker
Botany
"Mostof the marijuanain the late sixtieswas brownMexican,
but wealsohad accessto Colombian 90/d, Panamared,
Acapulco90/d, andThai sticks.so we had plent~of hi9h-
concentrationTHC. We also had connectionsforVietnamese
'pot.'The~didn'tcheckthe G/s' duffelba9s. A lot of pot
nowad.a~sjust makes~ou incapacitatedor ~au munch and
90 to sleepor havejusta 20-minutem~ster~tripor rush,
then ~ou munch, then crash out."
SB-year-old ma le former marijuana smoker
The various terms used to describe the plant are a source of
confusion. Terms such as vulgaris, pedemontana, lupulus,
Mexicana, and sinensis have been used over the past hundred
years, but there is a consensus that Cannabis is the botanical
genus of all these plants. Hemp is generally used to describe
Cannabis plants that are high in fiber content. Marijuana is
used to describe Cannabis plants that are high in psychoac-
In 1978, 37% of high-school seniors used
marijuana at least once a month. By 1992 that
percentage had dropped to 12% but was up to
22. 7% by 2013. Daily use for high-school seniors
rosefrom 1.98 % in 1992 to 6.5 % in 2013. This
rise in monthly and daily use since 1992 is also
apparent in the eighth and tenth grades.
Monitoring the Future, 2013
tive resins. The main psychoactive chemical in Cannabis
resins is delta-9-tetrahydrocannabinol (.6.9-THC), or THC.
"/ had.back sur9er~and. tried opiates and electricalstimulation
and. musclerelaxants.When I tried medical marijuana, I found.
that indicawasbetterforpainand for9ettin9me to sleep;
howeverit limitsm~9et-up-and.-90. I'm stuck to the couch.
Sativa seems to be shorteractin9 forme, and. ~au can smoke it
more often throu9hout the da~, and ~au can be more cerebral
and.activeon it. Sativa also worksforme on pain."
38-year-old female medical marijuana smoker
Species
Marijuana has dozens of street names: "pot," "bud," "herb,"
"grass," chronic, 420, "weed," muggles, Mary Jane, grifa,
dank, da kind, "pocalolo," "tree.s," "leaf," ganja, charas, sens,
and "dope." There are also hundreds of strains that sound
like geographic brand name.s: Maui wowie, Acapulco gold,
African black, Panama red, Humboldt green, BC {British
Columbia] bud, and Buddha Thai (rare except in Thailand).
Constant experimentation by growers has resulted in varia-
tions in the plant size, concentration of psychoactive re.sin,
and shape of the leaf. Although all botanists agree that there
are hundreds of unique variants of the marijuana plant, some
believe that Cannabis sativa is the only true specie.s; others
believe that there are three distinct marijuana species:
Cannabis sativa, Cannabis indica, and Cannabis ru.deralis.
Cannabis sativa grows under a variety of conditions in trop-
ical, subtropical, and temperate regions throughout the
world. Variations of Cannabis sativa have sufficient quantities
of active re.sins to cause psychedelic phenomena, while other
variations instead have a high concentration of fiber and
are used for hemp. The average plant is 5 to 12 ft. tall but
can grow up to 20 ft. The plant produces five thin, serrated
leaves on each stem plus two smaller ve.stigial leaves at the
ends of the leaf clusters. Some variants have more leaves. A
typical plant produces 1 to 5 lbs. of buds and smokable

leaves containi ng high concentrations of the psychedelic
resin THC.
Cannabis indica, sometimes called Indian hemp, is a shorter,
bushier plant with fatter leaves but is rarely harvested for
fiber. It is especially plen tiful in Ind ia, Afghanistan , Pakistan,
and the Himalayas. It did not arrive in Europe until the mid-
1800s, when its geographical area of cultivat ion expanded.
Cannabis indica is the source of most of the world's hashish.
Modifications of the plant have resulted in a stronger, pun-
gent variety, earning it the nickname skunk weed. 4 At one
time many illegal growers preferred Cannabis indica, believ-
ing that it was legal to grow this species; the law as written
prohibited on ly Cannabis saliva. Legal challenges have
expanded the law's interpretation, and today it includes every
species and cross-bred species of marijuana.
Cannabis ruderalis (weedy hemp) is a small, thin plant with
slight amounts of THC that grows plentifully in Siberia and
western Asia. It is most likely the species that the historian
Herodotus described when writing a history on the ancient
Scythians' use of the drug thousands of years ago in the
Middle East.
The flowering top of the female Cannab is indica plant has shorter,
stouter leaves than does Cannab is saliva. Intense hybridizmion and
cross-pollination, however, can make distinguishing the two species
difficult. Once flowering, Cannab is indica plants take 6 to 8 weeks
to fully mature.
0 2010 Keith Mansur
All Arounders 6.29
'The Sc~thianstakeCannabisseed,creepin underthe felts,
and throw it on the red-hot stones. It smoldersand sends up
such billowsof steam-smoke that no Greek,aporbathcan
surpassit. The Sc~thianshowlwithjo~in these,apor-baths,
which servethem instead ofhathin9, forthe~ neverwash their
bodies with water."
Herodotus, The Histories , 4 .7S.l, 460 B.C.
Sinsemilla and Other Forms of Marijuana
Sinsemilla is Spanish for "without seeds." The sinsemilla
growing technique increases the potency of the marijuana
plant and is used to grow both Cannabis indica and Cannabis
saliva. This techn ique maximizes the fact that female plants
produce more psychoactive resin than do male plants, espe-
cially if left unpollinated. The female plants are separated
from the male plants before pollination can occur, resu lting
in female plants "without seeds." The term commercial grade
refers to marijuana that is not grown by the sinsemilla
technique. Other common names for low-grade Cannabis
are ditchweed, "Mex," "bricks," bitchweed, schwag, regs,
hammer, and mersh.
Cannab is saliva has relmively long, slender leaf projections.
The plants grow quickly and can reach 20 feet in height. Once
flowering, they can take 10 to 16 weeks to fully mature. Cannab is
saliva and Cannabis indica can be cross-bred to combine the
different effects.
0 2010 Keith Mansur
 6.10 CHAPTER 6
Leaf trichomes are scanned by an elecrron
micrograph on the surface of a Cannabis saliva
plant. These trichomes secrete a resin containing
THC, the active component of Cannabis.
0 Thierry Berrod, Mona LisaProduction/Science Photo Library
Cannabis sativa, Cannabis indica, and
Cannabis ruderalis are the three main species.
I
There are also dozens of variations due to
sophisticated growing techniques.
Dried marijuana buds, leaves, and flowers are crushed and
rolled into joints or smoked in pipes. In India and some
other countries, marijuana in its various forms is smoked in
chillums. Marijuana is also used as an ingredient in food or
drink or is simply chewed. In many countries marijuana is
categorized into three different strengths, each one coming
from a different part of the plant.
• Bhang is made from the stem and the leaves and has the
lowest potency. In central Asia and India, it is often pre-
pared as a drink, often with honey, sugar, molasses, or
yogurt. It is not drunk to get high.
• Ganja is made from the stronger leaves and the flowering
tops. It is smoked alone or sometimes mixed with other
herbs.
• Charas is the concentrated resin from the plant and is
the most potent. It can be mixed with food and eaten or
smoked alone or with other herbs. "
Hashish comes from the sticky resin of the Cannabis plant,
which contains most of the psychoactive ingredients. The
resin is pressed into cakes and most often smoked in water
pipes, called bongs, "bubblers," or hookahs, or added to a
marijuana cigarette to enhance the potency of the weaker
leaves. Bongs are also used to smoke the less-concentrated
parts of the marijuana plant. In India, Nepal, and neighbor-
ing countries, hashish use is widespread. An early-nineteenth-
century writer described five or six methods for collecting
the resin and another dozen methods of preparing it for use,
including forming it into pressed cakes, small pills, candies,
or tiny balls.
Hash oil can be extracted from the plant using solvents and
added to foods. Most often it is smeared onto rolling paper or
dripped over crushed marijuana leaves and smoked to
enhance the psychoactive effects. The THC concentration of
hash oil has been measured as high as 90%.
Dabbing (wax, dab, amber , shatter)
Dabbing is a method for vaporizing hash oil by "dabbing" it
onto a hot element connected to a glass pipe. This method,
called "BHO" (butane hash oil), extracts the THC by spray-
ing butane, Everclear ® alcoho l, or another solvent through
buds or twigs and leaves of marijuana. The resultant slush
contains not only trichomes (THC-producing resin glands)
but also other substances from the plant, a number of which
also have CNS effects and possibly healing qualities. 127 The
mixture is filtered to remove the plant matter, and the butane
or other solvent is purged though heating. This method of
refinement is dangerous if the fumes are ignited. The resul-
tant explosions can be painful, costly, or even deadly.
The THC content is generally above 40%. The residue, a
waxy substance, is usually sold in gram weights for $30 or
$40; 1 gm will supply about 10 "hits." A dab or hit - a little
waxy ball-is placed on a hot nail or other hot metal surface
(that is often heated with a torch) to vaporize the substance;
when the vapor is inhaled, it strongly affects the user for four
to five hours. It is a powerful substance that can make some
of the smokers "useless" while high. When butane liquid is
used, the resultant product is known as butane hash oil,
which is said to contain at least 90% THC.
Another version of solidified hash oil is created when the
resultant slush is highly filtered and allowed to solidify on a
flat surface until it looks like glass. It is broken into small
pieces, hence the names "shattered glass" and "am ber ." This
process intensifies the concentration of cannabinoids even
further. 127 The shards are heated like dabs, and the resultant
fumes are inhaled.
 All Arounders 6.31

These forms of marijuana are being sold in Colorado and
medical marijuana dispensaries. Because these concentrated
forms are so potent, regulating them is problematic.
Legislators are wrestling with this quandary and dozens of
other issues that were not fully understood before the legisla-
tion to legalize was passed. New laws are always being devel-
oped and vary greatly by region. 127A
"/ don'tparticular/~liketo dab9rass.I ~ndthat I just
follasleepforo coupleof hoursratherthanenjo~in9the hi9h.
If I wantto sta~stoned,/'II usesomethin9else,but /',e 9ot
friends that sta~ active but are certain/~ more impaired
than ta(in9o fewpuffson a pipe."
23-year-o ld marijuana smoker
Growers
By the start of 2014, most government agencies reported
that marijuana availability was high in their regions, this in
spite of seizures at the U.S.-Mexico border amounting to
more than 1 million kilograms. 27
The high demand for marijuana prompted Mexican drug-
trafficking organizations (DTOs) to continue large-scale
Cannabis cultivation in the United States, often on public
lands in the West, to augment the thousands of tons they
smuggle from Mexico and Colombia. To avoid detection by
satellites and possibly drones, Mexican and Asian DTOs are
turning to indoor cultivation. Authorities seized 4 million
plants from indoor and outdoor grows in 2012 compared
with 8 million in 2008. 128 The decrease indicates that either
the eradication program is working or the cartels and the
growers are getting better at hiding their crops. Outdoor
plantings average 10,000 to 20,000 plants per grow. 110
Other major growing countries in the Western Hemisphere,
besides Canada, Colombia, Mexico, and the United States,
include Belize, Brazil, Guatemala, Jamaica, and Trinidad and
Tobago. In the Far East, major growers include Cambodia,
Laos, Thailand, and the Philippines. The African countries of
Morocco, Nigeria, and South Africa produce mostly Cannabis
indica. In southwest and Central Asia, Afghanistan and
Pakistan are the big producers (much of it hashish).

A. To transform marijuana for dabbing, trim from manicured marijuana buds is packed into a long glass rube, where iris saturated wHh liquid
butane and pressurized, which exrracrs the hash. The caramel -looking butane/hash mixture is collected and filt.ered.
B. The solution is collecred in a pan, where the gas evaporates, leaving a sticky film of Cannabis residue.
C. A "dab" of the dried solution is heated (in this case, in an e-cigareHe) and inhaled for a powerful effect Many schools are banning e-cigareHes
on school grounds for this reason.
0 CNS Productions, Inc.
 6.12 CHAPTER 6
In the 20 or more states that allow medical marijuana and in the two
states that allow recreational marijuana , legal growing has become
commonplace. Cannabis cultivation has several unique drawbacks
however: the unpleasant odor the plants emir and the risk of rip-offs
and robberies.
0 2011 Keith Mansur
Lebanon was formerly a prominent player in the Middle East,
I
but its production has declined in recent years. 67
The federal Office of National Drug Control Policy (ONDCP)
estimates that growing 1 acre of marijuana damages 10 acres
of adjacent land through runoff, excess fertilizer, deadly pes-
ticides, and damage to trees and other foliage. 112 In the United
States, 10% to 50% of the available marijuana is home-
grown. Stiffer penalties and greater surveillance by law
enforcement agencies have prompted more and more grow-
ers to move their operations indoors. The other advantage of
indoor growing is more control over the quality. California's
indoor-grown marijuana is more expensive than Oregon's
mostly outdoor-grown crops. Some enterprising drug traf-
fickers have taken to buying nondescript suburban homes
and installing raised plant beds and sophisticated grow lights
powered by bootlegged electricity, giving new meaning to the
term indoor gardening.113
The escalation of indoor cultivation coupled with the
plethora of growing tips and techniques available on the
Internet has resulted in high-potency marijuana plants
grown all over the world. 67 Some marijuana is grown hydro-
ponically (in water). According to the Potency Monitoring
Project at the University of Mississippi, the average mari-
juana THC concentrations are continually increasing:
• 0.9% in 1977
• 3.3% in 1988
• 4.9% in 2000
• 8.7% in 2007
e ll.9% in 2011
• 13% in 2012 110
High-concentration THC marijuana has been around for
many years but has never been as readily available as it is
today. 114 In the past, buds were mixed with stems and leaves,
lowering the average THC content. Partial proof of the higher
potency is an increase in the number of individuals treated
for marijuana dependence and a link between marijuana use
and an increased risk of schizophrenia in those with a high
susceptibility to the mental illness. 115J 16
The common unit of sale for bulk amounts of marijuana is
1 oz. (called a "lid"), with an average street price in the United
States of $200 to $400. The price can vary radically depending
on the quality, quantity, and location of purchase. Sales of
smaller amounts accommodate those with lighter wallets:
l gm (28.3 gm equal l oz.) averages $10, while the most com-
mon measure, one-eighth of an ounce (about 3 .5 gm), goes
for $40 to $60. An average joint contains 0.5 to 1 gm of mari-
juana. Prices for commercial-grade marijuana when bought in
larger quantities have remained relatively stable; the current
price for l lb. ranges from $2.500 to $6,000 in Southern
California. The profits are enormous when dealing in very
large amounts: 500 lbs. of marijuana bought in Mexico for
$50,000 can bring $400,000 in St. Louis. 117
Synthetics
Synthetic THC
Synthetic THC, called dronabinol (Marinol ®), is theoreti-
cally available to treat health conditions but in practice is
rarely prescribed. Patients say they prefer marijuana in its
smokable form because it works faster than Marinol ® and
they can smoke as much or as little as they need to relieve
symptoms. A premeasured Marinol ® capsule may be too
much or not enough for a patient's condition. Two other
products were introduced in 2004 and 2006: Sativex ®(nabix-
imols) and Cesamet ® (nabilone). Sativex ® was approved in
2005 in Canada to treat multiple sclerosis (MS) and is being
prescribed to many of the 110,000 MS sufferers in the United
Kingdom . Worldwide an estimated 2.5 million people have
MS--400,000 in the United States. 118 Sativex ® is in the final
stage of testing in the United States. Sativex ® has more can-
nabidiol (CBD) than natural marijuana. CBD has very small
psychoactive effects and was created to provide the medical
benefits of "pot" without the high.
SyntheticCannabinoids
of
"S~ntheticcannabinoids:a new frontier desi9nerdru.9s."
Annals of Internal Medicine , October 15, 2013
"S~ntheticmarijuanasickens221 in Colorado. CDC sa~s no
deaths reported; four storesshut down."
McClatchy Washington Bureau, December 13, 2013
"Fewerteens usin9s~ntheticmarijuanaand other desi9nerdru.9s."
Vancouver Sun, Canadian survey, December 18, 2013
Designer cannabinoids are synthetic cannabinoid-like
chemicals sold over the Internet and in head shops as
"incense" or "herbal smoking blends" under a variety of
trade names, such as K2, Spice Gold, Spice Silver, Black

..._ as well as heart and seizure activity are beginning to surface
Sy nthetic marijuana consists of various herbs and spices that have
been sprayed with a liquid containing a sy nthetic cannabinoid that is
similar to marijuana but can be much stronger. It can be made to be
nondetectable by standard cannabinoid tests.
Courtesyof the U.S.Drug Enforcement Administration
Mamba , Buddha Melt or Blend, Yucatan Fire, Blaze, and Red
X Dawn. They are a mixture of herbs and spices sprayed with
a synthetic chemical that acts like marijuana. These products
initially surfaced in Europe and Canada around 2002. Those
who smoked the various Spice incense products claimed that
they produced marijuana-like effects and can be four to 800
times stronger than THC. Prior to 2008 laboratory analysis
of the substances contained in the Spice product packets
could not detect any abused drug or chemical that could be
responsible for the alleged effects.
In December 2008, THC Pharm, a German pharmaceutical
firm developing synthetic THC compounds for medicinal
uses, announced the discovery of a synthetic cannabinoid,
JWH-018, found in three versions of Spice that were sold as
herbal smoking blends. A month later the University of
Freiburg in Germany discovered a second synthetic cannabi-
noid, CP 47,497, along with three of its homologue chemi-
cals in a variety of Spice incense products. Varying
concentrations and ratios of these two synthetic cannabi-
noids are responsible for the psychoactive effects of the many
different Spice products commercially available. 119J 20
The DEA listed three additional synthetic cannabinoids
found in various Spice products seized by customs officials.
On January 22, 2009, CP 47,497 and its homologues along
withJWH-018 and its homologues were added to the sched-
ule of controlled drugs in Germany. These molecules as well
as other designer cannabinoids are now illegal in Austria,
Chile, France, Russia, South Korea, Switzerland, and the
United States.
These designer cannabinoids have molecular structures that
are very different from the 66 cannabinoids isolated from
the marijuana plant, so users do not test positive for THC
or the THC metabolites usually identified by traditional
drug-testing methods. Forum entries on this issue posted on
a variety of Web sites support the claim that those who smoke
All Arounders 6.33
Spice or other "incense" or herbal smoking blends contain-
ing designer cannabinoids do not test positive for marijuana
use. By June 2010 there were about two dozen synthetic
designer cannabinoids that were touted to be from five to a
whopping 800 times more powerful than THC.
Reports of dependence with physical withdrawal symptoms
but with poor documentation. More research is needed to
determine the potential health or addiction risks from the use
of these synthetic chemicals. By 2014 many new synthetic
cannabinoids have been developed from six distinct chemical
families. Scrutiny of herbal incense products has resulted in
a shift to selling them as herbal potpourri (Green Grenade,
Super Kush, Clown Royal) or as Chill Spice aromatherapy-
not for human consumption of course. 121A
Synthetic marijuana was originally created
to avoid detection when users are being
drug tested, and of course to make money .
The strength can vary wildly and cause
unexpected reactions.
Pharmacology of Cannabis
I
To date, researchers have discovered more than 420 chemi-
cals in a single Cannabis plant-a meaningful number used
by many teenagers as a texting code to signal the availabilit y
of marijuana. At least 30 of these chemicals, called cannabi-
noids, are studied for their psychoactive effects. Delta-9-
tetrahydrocannabinol, or THC, was discovered in 1964 by
two Israeli researchers. Cannabinol and cannabidiol are two
other prominent cannabinoids, but they are not thought to
have psychoactive properties. When smoked or ingested,
these potent psychoactive chemicals are converted by the
liver into more than 60 other metabolites, some of which
are psychoactive. When smoked, only about 20% of the
THC is absorbed; however, the longer a lung full of smoke
is held, the more THC is absorbed and the stronger the high.
Many early studies on marijuana-and man y of the percep-
tions held by the counterculture about the effects of the
drug-were based on weaker THC plants. The strength of
marijuana today is much greater and is considered the norm
by the using population. More-sophisticated levels of research
using higher percentages of THC have given crucial insights
into the psychoactive mechanisms of the drug.
Marijuana/ Anandamide Receptors and Neurotransmitters
In 1988 and 1990, researchers detected receptor sites in the
brain that were specifically reactive to THC. 121 This discov-
ery implied that the brain had its own natural neurotransmit-
ters that fit into these receptor sites and that they affected the
same areas of the brain as does marijuana. These brain chem-
icals were called endogenous cannabinoid neurotransmit-
ters, or endocannabinoids.
Two years later researchers at the National Institute on Drug
Abuse announced the discovery of anandamide, an endocan-
nabinoid that fits into the cannabinoid receptor sites. 122
 6.14 CHAPTER 6

A few years later, another endocannabinoid called 2-arachido-
nyl glycerol (2AG) was discovered. 2AG is more abundant
but not as active as anandamide in the brain, though it may
be more active on other body receptors.
Several other endocannabinoid ligands have been discovered
in the brain:
• 2-arachidonoylglycerol ether (noladin ether)
• N-Arachidonoyl dopamine (NADA)
• virodhamine (OAE)
• lysophosphatidyl inositol (LPI) 122A
A ligand is a molecule that binds to a receptor. Cannabinoid
ligands bind to the cannabinoid receptors in the brain and
the body. 1 22A There is evidence of other endocannabinoid
ligands yet to be discovered.
Receptors for anandamide were initially found in several
areas of the limbic system, including the reward/control
pathway. In succeeding years two major receptors were dis-
covered, designated the CB 1 and CB 2 receptors. CB2 recep-
tors seem to be limited to the immune system and a few other
sites in the lower body; CB1 receptors are primarily found in
the brain, in particular the hippocampus, amygdala, basal
ganglia (including the nucleus accumbens), and cerebel-
lum. m These parts of the brain regulate the integration of
as a treatment for glaucoma), increased blood flow through
the mucous membranes of the eye resulting in conjunctivi-
tis or red eye, and decreased nausea (capsules and joints are
also used for cancer patients undergoing chemotherapy).
It helps epileptics during the onset of a seizure.
Marijuana impairs tracking ability (the ability to follow a
moving object) and causes a trailing phenomenon-seeing
an after-image of a moving object. These effects coupled
with slight sedation make performing tasks that require
depth perception and good hand/eye coordination, such as
flying an airplane or catching a football, difficult. Marijuana
acts as a stimulant or a depressant, depending on the variety
of Cannabis and the amount of THC that is absorbed in the
brain, the setting in which it is used, and the personality and
the neurochemistry of the user.
'When I 90 {orm~medicalmarijuanaat the club.
the~havedozensof differentt~peslaidout withpricesand
descriptions
of effects.Somearelabeledforpeoplewho
wantto sleepor'be sedated,and othersarelabeledfor
those that want to sta~ active."
54-year-old medical marijuana smoker
Marijuana also causes a small, temporary disruption of the
secretion of the male hormone testosterone. That might be

I
sensory experiences with emotions , and they control learn- important to a user with a hormonal imbalance or someone
ing, memory, a sense of novelty, motor coordination, and
some automatic bodily functions. The presence of CB1 anan-
damide receptors makes these areas of the brain highly
susceptible to the effects of marijuana. 124
There are 10 times as many endocannabinoids in the body as
there are endorphins. They are involved in a vast range of
physical and mental functions, most of which involve
increasing or decreasing the sensitivity of the mind to cer-
tain sensory inputs , particularly those involved in stress. 125
There are fewer anandamide receptors in the brainstem for
marijuana compared with the number of endorphin recep-
tors for opioids and norepinephrine receptors for cocaine.
This area of the brain controls heart rate, respiration, and
other bodily functions, which is the reason why dangerous
overdoses from cocaine and opioids cause respiratory depres-
sion or cardiac overstimulation and why there are no over-
doses from using marijuana. 124•126

Short-TermEffects
Physical Effects
The immediate physical effects of marijuana often include
physical relaxation or sedation, some pain control, blood-
shot eyes, coughing from lung irritation, increased appetite,
and a small to moderate loss in muscular coordination. At
low doses it can relieve asthma but at high doses can induce An enterprising Girl Scout set up a cookie sales table in front of a
asthma. The effects of high-dose marijuana on dopamine and marijuana dispensary in San Francisco. Sales boomed (117 boxes in
the increase of heart rate are the main causes of ER visits. two hours), resulting in dozens of other Girl Scouts copying her tactic
in states where medical dispensaries are legal. The Girl Scout
Other physical effects include a moderately increased heart Councils discourage the practice.
rate, decreased blood pressure, decreased eye pressure (the Courtesyof KRON-TY,San Francisco,2014
reason why Marinol ® capsules or marijuana joints are used

These computerized versions of actual spider webs show the effects of psychoactive drugs on a spiders ability to make a web, which is normally
symmetrical. Spiders that had the stimulants Benzedrine ®and caffeine produced erratic and misshapen webs, whereas the spiders with marijuana
and chloral hydrate failed to complete their webs.
NASA/Science Photo Laboratory. 0 NASATech Briefs, April 1995
in the throes of puberty and sexual maturation. The testos-
terone effect also results in a slight decrease in both sperm
count and sperm motility in chronic "pot" users. 129
Marijuana increases hunger, resulting in what is often
called "the munchies." Normally, the endocannabinoid sys-
tem controls food intake through both centra l and periphera l
mechanisms, particular ly the CB1 receptors in the hypothala-
mus. 130By flooding the receptors with THC, appetite is
greatly increased. Smoking marijuana does not sharpen the
sense of taste and does not change the perception of sour-
ness, sweetness, saltiness, or bitterness, nor does it impair the
satiation mechanisms. It enhances the sensory appeal of
foods , especially if the environment is friendly. The sense
of novelty caused by marijuana makes the smoker pay acute
attention to the taste and the sensations of any food eaten.
"Likeif I'msittin9homeand I smokea jointand I knowI 9ot
food in mq iceboxor whatever.maqbe about 10 minutesa~er
I smokethat joint/'m in therefixin·sandwichesthisbi9, ~au
know. It all tastes900d. Evena Twinkie®tastes9ood."
18-year-o ld recovering marijuana user
Once the effects of cannabinoids on hunger were discovered,
experiments with cannabinoid CB1 antagonists (SR141716A
and AM251) that block normal activity showed significant
decreases in appetite. 130SRI 41716A, marketed as Acomplia ®
(rimonabant), was the subject of numerous clinical trials and
was shown to reduce hunger by blocking the CB1 receptors.
Research also revealed, however, that it causes emotio nal
depression, so the deve lopment of Acomplia ® as a weight-
contro l medication was discontinued. Other therapies
invo lving the anandamide/cannabinoid systems are being
explored. 131
Mental Effects
Within a few minutes of smoking marijuana, the user
becomes slightly confused and mentally separated from the
environment. Marijuana produces deja vu, the feeling that
All Arounders 6.35
whatever is happening has happened before. Additional
effects include drowsiness, an aloof feeling , and difficulty
concentrating.
"It'skindof likelifewithouta coherentthou/iht.It'skindof/ikean
I
escape.It'slikewhen~au90 to sleep,~au/or9etaboutthin.95 . It's
likeeverqthin9
's dreamlikeand there are no restraintson anqthin9.
Youcan have freed.omto saq what qou want to saq."
16--year--oldmarijuana smoker
Strong varieties of marijuana can cause giddiness, increased
alertness, and major distortions of time, color, and sound.
Very potent doses have produced illusions, the sensation of
movement under the user's feet, and sometimes hallucina-
tions. Two of the most frequently mentioned psycho logical
reactions attributed to smoking marijuana are paranoia and
a depersonification (detachment from one 's sense of selO.
'You can't hethere for peoplewhen qou'renot insideqourself
And when~auJ!:t loaded, ~au'renot inside~ourselfIt'slike~au
removeqourselffrom qourselfand.then qou're another person."
35-year--old marijuana user
Marijuana acts somewhat like a mild hypnotic. Charles
Baudelaire, the nineteenth-century French poet, referred to
it as "the mirror that magnifies." It exaggerates mood and
personality and makes smokers more empathetic to others'
feelings but also makes them more suggestible. The impact
of THC on the amygdala-the emotional center of the
brain-is the key to understanding many of the effects. The
amygda la helps regu late appetite, pain, anxiety, fear, the sup-
pression of painful memories, and the sense of novelty.
Novelty
One of the most important functions of the amygdala is to
judge the emotional significance and the possible danger of
objects and ideas encountered in the environment. When
a person encounters an unknown object, the amygdala is
 6.36 CHAPTER6
"Marijuanais themirrorthatmagnifies.
" complexity of the activity. For a straightforward activity like
Charles Baudelaire, French poet (1821 to 1867), Courtesy of West Rock/Getty
activated by the release of anandamides that alert the brain to
be aware of the object's possible dangers or benefits , making
the object of great interest. When a person uses marijuana,
the THC artificially stimulates the amygdala, making even
mundane objects and activities interesting. Some users
describe it as "virtual novelty" (drug-induced novelty) . The
senses themselves are not altered or sharpened; what is
I
altered is the way the brain processes the information. 132
'When I smoked,I lovedcolors,shapes,smells, sounds,mq
spouse. I don't thinkI actuallqheardor saw or smelledbetter;
I just paid moreattention.Eventhe rfth rerunof Gilli9an's
Islandepisode#'29wasinterestin9."
38-year-old recovering marijuana user
THC artificiallystimulatesthe brain's"novelty
center"in the amygdala,makingeven known
sensoryinputsmore interesting.
As the amygdala is continually bombarded with THC, the
CB1 receptors respond with delight. But soon , particularly
with excess use, these cells react to overstimulation by
retracting into the cell membrane and becoming inactive;
this process is called down regulation. If marijuana is used
chronically, these receptors can be disabled and their num-
bers can be reduced by up to 70%.133 , 134 A person who
becomes down regulated and then stops smoking is left with
a normal amount of anandamide but fewer receptor sites, so
even things that are truly novel are not perceived as being
fresh or interesting, and therefore everything becomes bor-
ing. To regain the sense of novelty, one must resume use or
stay abstinent for long periods of time, often a full year. 132
'That's what I likedaboutsmokin99rassin colle9eup until
recentlq. We couldsee the samemovieor bookoverand over
and couldenjoqit everqtime.We just sat aroundsmokin9,and
it didn't take that much to makea discussionaboutnothin9
interestin9."
44-year-old female college graduate
If a marijuana smoker is not really interested in working , is
not really interested in studying, is not really interested in a
relationship , his primitive brain takes over and delivers a
"Forget it-let 's not do this" message. Once CB1 receptor sites
are down regulated , it takes approximately two weeks for
them to re-emerge. In the case of a very heavy smoker, it
might take four to six weeks or longer.
Memory and Learning
The hippocampus is the part of the brain most involved in
short-term memory , storing current input for immediate
use . Eventually, short-term information is shifted to long-
term memory. The body's own anandamide determines how
much of the hippocampus is available, depending on the
remembering a grocery list, the hippocampus input is lim-
ited , so only a small portion of it is made available. Cramming
for an exam requires greater capacity, so more of the hippo-
campus is made available. When an external cannabinoid
like THC is taken into the body, it severely limits the avail-
able amount of hippocampal short-term memory. THC
affects memory by acting as an agonist at GABA and gluta-
mate receptors in the hippocampus. 135 Functiona l magnetic
resonance imaging scans of the brain indicate the involve-
ment of the hippocampus and other areas of the brain in
memory impairment. 136
"Ifqou90 homeand havehomeworkto do that ni9htand qou
saq, 'Okaq, I'm9oin9to 9et stonedbeforeI do mq homework'
qou'renever9oin9to 9et qourhomeworkdone."
High-school student
Similar problems can occur on the job when many details
must be manipulated.
"I'd be doin9the job and all of a suddenI'd lookup and freeze
and not knowwhat to do. I wouldhavea handfulof checksin
mq hand and just lookat the machinefor a whileand thinkto
mqself,What is this?What do I do with it?' So I just stand
thereand thinkto mqself,'Okaq, it's 9oin9to come.
It's9Din9to come.' And eventuallqit would."
36-year- old male recovering marijuana smoker
When use is discontinued, short-term memory is almost fully
restored; but if previous experiences and facts were never
processed through short-term memory, they are gone forever.
The more chronic the use, the larger the chunks of the user's
life are forgotten.
"/ don't rememberthe qearsthat I did smoke.I rememberthe
mostimportantthin9s,but the littledetailsI couldn'ttell qou.
I don't rememberwhat I ate a littlebit a90."
20-year-old male marij uana smoker
Although marijuana slows learning and disrupts concentra-
tion by influencing short-term memory, it has a lesser effect
on long-term memory. This explains why some students are
able to maintain good grades while using marijuana on a
regular basis while others flunk out. A recent study of 150

heavy users in treatment found that memory as well as atten-
tion span and cognitive functioning were impaired, and the
heavier the use, the greater the impairment. 137 In one study
students with a D grade-point average were four times more
likely to have used marijuana than were A students_l38
"Schoolwasboringto a pointbeforeI startedweed;but once
I startedsmokingit moreand more,it justgot evenmoreboring.
I didn't wantto go. I didn't wantto interactat school.I went
thereand skippeda lot ofclasses.Actual/~,I skippedmore
than halfthe ~ear."
18-year-old recovering marijuana abuser
Marijuana causes many thoughts and feelings to be internal-
ized. Long-term marijuana smokers mistakenly believe that
their learning, thinking, feeling, and communication skills
are more acute.
"WhenI got high, I thoughtI wasthe smartestpersonin the
world.I knewI had the answerto ever~thing,
and oneda~ I sat
downwithm~cellphonerecorderand I startedrattlingoff all
thisbrilliance
that I had; the nextda~whenI wokeup in the
morningand I pla~edit back,it wasalmostlikeI wasn'teven
speakingEnglish"
38-year-old recovering compulsive marijuana smoker
Marijuana affects a juvenile brain more strongly than an
adult brain. Around the age of 12, an explosion in the num-
ber of connections and synapses among the nerve cells occurs
in the frontal lobes of the brain. Over the succeeding 10 to
12 years, there is a gradual pruning process as these connec-
tions are strengthened or weakened . When a person experi-
ences a new idea or sensory input, the connections are
strengthened . Unused connections become weak and ulti-
mately break. Cannabinoid receptors are denser in the frontal
lobes than in any other pan of the cortex, so excess mari-
juana use can cause distorted thinking . A person's ability to
home in on things that are imponant and ignore things that
are not diminishes over time . This deficit can impair a per-
son's ability to recognize dangerous situations and to priori-
tize actions and activities. Combining ecstasy and marijuana
is popular among young users even though research has
determined that this combination has a synergistic negative
effect on memory 139 •140
>
Marijuanaaffectsa juvenile brain more
stronglythan it does an adult brain.
When a chronic smoker finally quits, memory problems
commonly persist. Some say it takes years to recover a com-
pletely functional memory, and some say a dysfunctional
memory remains for life.
nme
Temporal disintegration distons a sense of time and is
responsible for several of the perceived effects of marijuana.
Time spent doing dull, repetitive tasks seems to go by faster.
In Jamaica some cane field workers smoke "ganja" to make
All Arounders 6.37
their monotonous workday pass more quickly. Smoking
marijuana while engaged in a comp lex activity like studying
for an exam causes boredom, and the smoker often abandons
the books.
The effects of distortion of the passage of time, impaired
judgment, and shon-term memory loss result in a user's
inability to perform multiple and interactive tasks, like
connecting computer components, while under the influ-
ence .141·142
A study of current and former marijuana users
tested smokers at 1, 7, and 28 days after stopping various
levels of use . Former heavy users showed significant impair-
ment on days 1 and 7 but by day 28 the impairment had
almost disappeared_l43
Long-TermEffects
RespiratoryComplications
The main psychoactive substances in THC and nicotine are
different, but the smoke of both contains a mixture of toxic
gases and paniculate matter. As smoking becomes chronic,
so does irritation to the breathing passages . Marijuana is
grown under a wide variety of conditions and is unrefined,
so joints containing buds and/or leaves are harsh, unfiltered,
irregu lar in quality, and composed of many different chemi-
I
cals. When smoke from four or five joints is inhaled and held
in the lungs, the lungs and the mucous membranes are
exposed to the same cumulative level of harm generated by
smoking a pack of cigarettes, according to studies by Dr.
Donald Tashkin at the University of California, Los Angeles
(UCLA). 141,144,145For these and other reasons, health profes-
sionals have determined that smoking marijuana has a dam-
aging effect on the respiratory system.
Marijuana smoking on a regular basis causes coughing and
other symptoms of acute and chronic bronchitis . In micro-
scopic studies of these mucous membranes, Dr. Tashkin
found that the most damaged lungs were those of people
who smoked both cigarettes and marijuana. This is signifi-
cant because approximately 82% of marijuana smokers also
smoke cigarettes compared to just 20% for the rest of the
population in the United States. 146The airway damage from
smoking both cigarettes and marijuana is not just additive
but synergistic. It increases respiratory symptoms and aggra-
vates chronic obstructive pulmonary disease. 147It is impor-
tant to remember that the wrapper around marijuana "blunts"
is tobacco.
Figure 6-3 shows magnifications from a microscope showing
the differences among ciliated surface epithelial cells in the
mucous membranes of nonsmokers and smokers . Figure 6-3A
shows healthy, densely packed cilia that clear the breathing
passages of mucus, dust, and debris . The breathing passages
of a chronic marijuana smoker (6-3B) show increased numbers
of mucus-secreting surface epithelial cells that do not have
cilia, so phlegm production is increased but is not cleared as
readily from the breathing passages . The third image (6-3C)
shows the breathing passages of a chronic smoker of both
marijuana and cigarettes . Note the absence of normal surface
cells; they have been completely replaced by nonciliated
 6.38 CHAPTER 6
Healthy mucous membrane of a nonsmoker Mucous membrane of a marijuana smoker
Courtesyof DonaldTashkin
, M.D.,Pulmonary ResearchDepartment,UCLAMedicalCenter,LosAngeles,CA
cells resembling skin. Because the ciliated cells are gone, the
smoker must cough to clear any mucous from the lungs.
"/'m sure /'ve done some damage to mq lungs. I mean, qou
of
can't put that kind tar down in qour sqstem, heated tar
for
I
into qour sqstemconstantlq 23 qears,and sit here and
saq there'snothing wrongand nothing has happened.
Surelq somethinghas happened."
48-year-old female marijuana smoker
Marijuana smoking does damage lung and other respiratory
tissue, but the jury is still out on whether it causes cancer.
Some of the changes involving the cell nucleus suggested to
researchers that malignancy could be a consequence of regu-
lar marijuana smoking because the changes observed are
precursors of cancer . In 2006, however, Dr. Tashkin and
researchers at UCLA released a study, funded by the National
Institute on Drug Abuse, of 1,200 people with lung, neck, or
head cancer and another 1,000 controls and found no link
between marijuana smoking and lung cancer, even among
heavy marijuana smokers. It is no surprise that cigarette
smokers who smoked two or more packs a day had a 20-fold
increased risk of cancer. Heavier marijuana use among smok-
ers with cancer did not affect the rate of progression of the
cancer .148 Some researchers believe that an explanation for
the lowered cancer risk in marijuana smokers may be the
result of the THC in marijuana killing off aging cells that
could become cancerous. Few studies have explored the con-
nection between marijuana smoking and lung cancer.
Hyperemesis
Long-term high-potency marijuana use has been associated
with a vomiting syndrome called Cannabis hyperemesis syn-
drome (CHS), which cannot be controlled with traditional
anti-vomiting medications. Sitting in a hot shower or bath is
one of the few things that relieve the vomiting. 152 In one case
report, a 4 7-year-old male with intractable abdominal pain suf-
fered for days from nausea and vomiting, and only warm baths
would provide relief. When he stopped using (he was a daily
Mucous membrane of a marijuana and
cigarettesmoker
heavy user) during his stay at the hospital, the vomiting and
nausea went away 149 In a report where synthetic marijuana
was known to have caused the vomiting, it was speculated that
overstimulation of the cannabinoid CB1 receptor caused the
syndrome. 151 Another theory for the syndrome is that the auto-
nomic nervous system becomes overwhelmed by the THC and
a hot shower helps reset the nerves in the system.
About 50% of patients diagnosed with CHS are daily Cannabis
users . Even though this syndrome was first recognized in
2004, 153 it is still underrecognized, so the incidence might
be higher than reported cases. Also, most patients cease
smoking while hospitalized, which causes the syndrome to
disappear and therefore goes undiagnosed.
Immune System
Epidemiological studies identified marijuana as a cofactor
in the progression of HIV infection . Animal studies at UCLA
found that the administration of marijuana increased the
replication of the immunodeficiency virus and measurably
suppressed immune function. 154 Another animal study found
that THC can lead to enhanced growth of tumors, including
those associated with breast cancer, due to suppression of
the anti-tumor immune response. 155
Evidence also suggests that heavy marijuana use can make
users more susceptible to colds, flu, and other viral infec-
tions. If this is proven true, it would be counterproductive for
people who are already immune depressed to smoke mari-
juana for therapeutic purposes because it would further
expose their lungs to pathogens, such as the fungi and bac-
teria found in marijuana smoke. The total health impact of
marijuana on the immune system remains unclear.
Acute Mental Effects
Some people with mental illness use drugs to try to control
their symptoms. One study found that some smoke Cannabis
as a means of satisfying the schizophrenia-related need for
relaxation, sense of self-worth, and distraction .156 The side
effects, however, can have the opposite effect.

There is a debate over marijuana's role in causing a psychosis
or serious mental illness rather than simply increasing para-
noia , acute anxiety; or depression. Because it is hard to
separate other factors, especially pre-existing mental prob-
lems, from the precipitating influence of marijuana, the
question may never be resolved. Often the use of marijuana
(with particularly high levels of THC) will tip the mental
balance of someone just holding on. Thorough investigative
studies of patients in treatment found that the vast prepon-
derance of psychoses and mental problems were preexist-
ing. 157,158
However, the incidence of mood disorders in those
with marijuana dependence is significantly higher than in the
general population. 159A
Some users believe that they have lost control of their mental
state. Besides paranoia there is often a belief that they have
severely damaged themselves or that their underlying insecuri-
ties are insurmountable. These acute problems are usually treat-
able, but sometimes the symptoms persist. Counselors often
see people who, after experiencing a bad trip, don't come all
the way back and have difficulty going on with their lives. They
experience continued confusion, difficulty concentrating, and
spotty memory, and they feel as though their mind is in a fog.
Psychiatry designated this reaction as a type of hallucinogen
persisting perception disorder induced by marijuana.
"I once workedwith a 13-qear-oldclient who had no premorbid
sqmptomsthat could be identipedpriorto his thirteenthbirth-
daq, when his friendsturned him on to a 'honeq blunt,' which
is a cigarpackedwith marijuanasoaked in honeq and dried.
It happened to be verqstron9sinsemilla,and he experienced
an acute anxietq reactionfollowedbq a hallucino9enpersistin9
perceptualdisorder,includin9a ~rofounddepressionand an
inabilitqto concentrate.We don t know how lon9 these
problemswill last."
Counselor, Addictions Recovery Center, Medford, OR
If a veteran smoker is used to smoking low-grade "pot" and
encounters strong "BC bud" sinsemilla, he may think some-
one slipped him a stronger hallucinogen like PCP or LSD.
The experience could create anxiety and paranoia that esca-
lates into a much higher level of anxiety.
Some users mix marijuana with other drugs like cocaine,
amphetamine, and PCP,which can cause exaggerated reac-
tions . Some users soak joints in formaldehyde or embalming
fluid ("clickems," "wet," or "fry") for an even bigger kick.
"Clickems " produce a PCP-like effect when smoked.
According to researchers, deliberately ingesting formalde-
hyde can cause cognit ive impairment in both vocabu lary and
abstract thinking. 159There is also a "chewy blunt ," a joint
mixed with cocaine or crack.
Tolerance,Withdrawal,and Addiction
Tolerance
Tolerance to marijuana occurs fairly rapidly, even though
initially many smokers become more sensitive, not less, to
the desired effects (inverse tolerance). Although high-dose
chronic users can recognize the effects of low levels of THC
All Arounders 6.39
Marijuana
BloodLevelvs.
UrineLevel(approximations)
lO 15 20 25 30 35
Daysafter smoking
Becausetracesof marijuanaremainin the urine longerthan in the
blood,a personcan testpositivefor the drugeventhoughhe or she is
not impaired.
© 20 14 CNSProductions, Inc.
in their systems, they can tolerate much higher levels with-
I
out experiencing the severe emotional and psychic effects to
which first-time users are subject. Current research suggests
that pharmacodynamic tolerance (reduction of nerve cell
sensitivity to marijuana) is the more common mechanism
rather than reduced bioavailability (speeding up the break-
down of the drug, known as drug dispositional tolerance).
"Ori9inallq,we could smoke,saq, two bon9 loads and be just to-
tallq stoned, whereasnow we have to keepcontinuouslqsmokin9
just to keep the hi9h9oin9, even with the hi9her-potencqstuff."
24-year-old recovering marijuana user
Marijuana persists in the body of a chronic user for up to
three months, though the major effects last only four to six
hours after smoking, causing these residual amounts to
potentially disrupt some physiological, mental , and emo-
tional functions.
Withdrawal
Because withdrawal from marijuana does not involve the
rapid onset characteristic of alcohol or heroin withdrawal ,
many people deny it occurs . The drawn-out nature of with-
drawal from marijuana is due to the amount of THC retained
in the brain; only after a relatively long period of abstinence
will the withdrawal effects appear.
"Sometimespeople who've been smokin9for pve qearsdecide to
quit. Theq stop 1, 2, 3 daqs, evena week.,and theq (especiallq
those who think marijuanais beni9n)saq, 'Wow, I feelareat.
Marijuana'sno problem. I have no withdrawalsqmptoms-
nothin9 at all.' Then theq start up a9ain.Theq neverexperience
withdrawal.Withdrawalsqmptomsof marijuanaare dela~ed
sometimesfor severalweeksto a month a~er a personstops."
Darryl lnaba , Phann .D., Addictions Recovery Center, Medford , OR
 6.40 CHAPTER6
The discovery by French scientists in 1994 of an antagonist
that instantly blocks the effects of marijuana enabled
researchers to search for true signs of tolerance , tissue depen-
dence , and withdrawal symptoms in long-term users.
Experiments demonstrated that cessation of marijuana use
could cause true physical withdrawal symptoms. Dr. Billy
Martin, a researcher at Virginia Commonwealth University's
Medical College of Virginia, gave the THC antagonist
SRI 41716A to rats that had been exposed to marijuana for
four consecutive days. The antagonist negated the influence
of the marijuana . Within 10 minutes the rats exhibited
physical withdrawal behaviors that included "wet dog
shakes " and facial rubbing, which is the rat equivalent
of withdrawal. These experiments indicate that marijuana
tissue dependence occurs more rapidly than previously
suspected_ 100, 101,102
Withdrawal effects of marijuana include:
• anger, irritability, anxiety, and aggression
• aches, pains, and chills
• depression
• inability to concentrate
• sweating
• craving
• slight tremors
I
• sleep disturbances
• decreased appetite and stomach pain
Not everyone experiences every effect, but everyone will
experience some of them, especially craving. Human
research demonstrated that irrit ability, anxiety, aggression ,
and even stomach pain caused by marijuana withdrawal
occurs within three to seven days of abstinence. 163, 164, 165, 166
"I wouldbreakinto a sweatin the shower.I could not maintain
mq concentrationfor the firstmonth or two. To reallqtreasure
mq sobrietq,it took me about threeor fourmonthsbeforeI
reallqcameout of the fo9 and reallqstarted9ettin9a araspof
what was9oin9on aroundme."
JS.year-old recovering marijuana addict
The 2013 edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5), classified Cannabis-Related
Disorders as:
• Cannabis Use Disorder, mild, moderate, severe (for-
merly called addiction or dependence)
• Cannabis Intoxication (getting loaded to the point that
functioning becomes difficult)
• Cannabis Withdrawal (classified by specific symptoms
such as irritability and difficulty sleeping)
• Other Cannabis-Induced Disorders (includes milder ver-
sions of the first three diagnoses)
• Unspecified Cannabis-Related Disorder 167
There are true withdrawal symptomsand
true addiction,especiallywith the higherTHC
concentrationsin today'smarijuana.
Addiction
Just as the refinement of coca leaves into cocaine and of
opium into heroin led to greater abuse of those drugs , sinse-
milla and better cultivation techniques led to higher THC
concentrations, which increased the compulsive liability of
marijuana and the severity of withdrawal symptoms. Unlike
opiates, sedative-hypnotics, alcohol, and some stimulants,
psychological addiction is considered more of a factor than
physical addiction, but research over the past 18 years vali-
dates the physical components of marijuana dependence
and withdrawal.
"I thou9ht I could controlit becausewhen I wokeup in the
mornin9,I didn't9et hi9hfor the first hourand a half I fi£1,ured
an hourand a half provesthat I'm not hookedon this stuff
becauseI don't reallqneed it."
Recovering user in Marijuana Anonymous , a 12-step program
Today many people smoke the drug in a chronic, compul-
sive way and have difficulty discontinuing its use . Nearly
336,000 marijuana users sought treatment in the United
States in 2010 .168 Like cocaine, heroin, alcohol, nicotine, and
other addictive drugs, marijuana has the ability to induce
compulsive use in spite of the negative consequences it may
cause in the user's life.
'Todaq'spotent formof marijuanaand newrefinement
techniquessuch as dabbin9and shattered9lassare causin9
moreproblemsthan we saw in the 1960s.Therewereno
self-admittedmarijuanaaddictsin the clinicdurin9the sixties,
the seventies,or throu9hthe ei9hties.Bq the late ei9hties,
we startedseein9peoplecomin9in. Everqonecame in of their
own volition,saqin9,'Helpme. I want to stop usin9pot.
It is causin9me problems,memorqproblems.I am too
spacedout. I havewithdrawalsqmptoms.I want to stop
and I can't.' At our proaramin San Francisco,we had about
100 patientsin treatmentat anq9iventimespecificallqfor
marijuanaaddiction."
Darryl Inaba , Pharm .D., Addi ctions Recovery Center, Medford, OR
Although the dependence liability of marijuana is purported
to be lower than that of other drugs, when it comes to the
bottom line of any addiction , it is the consequences that
matter most.
'Whq am I doin9this?What's wronfiwith me? Whq do I have
to keepdoin9this?And I did this for a 900d ei9htto 10 qears.
I startedbuqin9dime ba9s,fi9urin9it wouldcost a lot more
and then eventuallq I'd9et the point. It didn't work.I just kept
on buqin9."
38-year-old recovering marijuana abuser
The University of California , San Francisco (UCSF) Family
Study examined the heritability of marijuana dependence .
The study included 2,524 adults, and the findings suggest
that within this cohort the following is true:
• Cannabis use and dependence as well as individual
Cannabis dependence symptoms have a significant her-
itable component .

• Cannabis dependence is more likely to occur when use
begins during adolescence.
• The Cannabis dependence syndrome includes a num-
ber of heritable untoward psychiatric side effects,
including withdrawal. 169
Is Marijuana a Gateway Drug?
Anti drug movies from the 1930s like Reefer Madness and
Marijuana, Assassin of Youth claimed that marijuana physi-
cally and mentally changed users, ultimately leading them to
heroin and cocaine and turning them into hopeless addicts.
These exaggerated notions actually undermined the drug
education efforts of the day because people who did smoke
marijuana never became raving lunatics or depraved dope
fiends. Those who experimented with marijuana assumed
that because nothing terrible happened as a result of smoking
a joint, the warnings about marijuana were lies and therefore
all warnings about all drugs were lies.
This exaggeration and resultant ridicule of propaganda or
scare films and books probably caused more drug abuse
than it prevented. It also obscured the real role that mari-
juana use plays in future drug use and abuse.
"I'vebeenin a 12-steppro9ramfor a littleover six ~ears,and I'm
not 9oin9to sa~,like,one and one equaltwo, but just about
ever~bod~ I meetin the 12-steppro9ramstartedout witheither
marijuanaor alcohol."
44-year -old male recovering marijuana addict
Marijuana is a gateway drug in the sense that people who
smoke it probably hang around with others who smoke it
and/or use other drugs, which creates more opportunities
to experiment with other drugs. Viewed from this perspec-
tive, it is not surprising that after early use of alcohol or
nicotine and before current use of other illicit drugs, mari-
juana was the drug of choice . Users moved on to marijuana
after first using alcohol or nicotine. 106,141 -170
No two people have the same reaction to marijuana, but all
people who use it regularly establish a pattern of use and look
for opportunities where drugs other than marijuana are avail-
able . There is also growing evidence that the use of any addic-
tive drug at an early age changes vulnerable brain functions,
making a person more likely to develop an addiction.
'The majorit~of peoplethat I know, that I han9aroundwith,
if the~ain'tsmokin9weed, the~'resmokin9crackor drinkin9.
I'mnot sa~in9that the~arebadpeople, but that's just howit is."
30-year-old polydrug user who started smoking marijuana at age 13
A study of311 young adults in Australia who were identical or
fraternal twins found that those who smoked Cannabis by age
17 were 2.1 to 5.2 times more likely to use or abuse other
drugs or to become alcohol or drug dependent than were
those who never smoked Cannabis. There was no significant
difference in alcohoVdrug use or dependence between frater-
nal or identical twins , emphasizing the direct effect of mari-
juana and of environmental influences. 171 A Dutch study of
twins reported that early Cannabis use by one twin increased
All Arounders 6.41
the potential for future illicit-drug use, but the twin who did
not use marijuana while young had no increased risk. 172
Marijuana (Cannabis) and the Law
Onjanuary 1, 2014, it became legal to consume marijuana in
Colorado and Washington State for recreational use, but
implementing the laws and preventing a subculture that
sells the drug out of state, sells to minors, or avoids tax
laws is going to be difficult. Currently , these state statutes
contradict federal law, which still considers the drug illegal.
The demand for marijuana has been a constant for the past
45 years in the United States, and there are no signs of its
falling from favor. Marijuana is the most widely used illicit
drug in the United States, Canada, Costa Rica, El Salvador,
Mexico, Panama, and South Africa_27 -67 Penalties for posses-
sion and use vary widely from country to country . As of 2014
medicinal use of marijuana is legal in Australia, Belgium,
Canada, the Netherlands, and 20 U.S. states and the District
of Columbia . The likelihood of future changes in the laws
controlling marijuana are very high based partly on econom-
ics, partly on the difficulty of enforcing current laws, and
partly on new marijuana research that is more extensive and
more accurate than before.
The economic factors are compelling. Thousands of arrests
I
and incarcerations for possession of small amounts of mari-
juana cost federal and state governments billions of dollars .
In some states marijuana is the biggest cash crop. In
California it is $14 billion, with the potential of generating
$1 billion in taxes at $50 per ounce . Colorado imposed a
total of 27 .9% in taxes on sales (2.9% state sales tax, 10%
sales tax on retail sales , and a 15% excise tax on wholesale
marijuana) plus any local taxes.
>
The combinedtax rate on marijuana in the
State of Coloradois approximately28%
The laws and the penalties for marijuana use or possession
vary from state to state as well as at the federal level. Federal
laws focus mor e on heavy trafficking, although there are pen-
alties for simple possession and personal use . The sale of 200
to 2,000 lbs. will send a dealer to federal prison for five to 40
years accompanied by up to $2 million in fines. In 2010 the
Obama administration exempted from arrest medical mari-
juana users and suppliers if they are in compliance with state
law. The Fair Sentencing Act of 2010 was signed into law by
President Barack Obama, reducing the disparity between the
amount of crack cocaine and powder cocaine needed to trig-
ger certain U.S. federal criminal penalties.
In the United States:
• Drug arrests account for about 12% of all arrests .
• In 2012, 50% of the 1,552,432 arrests for drug-abuse vio-
lations were for marijuana.
• Marijuana arrests went from 401,982 in 1980 to 749,825
in 2012.
• Almost 90% of marijuana arrests are for possession . 173
 6.42 CHAPTER 6
Courtesyof eagle cartoons
Worldwide:
I • In 2013 Uruguay made it legal to produce and sell mar-
ijuana. It also enacted laws to regulate the amount sold
and its distribution. Uruguay's president, Jose Mujica,
urged richer countries (which are the largest consumers
of drugs) to change their approach to the so-called War
on Drugs because it does not seem to be working.
• In 2000 Portugal partially decriminalized all illicit-drug
use including heroin and marijuana. This law still made
it a crime to possess illicit drugs but changed the offense
from a criminal one to an administrative process. Those
caught possessing illicit drugs were rigorously assessed.
If they were deemed to be addicted, they were sent into
treatment. Recreational, non-addicted users were fined.
This has been said to result in decreased HIV cases and
fewer cases of addiction to heavy drugs like heroin and
cocaine, though marijuana use did increase. 173A
• Argentina, Austria, Belgium, Colombia, Germany, Italy,
and Spain generally don't prosecute for possession of
small amounts of marijuana for personal use even though
it might be illegal.
• Medical marijuana is legal in Canada, although mari-
juana for recreational use is illegal (though personal use
is generally tolerated). Proposed changes in drug laws
focus on prosecuting serious dealers.
• In England Cannabis was designated as a class B drug by
the Misuse of Drugs Act of 1971; in 2008 a government
commission favored lowering the designation to a class
C drug, but the government ignored the commission's
recommendation; in 2009 Cannabis was again classified
as a class B drug. Possession could lead to a five-year
prison term, but most sentences are minimal. The public
tolerates personal use in the home.
• In India laws vary from state to state, but use is gener-
ally tolerated because marijuana is used in religious rites
(e.g., by sadhus and Indian ascetics). Hashish is widely
available.
• In Japan possessing less than 1 gm of marijuana can land
a person in jail. Smugglers caught with a few hundred
grams, up to a few kilograms, are routinely sent to prison
for three to four years. Foreigners are deported after serv-
ing their sentence for possession, often with a lifetime
ban on returning (e.g., Paul McCartney).
• In Mexico in 2009, a law was passed that decriminalized
personal use of marijuana and allowed possession of up
to 5 gm.
• In the Netherlands use is controlled by limiting the point
of sale to designated "coffee shops"; sales outside these
locations are illegal.
• In the People's Republic of China, Cannabis is culti-
vated for its seeds and fiber and for its medicinal value .
Ingesting it for recreation is illegal.
• In Russia marijuana possession (up to 6 gm) and use is
tolerated (but fined); growing Cannabis (fewer than 20
plants) was decriminalized in 2010, but fines are levied.
• Some countries impose a death penalty for drug dealing
(usually hard drugs) and some for possession.174
• The push for the medical use of marijuana worldwide
is causing a reassessment of many of the legal penalties
for use and sale (e.g., medical marijuana clubs).
Marijuana,Driving,and DrugTesting
With the legalization of marijuana in Washington and
Colorado, the number of arrests for impaired driving is show-
ing a significant increase. What is interesting is that the
 All Arounders 6.43

arrests are for the combination of alcohol and marijuana,
not for marijuana alone. In Europe, the largest cause of traf-
fic fatalities is the combination of alcohol and Cannabis.
Research in Norway found that marijuana and alcohol had
additive effects on the quality of someone's driving under the
influence, as opposed to sedative-hypnotics or prescription
opiates, which had synergistic effects .185 This increasing use,
coupled with 20 states that allow medical marijuana, pre-
sents problems for traffic officers and lawmakers.
ally did, while the drinkers thought they did better. Alcohol
lowers inhibitions and boosts confidence, whereas mari-
juana makes the drivers overly wary or paranoid . 179
"At first I wouldn't drivewhen I was stoned. but after it
becamemoreof a habit and it didn't do as much to me.
I was more conscientiousof m~ drivin9.I would drive the
speed limit. I didn't want to 9et pulled over."
19-year-old male marijuana user

The increasing use, legality, and medical use of marijuana

present problems for traffic officers encountering individuals
driving under the influence or while impaired. Roadside
saliva tests indicate if a driver has used marijuana but cannot
measure the quantity, the time frame of use, or the amount
remaining in a person's system. The level of impairment,
however, is tested using the same field sobriety measures
used for determining alcohol impairment. Today it is not
uncommon for drivers arrested for reckless driving or oth-
erwise involved in vehicular accidents to be tested for
marijuana and other drugs, in addition to alcohol. Measuring
a driver 's blood alcohol concentration is a simple matter,
whereas drawing conclusions about a driver's recent mari-
juana use and its contribution to the incident is more difficult
for a number of reasons.
• The drug persists for a number of days in the body and
In one study 60% of marijuana smokers failed a field sobriety
test 2.5 hours after smoking moderate amounts; other
tests showed some impairment 3 to 7 hours after smoking,
and some measured minimal impairment up to 8 hours
later_1so,1s 1,1s2
Repetitive tasks such as driving under normal conditions on
familiar streets are not very challenging to a driver who just
smoked a joint; but if a complicated driving situation arises
that requires decision-making and swift reaction time, the
chances of error if marijuana is in the system are signifi-
cantly increased. In a number of U.S. studies, 4% to 14% of
drivers who were injured or killed in accidents tested positive
for marijuana or marijuana and another drug. 183 In a French
study, 2.5% of fatal crashes involved marijuana; 11 times that
amount (28 .6%) involved alcohol. Another survey of 6,766

I
can sometimes be detected weeks after use. French drivers considered at fault in accidents found that
681 tested positive for marijuana. 184
• The elimination rate varies radically compared with that
for alcohol, which has a defined rate of metabolism. Medical Use of Marijuana
• There is a scarcity of conclusive data about the level of
Epidemiologyand Dispensaries
marijuana in the blood vs. the level of impairment.
In 2000 the voters of Colorado legalized medical marijuana.
• In most instances there is another drug in the system in
As of 2010, 66,000 medical marijuana cards had been issued
addition to marijuana, usually alcohol. 175 ,176 -' 77 -' 78
to people who claimed an illness with symptoms marijuana
Testing machines can measure minute amounts of the THC
metabolite but are generally calibrated to start registering at
50 nanograms per milliliter (ng/mL) in urine samples. The
50 ng/mL level does not measure impairment-just the fact
that marijuana was used. It would take about 3 weeks of absti-
nence for long-term users not to register on a test with a 50
ng/mL cutoff and another 3 weeks to be completely negative.
The International Olympic Committee uses 15 ng/mL as its
cutoff level. In a few instances, it has taken 10 weeks for the
drug to completely clear from the body Someone who smoked
a joint at a party but is not a longtime user usually tests nega-
tive 24 to 48 hours after use.
Even if marijuana alone is proven to have a relatively small
effect on a person's driving capability, its effect is magnified
by polydrug use and abuse . Given that 65% of heavy drinkers
also use marijuana, it is not surprising that positive polydrug
test results are the rule and not the exception for drivers
arrested for driving while under the influence. 177 -178
In a Lakewood, Colorado, marijuana dispensary,run by Kristi Kelly,
Tests on drivers using marijuana or alcohol measured lower
cofounderof the Good Meds Network, a patient checks out some buds.
levels of impairment after smoking a small amount of Some strains are betterfor pain, somefor sleep, and some to handle
marijuana compared with drinking a small amount of alco- anxiety. Once Colorado legalized marijuana, many dispensaries
hol. Impairment increased with the dosage but at a lower openedfor business.
curve for marijuana smokers than for drinkers. It is interest- Courtesyof the WashingtonPost/GettyImages
ing that the smokers thought they did worse than they actu-
 6.44 CHAPTER6
,t()Wle49t"b
le, Friendfy StJlff Vapor Room, a medical
Potent
, Affordable Iaibfts marijuana dispensary,
iOCi1f
Lounge Ideal for Va.lJOri
lll!I
opened in 2004 and was
i;"i'i
com(ortn ble AtmOS Pht~ 1 probably follow.
very popular. Even though
it was legitimate according
to California state law, it
closed its doors due to
pressurefrom the federal
government. The specific
reason cited was the
businessSproximity to a
park where children
played.
0 2014 CNS Productions, Inc.
supposedly could help. In 2012 Colorado voters legalized
marijuana for recreational use . On January 1, 2014-the
first day anyone over 21 could legally purchase "pot"-there
was a run on dispensaries. 186 ,187 Sales and excise taxes will
bring in millions of dollars to Colorado state coffers. In
I
California the Board of Equa lization estimated that legalizing
marijuana in that state would generate $1.38 billion in taxes,
$990 million in excise taxes alone.
In the more than 20 states where it is legal to prescribe
medica l marij uana, there are growing numbers of marijuana
buyers' clubs, dispensaries, and growers supplying mari-
juana to those who have a medica l mar ijuana card. The sys-
tem is abused by over-prescription of medical marijuana
cards to people who don't want to be hassled by law enforce-
ment for using the drug recreationally. About 83% of people
who have medical marijuana cards are males from 18 to
25 years old. In most states growing by unauthorized users is
illegal even if they are supplying medica l marijuana buyers'
clubs under the table.
Besides baggies of the buds, buyers' clubs and dispensaries
sell marijuana in a variety of edible forms, called "medi-
bles," such as marijuana-laced butter, brownies, cookies ,
extracts for inhalers, and soft drinks. In Denver 1 oz. of
medical marijuana costs about $350 for a six-week supply.
A patient may possess up to 2 oz. or cultivate six plants for
persona l use. Some of the dispensaries are sincere in advocat-
ing total wellness and healing, but approximately half are
interested only in moving product (according to an officer of
the Colorado Wellness Association). 188 ,189
After the Ninth U.S. Circuit Court of Appeals in San Francisco
ruled that Congress did not have the constitutional authority
to regulate the noncommercial cultivation and use of mari-
juana that does not cross state lines, the U.S. Supreme Court,
in a 6-to-3 decision, ruled that the federal government had
the right to supersede state laws that permit the medical
use of marijuana and that Congress acted within its mandate
to control interstate trade. 190President Obama never favored
the legalization of marijuana for recreational use; but when
the Obama administration said that it would not supersede
state law with regard to medica l marijuana and wou ld not
raid legitimate marijuana buyers' clubs, the stage was set for
expansion of its use. Alaska, Arizona, California, Colorado,
Delaware, Hawaii, Maine, Michigan, Montana, Nevada, New
Jersey, New Mexico, Oregon, Rhode Island, Vermont, and
Washington allow the practice, and a dozen other states will
Medical Effects
Over the past 150 years, the medical profession has clini-
cally and scientifically examined the use of Cannabis and
its extracts for medicinal purposes . Because there were a
limited number of all-purpose medications available (e.g.,
opium, theriac, and willow bark), substances that had real
therapeutic effects were prized. Dr. William O'Shaughnessy
spurred curiosity about the drug in Europe in the 1830s. In
an 1860 report to the Ohio State Medical Society, Cannabis
researcher and physician Dr. R. R. McMeens presented his
conviction that the drug was of immense value because of its
immediate action to appease the appetite for chloral hydrate
or opium and restore the ability to appreciate food. He also
recommended it as a treatment for disordered bowels, as a
diuretic, and as a sleep ing tonic. 191
Then as now there were warnings about the drug's dangers.
As far back as 1890, Dr. John Russell Reynolds wrote of his
experiences using Cannabis medicinally over a period of 30
years. He said he observed a wide variation in the strength of
any Cannabis indica preparation, a wide range of reactions to
the same dose, and severe reactions if high concentrations
were taken. 192By 1900 a number of prominent drug compa-
nies marketed Cannabis extracts and patent medicines as
cures for a variety of illnesses.
Historica lly, marijuana has been used as a muscle relaxant, a
painkiller (analgesic), and an appetite stimulant and to con-
trol spasms and convulsions, calm anxiety, stimulate child-
birth, relieve coughs (antitussive), and treat symptoms of
withdrawal from opiates and alcohol.
The passage of the Marijuana Tax Act of 193 7 discouraged
research until the 1980s, when the resumption of research
explored and in some cases recommended Cannabis for:
• nausea (especially from chemotherapy)
• stimulating weight gain for wasting illnesses such as can-
cer and AIDS
• seizure disorders such as epilepsy
• chronic and acute pain from migraine, cancer, and rheu-
matism
• multip le sclerosis and other autoimmune diseases
• some types of glaucoma
• depression and anxiety 100,124
,193
A recent study of AIDS patients at San Francisco Genera l
Hospita l found that they experienced substantial pain relief
from smoking marijuana; most relief occurred on the first
day of use. 19" Marijuana provides pain relief by acting as a
synaptic circuit breaker, suppressing pain signals by activat-
ing CB1 and CB2 receptors. 195

© 2008 Taylor Jones. By permission of eagle cartoons. All rights reserved.
There is evidence that marijuana reduces intraocular pres-
sure in glaucoma patients, calms nausea, reduces some pain,
and stimulates appetite-but other drugs are just as effective
and in some cases better.
The focus of the most recent research is on the other can-
nabinoids in marijuana, particularly cannabidiol. Regardless
of THC concentration, CBD seems to affect convulsions,
tremors related to multiple sclerosis, and anxiety. Cannabis
sativa has more effect on body tremors, whereas Cannabis
indica is more effective as a treatment for pain and mental
stress . The challenge is to create a more standardized plant
with reliable levels of the active ingredients and fewer con-
taminants. It is important that medical marijuana dispensaries
test for THC and cannabinoid levels rather than rely on anec-
dotal reports from patients and suppliers. Other efforts are
aimed at growing specific strains that have more-specific
effects and that are aimed at specific illnesses .
Avidekel is a marijuana hybrid with increased levels of CBD
(15 .8%) and decreased levels of THC (0% to 0.03%) . It was
developed for medical use, as it has virtually no psychoactive
properties. Nicknamed Charlotte 's Web by the Colorado
growers who developed it, this strain was marketed as actual
"medical marijuana" because CBD retains all of the medi-
cally beneficial effects without the psychic effects sought by
recreational users. Unfortunately, there were too few buyers
interested in this true medical marijuana. 193A
Rationalefor and AgainstMedical Marijuana
One of the major drawbacks of the use of marijuana for
medical purposes is the great variation in the amount of
All Arounders 6.45
active ingredients in any given plant. Variations in /'i9-THC
potency, the relative concentration of other active cannabi-
noids, and the inconsistency of botanical factors make it dif-
ficult to confidently rely on this substance to treat medical
problems . For example , most forms of marijuana lower intra-
ocular pressure, which provides relief for glaucoma , but
some forms actually increase pressure, making a patient 's
glaucoma worse.
Beyond marijuana 's physiological effects are its mental effects .
Like opium cure-alls, such as theriac and laudanum, and
prescription opiates or sedative-hypnotics, it is often mari-
juana's mental effects of calming , anxiety relief, or mild
euphoria that make people feel good and believe they are
getting better rather than true physical healing effects .
One example of this effect is the search by the Figi family in
Colorado to find a treatment for their seven-year-old daugh-
ter's daily multiple powerful seizures (300 grand ma! seizures
per week). After exhausting all options over the years, in
2013 they found that a certain strain of marijuana controlled
the seizures . It was a strain high in cannabidiol and low in
THC, the main psychoactive ingredient (a necessity for
treating children). The non-psychoactive cannabidiol con-
tains most of th e medical benefits of marijuana without the
THC. After overcoming the medical community 's objections
I
to treating children with marijuana , the Figis contacted the
Cannabis grower who had developed the strain and discov-
ered that a large supply was available because no one wanted
"medical marijuana " if it didn 't also get you high . The child
responded and is living a healthy life. 196
Most of the medical benefitsof marijuana,such
as pain relief and seizurecontrol,seem not to
come from THC but from cannabidioland its
effect on CB, and CB2, receptors.
There are many reasons why the medical community is reluc-
tant to prescribe or approve marijuana for medical use . Some
are political, some are ethical, but the most relevant reasons
relate to a patient 's health .
• Marijuana smoke contains irritants, carcinogens, patho-
gens , fungi, ins ecticides , and other ch emicals , most of
which have not been studied.
• When marijuana (baked in brownies or other food) is
eaten , respiratory problems are avoided, but the 420 or
more compounds contained in marijuana remain, along
with their side effects.
• Marijuana is a psychoactive drug with dependency po-
tential , which is particularly problematic for those who
are recovering from abuse or addiction . It can cause its
own dependency or a relapse to other dependencies.
Medical research on marijuana will continue to uncover more
about the drug, but in the more than 6,000 scientific studies
conducted since the 1970s , conflicting conclusions have
made substantiating the appropriate medical use a Sisyphean
task. If one types in medical marijuana on an Internet search ,
257 million results will appear , most of them opinions.
6.46 CHAPTER 6
Introductionand History
• All arounders, also known as hallucinogens, are psy-
chedelics that can act like stimulants or depressants.
Most of these drugs alter a person's perceptions and
create a world in which reason takes a back seat to
intensified sensations marked by illusions, delusions,
and hallucinations.
• Humans have used them for tens of thousands of years
to cope with their fears and the environment. They
are used for religious, social, ceremonial, and medical
purposes. Psychedelics were originally found in some
of the 4,000 plants and fungi that have psychoactive
effects. Over the past century, thousands of psychedel-
ics have been synthesized.
Classification
• LSD, psilocybin mushrooms, peyote, MOMA, ket-
amine, DMT, PCP, and especially marijuana are the
most commonly used all arounders. The five general
categories are indoles, phenylalkylamines, anticholin-
ergics, miscellaneous psychedelics (e.g., PCP), and
cannabinoids. Synthetic marijuana was developed to
be undetectable in drug tests and is available in vari-
ous forms and products.
GeneralEffects
• Effects depend on the user's mind-set and the physical
setting in which the drug is used. Physical stimula-
tion, impaired judgment, and distorted reasoning are
common .
• Psychedelics cause intensified and crossed sensa-
tions (synesthesia, e.g., visual input becomes sound).
Psychedelics cause illusions (mistaken perceptions
of real stimuli), delusions (mistaken beliefs that are
not swayed by reason), and hallucinations (imaginary
sensory experiences).
LSD, PsilocybinMushrooms,and
Other lndole Psychedelics
• Indole psychedelics exert many of their effects through
serotonin receptors, which affect mood, sleep, anxiety,
and areas of the brain that generate hallucinations and
illusions.
• LSD is naturally found in ergot fungus toxin growing
on rye grains. It was extracted by Dr. Albert Hoffman
in 1938 .
• LSD is very potent in both its natural and its synthetic
forms. It lasts six to eight hours, causing stimulation,
mood changes, loss of judgment, sensory distortions,
hallucinations, and illusions . When someone has a
bad emotional reaction to the drug, it is considered a
"bum trip."
• Initially popularized by Dr. Timothy Leary and writer
Ken Kesey in the 1960s, LSD was studied as an aid to
investigating thought processes.
• Psychedelic or magic mushrooms, the other major
indole psychedelic, contain psilocybin and psilocin.
More than 100 species contain the active ingredients.
They can cause nausea and induce hallucinations.
Effects include visceral sensations; changes in sight,
hearing, taste, and touch; and altered consciousness.
• Other indole psychedelics have limited availabil-
ity: ibogaine, morning glory seeds (ololiuqui), DMT
(dimethyltryptamine), ayahuasca (yage), foxy (5-Me-
DIPT), and AMT (alpha-methyltryptamine).
• Ibogaine, found mostly in Africa, produces long-
acting psychedelic effects, illusions, and hallucina-
tions, producing deep introspective states. It is being
used experimentally to treat alcohol, cocaine, and
opioid addiction.
• DMT is a quick-acting psychedelic, often used in aya-
huasca, a concoction of vines and plants found mostly
in South America that is used in ceremonies to gain
personal insights.
Peyote,MDMA, and Other Phenylalkylamine
Psychedelics
• Phenylalkylamines are chemically related to adrena-
line and amphetamine .
• Mescaline (peyote cacti) produces more hallucina-
tions than does LSD and is often used in sacred ritu-
als and ceremonies to generate visions; its effects last
about 12 hours.
• Psycho-stimulants are phenethylamine derivatives
such as MOMA (ecstasy), MDA, and 2C-B (CBR).
• MOMA (ecstasy) releases excess serotonin, causing
a sense of well-being, empathy, and calm along with
stimulatory effects. "Molly" is purer MOMA, usually
in capsule form.
• Patrons of raves and music/dance clubs favor MOMA,
marijuana, "purple drank " (a codeine/promethazine
combination), and to a lesser extent ketamine, nitrous
oxide, GHB, and dextromethorphan.
AnticholinergicPsychedelics
(belladonna, henbane, mandrake, and
datura [jimson weed, thornapple])
• Plants such as belladonna, henbane, and jimsonweed
have been used in the rituals of ancient cultures for
more than 3,000 years, mostly to induce visions. Their
active ingredients are hyoscyamine, atropine, and

scopolamine. These drugs speed up the heart, raise
body temperature, and cause a separation from reality
• About 1,000 jimson weed poisonings occur in the
United States each year.
PCP,Ketamine,Salvia Divinorum,
and Other Psychedelics
• PCP is an anesthetic used on animals. In humans it
causes mind/body separation, a sensory-deprived
state, and hallucinations. Ketamine is a similar an-
esthetic and produces many of the same effects.
PCP and ketamine are also known as dissociative
anesthetics.
• Salvia divinorum, a small sage plant, contains salvino-
rin A, a short-acting psychedelic chemical that causes
hallucinations, delirium, and out-of-body sensations
along with an inability to communicate or function
physically.
• Amanita mushrooms can cause a dreamy intoxication,
hallucinations, and delirious excitement, but they
can be deadly if too much is used. They are legal in
the United States and are usually acquired over the
Internet.
• Dextromethorphan is a nonprescription cough sup-
pressant that can cause psychedelic effects (and health
liabilities) when used to excess. High concentrations
can cause psychoactive and psychedelic effects . It is
kept behind the counter in pharmacies or available
only with a prescription.
• Nutmeg and mace are also psychedelics but are rarely
used because the psychedelic effects come at the ex-
pense of making one sick.
• Other all arounders found at raves include Bromo-
dragonFLY and lion's tail (Leonotis leonurus). An HIV/
AIDS medication, efavirenz (Sustiva®) is sometimes
used to induce lightheadedness, dizziness, vivid
dreams, hallucinations, and other effects.
Marijuana and Other Cannabinoids
• Marijuana (e.g., Cannabis sativa and Cannabis indica)
is the most popular psychoactive drug. It is used by
19 million Americans on a monthly basis.
• Historically, China, India, and many other countries
used marijuana as a food, a medicine, a fiber, and a
psychedelic .
• Marijuana has been alternately permitted and made
illegal. In the United States, it is legal to sell and use
marijuana for recreational purposes in Colorado and
Washington State. Another 20 states and the District
of Columbia made the use of medical marijuana legal.
• The two major species of marijuana are Cannabis
sativa and Cannabis indica. The active psychedelic
ingredient is delta-9-tetrahydrocannabinol (~9-THC
All Arounders 6.47
or simply THC). Using sinsemilla growing techniques,
the potency of the THC can be greatly increased. The
average THC in the United States is more than 13%.
• Hashish is the concentrated resin of the Cannabis indica
plant. The method of making hashish using butane
(butane hash oil or BHO), alcohol, CO 2 , or ice water is
called dabbing. Another name for a slightly different
process for making concentrated THC is "shattered
glass" and "amber."
• Most marijuana comes through Mexico or is grown
in the United States, where distribution is often con-
trolled by Mexican drug-trafficking organizations.
More indoor growing is taking place to avoid surveil-
lance.
• Synthetic cannabinoids-sold under the trade names
Spice Silver, Spice Gold, and K2, among others-are
gaining popularity.
• Researchers have discovered more than 420 chemi-
cals in a single Cannabis plant. At least 30 of these
chemicals, called cannabinoids, are studied for their
psychoactive effects. The brain's natural THC is called
anandamide.
• Marijuana can cause relaxation, sedation, increased
appetite, a heightened sense of novelty, giddiness,
bloodshot eyes, short-term memory impairment (not
necessarily long-term), impaired tracking ability, res-
piratory impairment, and mental confusion.
• Excess, chronic use of marijuana can cause hypereme-
sis, which is violent vomiting, a condition that reoc-
curs until the person stops smoking or using .
• Marijuana is called "the mirror that magnifies." It also
has a strong effect on the novelty center of the brain,
which is normally stimulated by anandamide. Theim-
pairment of the novelty center makes learning more
difficult .
• Tolerance, withdrawal symptoms, and addiction oc-
cur with chronic marijuana use . Nearly 336,000
Americans sought treatment for marijuana depen-
dence (addiction) in one year.
• More and more people are getting arrested for im-
paired driving while under the influence of marijuana,
although most stoned drivers drive under the speed
limit.
• There have been intense social and legal battles over
the use of marijuana for medical purposes.
• Medical marijuana is used to control pain, some forms
of glaucoma, nausea, and anxiety Many medical needs
presented as a rationale for obtaining a medical mari-
juana card are exaggerated.
• The legalization of marijuana is destined to cause con-
flicts among federal and state governments and law
enforcement agencies.
In the UnitedStates, thtR art 464 commcn:ial
casinos, 466 Indian casinos, 413 card rooms,
and tens of thousandsofslotandpokermachines;
43 states have lottery games , which include
multimillion-dollarlotteries, keno, and scratch-off
games.1 Sports betting, bingo. racetrackwagering,
and dozens of Asian games such as Pachinkoand
even mah-jongg-all are opportunitiesto gamble.
The moneygames such as day-trading, bundling
loans, and hawkingderivatives involve more
money than all otherfonns of gambling.1
0 20 12 Dave Grunland

On February 7, 2014 , baseball superstar Alex Rodriguez of the New York Yankees
accepted a 162-game suspension for the illegal use of peif ormanc e-enhancing
steroids. Biogenesis, an anti -aging clinic, supplied performanc e-enhancing design er
drugs to a number of ballplayers ; 13 other play ers were suspended for various
lengths of time.
0 2013 Pat Bagley Permission by Cagle Cartoons
 Other Drugs,
Other Addictions

•
This chapter gives an overview of other substances that have psychoactive effects,
particularly inhalants and sports drugs. Volatile solvent inhalants are used more
widely in poor communities and countries, nitrous oxide ("laughing gas") is
often used at electronic music parties, and volatile nitrites are often used in the gay
community.
Steroids, human growth hormone (HGH), and stimulants are used in amateur and
professional sports to enhance performance, especially in baseball, bicycling,
weightlifting, and track.
This chapter also looks at behavioral addictions such as gambling, compulsive
shopping (buying), eating disorders, hypersexuality, computer addictions, compul -
sive television viewing, and cell phone use-behaviors that cause many of the same
changes in brain chemistry that occur with drug addiction.

"It is importantto rememberthat the problem,or disease,or allergq,or brainanomalq-

whateverone calls it-is addiction, not just alcoholismor cocainism.This is whq, over the
past 45 qears,havingbeen involvedin the treatmentof more than 350,000 clients, I have
rarelqtreated anqone with just one problematicbehavioror addiction to just one drug use."
Darryl Inaba, Pharm.D., Addictions Recovery Center, Medford, OR

It is rare for an addict to use just one drug, although addicts usually have a favorite
drug of choice. Most marijuana smokers also smoke cigarettes; many cocaine abusers
have an alcohol problem; heroin addicts often use prescription opiates.

"When I got addicted to cocaine, it was becauseI was beingbatteredand I used that to hide.
When I quit cocaine, I used drinkingto hide. When I quit drinking,cigaretteskickedin. When
I quit smoking,I beganto eat. It was like I had to fill up that hole with something."
38-year-old female in recovery from multiple addictions

www.cnsproductions.com/e7vga
Addictions are not limited to psychoactive drugs. Behavioral addictions, such as com-
pulsive gambling, eating disorders, and Internet compulsions, are also common among
substance abusers. More than half of all compulsive gamblers are alcoholics. A study of
the roots of addiction and, ultimately, recovery, necessitates an examination of all
addictive substances and behaviors.

7.1
lnadditionto,timulants,d<p~nts,mdpsych<d< lics,oth<r
groupsoldrug,•lt<rU><r!l'm<ntal•ndph)"icalbal•r.c<
• Jnlw:rnt> >r<>'Olatil<liquidsor><roool,praysthatpro-
du« monyol th< ,.m, psychooctiv< dfects ••>tn<t
drug, . An,sth<tic,i>r<eir.clud«linthi,cat<gory
• Sporudrug,compri>< > >C1r
i<tyofruo tural•n d,ynth<tic
,ubswicu that >r< u,«l to l><"1injuri .. . ir.cras < p,rfor -
of c:c:,· ·h:'n:'.,"'cov<ryt'm<,or•l«rtl othl<t<~•tat<

• H.ord-to-clas,ifydrug,,uch.,•nim.alatrxts, h<rbal
pr<pn>tiom,·=n " drug,:rnddrinks, • ndnootropic,i

:t:.;:
hav< b«nuS<dforth<irpsychoact iv<<ff«ts,wha<.o,
purport<d to improv< on, , ph)-.ical :rnd m<n-
n.e .w,,wldt lj,.i-tdl" Mlo•,;«,< •l<""'' orldt, "i" I'"• """
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Inhalants
thei r cl>«ification is dilf=t from ,mollble drug, lik<
lnth,1970.,•numb<rolmu,ica l mi.sts,,uch.,EltonJohn tobacro,crack,•ndheroin . which:rn,burned:rndinh.ol«l
th< Ramon<>. >ndmE1y "punk " mu<icWl>f <>.tur«l lyrics :rnd powd<r<d drug, that •re ,non«! such a,; cocaine
nefrnendngglu , ,n iffing•ndoth<rinhalan t• bu"' "' •w•yto h)<drochloride:rnd "cry,tal"m<tlL
g<thigh•ndto,nubon,,nOS<>tsocirty , ,uch.,"lx«high
Th<near,thr<e<maingroupsofinhalana•nddo,en,of
inth<<wningmifjingpouofgl1t<"byElton Johnor
,ubgroul"'(T•bl<7 - l)
• Volati l<wlvm ts (:rnd•er050[s),•lsocall <dhydro cu-
bons . >re ,ynth,s i=l from p<trolrum •nd comb in«l
withotherch<m icals.Volatil<>0h'<nts • r<founding ln<
g>50line, • ndnoilpoli,hr<mo,u,•mongotherproduca
Som< ><ro>olsproduce•foggymi.stwhrn,pra,.,d;thcy
>r<inhaledfo,th<irga,,ou,prop<llmtsratherthanfor
Jnst••morijn•ruow .. th<drugofd<fun«forth<rounl<TCU! - th<irprimorycont<nt . lk>id<>volatilehydrocarbons
nu, in th< 19605, inhalants took on that rol< in th< 1970. other volalil< organic compound, like nt,r,; , k<tone,
,vrnthoughinhalant>buS<wup<n: <iv<da,; • lo w-cla55 (e.g .,oc<ton< ), • lrohoi.s,:rndglycol> • « • bus«l
add ictionbymostofsoci<ty • Vol>til< nitrit<,, including:nn)'l:rnd bu tylnitrit<, • ne
lnh.almtuS<:rnd>bu, , wo,th<psycOOKti,.,drugofchoie< us«lclinically••bloodV<M<Cldilator>(vosodilatcm;)for
inm ovi,sfromth,1980s:rndl990s,,uch ., 1'.irplan<l (.glu, ), h<•nprobl<m>>nd.,over -th<-count<rroomfr<>h<n<rs
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'mat rav<>OTdmc:,P"n · ,.oo · 5<m l 5tu•t'om
romput< rcl an<r ),frorandU><lthinginLllV<gosmdBlu,
V<l,~t(:nn)'ln itrit<), The&llk<tbol/Diari«(carboruocl <>.ning • Anesth<tics block !"'in or induce uncon<eiousnts,
liqu idl . •nd TheCid<r/!ou,eRuk>(<th<r ) during surgical :rnd medical proc«lur<>; theiT r«Ite •
>tionalu «a,;> d<lirimth•• • lwaysb<enuploit<d
Inhalants, •lso cla .. ifi<d Hddiri:rnts, rompriS< • wide Nitrous oxid< (N,O), •00 known ., "laughing gn; i,
vari<tyoF,ubst.onc,o:rn ddtliv,rym<thod s:volatil<liqu id , ,tillus«l•••n•nesth<tic(u,u.al lyindrnti.stry ) •ndi ,
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:: • lroho\withdryi«orh<atloinhal<th<lumu:rndg<t• impl k at<d in th< death of Michu l J:ack>on in 1009, >r<
us«lintnv<nou.s lJl

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 Other Drugs,Other Addictions 7.3

"At 15, maqbe16, I starteddoin9nitrous

, and I onlqdid it
at raves,peoplewouldbe walkJn9 aroundwitha wholebunch
of sa88in9balloons,lau9hin9,and theqwerea dollareach
and qouwouldjust90 up to peopleand saq, 'Can I buqa
balloon?'and qoujust inhalethem."
18-year-old inhalant abuser

The three main classesof inhalants

are volatile solventsand aerosols,
volatilenitrites,and anesthetics.

History
The practice of inhaling gaseous substances to get high
goes back to ancient times. There is speculation that starting
around 1400 B.C., the Greek Oracle of Delphi , who was con- In Sao Paulo square in the center of Luanda, Angola~ capital, street
sulted about many matters , from whether to go to war to childrenuse inhalants. These kids and 60 others live under a cargo
when to conceive a child , would breathe in vapors from the container and often belong to gangs. The childrenget high by sniffing
earth (naturally occurring carbon dioxide by some accounts, glue or by sucking a mix of turpentine and Valium®from rags stuffed
into their mouths. Their behavior can take a tum for the worse at any
ethylene gas or ethane by others) before uttering her prophe-
moment. They wash cars to earn money to support their drug habit
cies.2•3 Ethane is produced naturally by decaying fruits and and occasionallyto buy food.
vegetables and can produce violent trances. The ravings were
WolfgangLangenstrassen/picture-alliance/dpa/AP
Images
interpreted by the priests who attended to the current oracle.
In the Judaic world, spices, gums, herbs, and incense were
burned and inhaled during religious ceremonies , a practice
get high. 5 Nitrous oxide and the other anesthetics became
shared by other Mediterranean , African, and American Indian
popular in the United States, France, and the United Kingdom.
peoples. •
The gases were available at social events known as "gas frol-
In 1275 a Spanish chemist discovered ether; he called it ics," in bordellos, and at other gatherings. 6 There were even
"sweet vitriol, " and used it to treat a variety of illnesses as public exhibitions in the 1800s where people from the upper

well as for a substitute for alcohol. It took another 567 years
before it was used as an anesthetic in an
English hospital when removing two
tumors.
The discovery of nitrous oxide
("laughing gas") and chloroform
in the late 1700s and the rediscov-
ery of ether ushered in the mod-
em era of inhalant abuse after
experimenters and medical pro-
fessionals found that inhal-
ants could also be used to
I
middle class could inhale nitrous oxide and get high .
At the beginning of the twentieth century, when petroleum
refining created a whole new set of products-solvents, thin-
ners, and glues to name a few- more volatile substances
became available for their intoxicating or euphoric effects. In
the 1930s sniffing carbon dioxide (used to make seltzer
bubbles) was briefly popular as was sniffing gasoline .2 After
World War 11, the abuse of glue and metallic paints rose
dramatically, particularly in the midwestern United States
and Japan. The practice persists into the twenty-first century;
inhalants are reported to be responsible for 700 to 1,200
deaths each year in the United States; 8 but because medical
examiners sometimes mistake death from inhalant abuse as
suicide , suffocation, or an accident unrelated to inhalant
abuse, the actual number of deaths could be higher.

Epidemiology
Inha lants are popular because they are cheap, quick acting,
and readily available at work, at home, and on the street,
especially to children, adolescents, and the poor . Problems
This mask was used due to their use are mostly ignored.
by genteel inhalers
at O"'.)'gen
or nitrous Worldwide
oxide "revels" in the
early 1800s. Inhalant abuse remains a worldwide problem according to a
World Health Organization (WHO) report. Internationally, it
Courtesyof the Library
of Congress afflicts primarily the young, the poor, street children, recent
migrants to cities , indigenous peop les, and children exposed
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nKdinlwan t inmanyrountriesisg:uo lineb<can«iti,
widely,_ ., il, bk ' lnth,Philippines . ,ttt<tchildren•tteJ7
cim<>morelikelyton><!nh,lantslhanno ri--str«tchildren
afterthe,geoFH ." lnh>WltnKin<ighth -.t<nth -. md
twelfth -grader,ha,gener.tllygonedownbyatl<>>tSO%
since 1993." In lOD. lifet ime U><C W2S 8.9%. annual u ..
ju>tJ.8% ,, ndmonthlyu .. onlyl. ~. Adultinh>Wl tal,u,..
entrndto,tantheiTinh>lantn>< inadulth ood, uK l<55

......
.
bu t they • reonlyl .Jcim<>mor,clike lytouK•lcohol • r.donly (req~rn -~us • f~ erinh.o b.nts . •nd areno t as likelytorn g, ge
twice•slike lyto,moketobacoo. " !n50fflecountries.the
demographh , re.Jightl}-diffuent.lnlndia in h>Wlt>buser,
areal most<xdu.J,·el}-unmnried . male . 19)·e.:mo ldon •>=·
age. unemployed( ~) %) or a >tu<l<nt(38%).and h>v, middl e ~ o1Americansv.11o
IWUsed1tlty~ - 2012"
soci=onomic, <atus . •ndpoor«>eial,uppon ."
,,
Grnenlly . moreyou ngpeopletlunadu ltsabn><Cinh>lants
(Table 7-ll ;•nd•mongll - tol7 -year-olds.mor<)-Onngmrn
lhanyoungwomen•bus e, •lthoughi nth< l.!nit<d States
F<mll.leuseisslight lyhighertlunmaleuse.ln adultpopula -
cions th< numbn oF , buKn decline> by two-thirds or more
 D'n<Drug,,Othet-... 7.5

imlinh>lantsintolh< mouthorno><a~an•lru>do
wna!M"ill.ifmmeUsebyTweandAge
f~l< r<>pintory m<mbran<> to th< cm,t ic df«a of th<><
,ubstancn.lnh>bnaddivudangaou,amountso/pr, .. ur,
Gue.>hotpcli,h.or-.. intoth,lung,andC2Itc•u"'th<tisru,tofreue as the,ub-
Gi>olin,o,.iurlu<I

---
:;;::,=Aq=·:::U:r::.n~':~ro;:~~i~~~:~
~W~ .or°'"'"'t pro,idegratrontrolo,utheint<Mityandth<dur.ttionof
theeffec15,particul•rlybecan><thedrug,•reso,hortacting
O!t,eroero,ol,orq;
VolatileSolvents
~pse>~ propone)

Ethnically, use i, highest >mong Ameri= Jruli•ns (0 .7%),
mixed nee (0.6%), :and Whit<• (0 .2%) and lowest among
Asi>ns md Ba<:k,i." In term, ol tr<>tment, howevu, '18% of
tho« admiu«I fOT!nh>Wlt •bus< w<r< Whit<, lJ.J% were
Hi,panic.'i%wer<Am<ricanlndim1Alllk1N•tive . and9 .9%
,..,,., Black .''" ' Thi, , tali>tic reAecl5 th< >V>.ilobilityof <rut-
ment 'n50mecommun'f,srath<Tthonrdled ctu• lus e
-~~:~:;ti:~::J~'!"C:."'Jp:"m
·
Th<S<inhalants •re moslly carbon- :and hydrocarbon-1>2s<d
rompound,th> t •re volatile (tum to gas) at room t<mpaa-
tur<e. They include ,uch common materials"' g,.50lin< •nd
gnolin< aclditi>"<,, butane. k<ro,.rne , paints (<>ped•lly
m<l2llic paints). air du,t= . paint thinners, locqu<f'.5, ruoil
polish remov<T. ,pot removen , glues and pllltic cement,,
lightuAu id,md•wrietyoherosol,

Methods of Inhalation Volatil,soh"<nts>r<quickacting;they•reabooTbed intoth<

blood •lmost immediately aft<r inhalation •nd within onen
• Sniffing the inhalant dirtttly from the container to lO!ittOndsmov, to t he h<art,liv<r . bain . andother
throughthenos,isverycommon ti .. un.Solven,.•reexh>l«l bythe lun g,,cauoing•t<lltal<
• Huffinginvolvcsbr<eathingthrough a so[-,nt odorthotr<m>insonth<brath;ultim ,uely . 50m<ofthedrug
soakedfabricstuffedagainstthemouth , nose,or isexcr<t<dbythekidney, ."So h"<ntslik<toluene• l"'•ff«t
both{hujftrisalsoatermforanyi n halantabuser thebr.tin'sacldictionpothway. "
regard lcssoftherout<isused)
• "B•ggi ng "describrsinhalingfumcsfromsubsta nce
Theinitiol,fferuofvobtilesolven,. includet<mJ>OT2I"f
soaked material that is plac<,d in a P"I"' or plas
ticbag(rebr<e a thing1heexhaledairin1<nsifics1he '1imulatlon , • nd,v;at<dmood,andKducedinhibitions
effect) lmpul,iv!ty,<>1cit<m<nt . and irriubility >r<>l50,-,-ident,but
,oonth<d<p=•ive,ffectstok<ov,r , au,ingdW:in«•
• Spr.oyingtheinhalantdirecllyintothenoseor ,l u rKd ,pe,ch . •n unstndy gait . •n d drow,in«•- Two
mouthis a dangerousmethodofust
oth<r,ymptom,>t<impoiredjudgm<nl>ndmincI<C>S<druk
• "Bailoons •ndcracktt,;"dcscr ibcs inhalin gfromabal of falling or fainting
loon filled with nitrous oxide or other gas ("crac k
,rs • refers tothepinsorother "crac k ing " devices Highdo,;ag<•ndhighindividwtlrnoceptibility=ultin
ustdtopunctur<thegascanisters) mojOTcrntr•ln<rvon,'}'Ot<m{CNS)p,ych<delicdfects:ill u-
•ions, halluciruitlons, •n d delu,ion ,. Th< abns<r might
• Inhaling v:aporiud •lrohol furn<> is the newest <><p<ritne<• dr<amyOluporrulminatingin••hortperiodol
methodofinha lin gakohoL This in,o lvcshuling sl«p . The e/fect,r,.,mbl< •lroholo ,..,Wltiveintoxi cation
a lcoho l to allow the ,·apors tobe inhaled directly (inh>Wlt>bn><h>oberncall«l•"quickdru nk ").T h<into x-
!~::~~.:!!~
[~~r
1

a koholicbeve r.og,can
:~~=:~~~:i;~
~~~i~:.
ga lsohepouredoverdryice
·cat<d st.ot<, 1"1 'om m ' nut<, to m '
d<p<ndingonthekindrndthequmtityofth,solventinho
or mor<,
l«l
a,;well••thel,ngthofapo, ure . He>Wlch<>• ndru,us,•may
toform, a pors
followHpartol•n inh>lmth>ngov<r.
There•reoth<r,l<S>commonformoo/us,
• Spaying•n=linto •ba g,puttingth<bogov<r
ontShnd,•ndinlwing
• Pouringor,prayinginholantsontoclothinj;(ruff,,
,luvu,orcollan)>ndthen,niffingthefum<>ov<r•
p<riodoftim<is • noth<r.
Som,u,ersh<>t50lven,.torruoketh<mmor<volatile . • par-
ticub.rlydanguouspr.tcticeth> t h>or<,ult«lin,xploo.ion,,
bum,,andd<>.lhs . Di=: llybre •thing•nd•pr.ty!ngpr<Mur•
>
"'.l,til e :"'M!.nlinhalant.•_in~.i•!lycau.., ..
mmulabonand[....,eredmh,brtJon., but that
1
"°""tum• mlo depr<!S.SM! effect5 along wrth
d1zzmes.,.iurredspeech,andanunsteadygart.
Aft<rprolong<dinhalation,ddiriumwithronfu,ion,p•y-
chomotor dumsin< .. , emotioruil instability, imp•irci
thinking, andcom.o haveb«nrq,orted . The«n<nro logical
df,rufromlow -!<V<l,chronic , rndhigh -levd (ocut<)<xpo-
•ur<tovolatilesolvmts>r<U>uo llyr,ver,ib le. • lthough dan -
guou,rndf at21roM<qnence,can=ultfrominiti•lmd
high-dM<inh.alotion
• Hn.~t. •n d =l•r pr~~=».;, ~rrhi:i:miH and dmyo-

induce cardix •rrut. Thi, condition. cau«d by ctru in

inh>lmts'effect.sonthehe.on'swiring,ffWC<,r<,u!iCita -
tiondifficult a ndi,knmoma,;",uddm,niffingdeath
,yndrome. " hcrnb<cauS<dbytheFrron • orother
h.alogenat«lhydrocarbom . bygasoline,rndbynitril<>
amongoth<n
• Lungprobltms. Solvmtscancau«pulmom.ryhyp<,,.
t~uion , =pi,.. t ory distu,, , and loweru! bra.thing
capac ity UITi«ltoextr<m<> . asphyJrulandr<•pintory
amestduetoocclu,ion(lungblock>.g<)•r<J>OMib l<
• Uverprob lem,.Chronicexpoour<to!iOh'<ntowillcau.,
!iOm< liv<rtorici tyrndsui-qu,ntcbm.og< . whichi, Tlu.,colottdJDX -,.,.(/wn!Yl,-.,.)i,,ijWd 1t<1,ijo""'l<J""<ffl'
u,ually=Bible;how,ver,concurr=th<>.vydrinking ,..,.,.,,h,,,,,,l<olm"""""pu!""""'ry,lj.,..,(cOPD),a, __
r,:;.\Cfincr<ll<sinh> lmt-inducedh<p>totoxicity(toxic iUo«>of"'"'"'"""'l!..Aolo"'""""'"'"..i"""1t",of•I"""'""'
""""""'-'>"'l"""'-'l ..: ludtall«»Jwll<ttl•l" '' l!ll.la-i<""""""
ofm•"",Olld ""'~"'" ,ijbttotll. tt.uo..,,..,.,;,,..,..,,.,, ...~ltpix,,
• Blood problems. A !i0lvent like m<thyl<n< chloride
incr=cuboxyh<moglobininth,cin:ubtory•y,t<m c......,....
__ ,,,,,,.,,
a!,q,oaliiy<ooo!<o, .. s,<,\i.<d<><<1><

oftmc•u<ingbnrincbmag<
• Nron • t21 probl em , . Volatile !i0lvml5 ,uch as tolu -
,n,h>,.,b<,n,howntocou.,growthr<tardo tion,odd
facial f<>.tur<,, rnd tr<mon in newborn ,.' It i, ,..., that•
pr<gruonthuf!eru=inh>bntoudu,iv<o/,!iO>nyf,'21 rontrolone'sb<h.o,ior ."Chro nic •buseofto lu,ne canr<sult
cbm.og, couldalsob<•ttribut<dto • bu•ing• lcoholor indemen ti•. •pas ticmov<mmto . •ndoth<rdy,function,of
•noth<r,ubstanceand/ortothelif,otyl<ofth,u.,, - thebrain . Ocrupotionalexpo,ur<totolu<neha,notpro-
::::~~':.,;'n,!nf«tions,dom<>ticvio l<nc<.• ndg<n<tic du~thes<<f!ecto,probablyduetotheu,eo/prot<cti>'<
,qu ipm<n l

Long-TermEffed!i AnAustr:1 lianotudyu,ingdif!u,iontmsor!maginglound

signific:ant•bnonruolitiesinth<whit<matt<roflladol<«:<nl
Chronicinlllllant•buo,i,ch.oract<rindbyalackofcooo-
inhalan t u.,,., brain,, pu tiru i>rly ariy-onset u"" · Whit<
d'n•t'on,•n½'"" t ttoconc,ntratt . w<>kn<•• ·d ' · ta-
matter • bnonruoliti<>m.oyh<th<cau.,oflong -t<rm b<h>v-
tion,:andw<ightlos,.Soh '<ntoafl'«tth<hippoca mpus (•
ioral•ndm<nto l h<•lthproblem,.,,n in individu•lswho
memoryc<nt<r ·nth< bnrin),!iO long t<rm u., ' mpa'n m<m•
r<poTt«llong -t<nninh.alrnt•bu.,_Th,oontro l group
ory.''-'' Chronic •bu., can invoh'< cbng<TOuoiyhigh body
roncentr:1t'omofthe,ub e,>0m<t'm<>thousand,of :~c!~ =~~::i:::~~d th< drug n>h'< control group
time,h igherthan indu,tri> l ,xpo<ur<,whichc:anproduce
irr<V<CBib le tntnt21 •ndn<nrological datn1.g,,thoughth< Complicatiommoyr<,ultfromth,,f!ectofth<!iOIV<nlor
d•tn1.j!<d0<>not pro grnsonceu0<hasstoppcd.Magn<1ic oth<rtoJ<icingr<diento,such»l<ad inga,oline . lnjuri<0to

:i;~::~:.::~i:r:~=
~~;:~":!~gv~~::~ thebr.lin . liver,kidney, . bonemarro w.and particubrlyth<
lungomayr <>ultfromh <>.vyexpo,ureo r ti>r«ultofindi -
><V<r> l >rtt>thot tr:1nslot<dtolowl<velsoFg,ner.llinttl - vidualhyp,nenslt iv!ty.Bloodirr<gut.riti«rndchroma,om,
ltttuolfunctioning.p•nicularl ythosei nvol>ing workini; dnnogeca n•l>or<>ul 1. Chronic•bw.eof,omeo/th<0<so! -
memory andex<e11 tiverognitivefunctions,whichindude vrnl5canproduc<ulcer, • round1h,no,erndmouthHwdl
theinobilitytolocu, a llmtion . plrn,solveprobl<m5,rnd H c:ancerou,growth,. '
 D'n<Drug,,Othet-... 1.1

. , .. h,.uoundthene>< >ndmouth
• mmors "
• •hort-l<Tmm<mory!OM
• =otion.alinsubility
• cogniti,.,imp•irmrnl
• slow. thick.orslurrrd,peech
• •'-"gg<ringg:ait
• dOOri<nt.otion • nd•lackofcoordinotion(intoxication)
• headache,,

PsythiatricE!fects
AstudybytheN •ti oruol EpidemiologicSurveyonAlcohol•nd
RelatedConditionslound•veryhighr:,t<ofpsychiatricdi<-
orders•monginhaiant • busersintheUnit<dSUte> ; 70%of
,u,.,..yciinh•l>nt•b=metthecrit<ri.oforon<ormore
liF<timemood .mx i<ty,orp,rrson.alitydisordersandabout
h.alfthotpercn,12g<<Xp<Ti<ncci•moodor•nxi<tydi!i0rder
in th<pli t yttr ." Becauseinhaiant•busen •re likelyto • bu><

=~=
MajorVolati le So!venl!i
othudrug,.i1i>difficul11od<t<rminewhich,ubot>nc<H

=~~:~::.
i;h~"!',~=~~t
•.~::::: ~':o!~o !~~
~?;r:'':.i':,!:~i..~.:~:=
::•~,:;:,:
invol>ing3,400differen t inhal>ntproduct>.Propelianl5,
lik<lyto<ng:,geinself-de,tructive , ,uicicb l.mdh omicidal
gasoline.andpaintweretheme>lrommonproducl5report<d;
h<havior."Amorerecen tstudyronfirm,•two foldincreose
buton e,propon< . •nd>irfr«h<n<Bhodth<high<>tfa t.olity
!n conductdOOtdenamongrerov eri nginhalantabu «rs. »
r>.l<>.'" G•<0linewastheinhalantma,1u,edbyyoungchil -
G•rl.ond. Perron,•ndHow:,rdpubli,hedfinding,inth< dren . •nd propellants were me>l oftm u,,d by oldu children
JournaloJP,ycl,ow:1h~Dni.x, from • studyofinh.alrnt • bu><n
Ol>juve n il< offenders facility in Missouri•nd loundtha t :~:;:::;.,o~~i.a:,~::;::;~,:n;;l~ im1>hing

I
inhaiantabn><nhavehigherleveloof • nxi<ty•nddepr,s,;iv<

>
symptom> . ,howmoreimpu l,iveandf<.:trl,s,;t<m?<T>m<nl5,
reportmor<J>3'l •y•ar • nti>oci•lh<ha, ior.di> playmore,u i- Th•=••-wl"'-w.••"."•<lc~•.
tnchloroethylen e (TCE),N-heur.e,Freon, •
·c1a1 1rndm "••. •u n 1oretn.umat'cexpe "ence,s,>nd
alk.anes,alcohol5,ar,dg.,.ohnt!
~l:\~::f;_': , ubo12nce •bu« problem, Ihm other jm'< •

Toluono (,....i.,t MnHM) Xvenl studi<> •ugg<>t that tolu<n<

WarningSign,a/Solvt!n t Abuse hasmextremelyhigh•busepot<nWll. " ltisthemost •l,u,., d
Diagnostic cr!t<ri.o for inhalant intoxication in DSM-5; !iOlv<ntb<calll<Citis foundin<0mony,uhstoncn:gln<>,
,ymptom>dcvdopingduringor,hortly•l«rinh.alrntn><or drying:,g<nl5,!i0lv<nts.thinners . points. inks,mdcl<2Illng
<llJ>O'Ur<:
" ogrnts . Thi>highlylipid-!i0 luh!e,ubstoncei>r<adily•bsorh«l
• diuir><M •ndroncmtr:otedbyth< lipid-richlung,.li>'u.h <.:tn,and
• Il)'<l>gmu,(involunuryeyemov<mmt) bnin . Shortly•ft<r•u.serinhale,sto lume .thecon=tn.tionin
• lackofcoordinotion th<bninC2I1b<IOtim<>gre.ot<rthannornulbloodlev,l5. "
• •lurrrd,peech Chronic • bu>< can • ff<ctbalme< . h<21"lng.andeyesight•nd
• um"'-dyg•it oft<ncau«•prob l<m>withneurologic•lfunctions•ndcog -
• l<thaTJ!Y nitive•biliti« . lnon e >1udy6 5%of chron ic • bu><rooftolu -
• d,pressedt<Cfi<>«• m< from <pny paint had neurologi cal damage. which
• rsy chomoto rm.,.n:btion trm,Loted to cognitive dy<function .'·'" H<avy • busec•n
• <r<mor r<>ult in mid=g< h<.:tring loso. d,.J,.... , tr<mbling, demen -
• gmaaliz edmu,clewe>kn,.. tia. and change, to the whit< molt<r of th< CNS. •Tu .. ,hoe -
• blurr<dvi,ionordiplop ia( doublevision) •hin e," • •hoe-,hining ,pr.ty cont>ining to luen,, H wide ly
• >lupororcoma
• euphoria ;:;,: !~:n:f:::,;nited State,_ Kidney di>orden

Exl<m.llsign,tohe lpidentifyoomror.ewhoi>chronically __,,.,...,,. T CEi>•commono'&"nic<0h'<nt • nd•n

•bu•inginh.alrnts ingmli<nl in cor=:tion fluids. poinl5, antifreeze, metal
• chemicalodoronthebody•ndthecloth<, degrea«rs . •nd,pot=n=s;it >lilio u«dtoextr>.etoiloand
• ml,gWOy,orW:1t<ryey,.•nddil.otedpupilo f.otsfrom,..,g,ubleproducts. Atonetim<itwun><d.,•n
• inflamedn<>« • ndno,eb l«ds me>th<ticd,.pi1< itsd.ngeroussid eeffecl5.0ccupatio<Wl y,
~;:• .:.':'o~h!,m~::~,'::!n::.::~;."' •=~:~~
- AkohokEthanol , m<thanol,andiwpmpanol•reth<most
commonly ahu>ro alcohol oolvents.Ju<tinh>lingd«ply

:~k,=~::o:i;.: :::;1~,:",."':;~~E~;
lor'50y<2!'5>nd•re•imilutothos,oftolu,n,_Th<,ffec1>0/
i::,:,:i:; lrom•bnndy,nift< r c•ngiv<!iOmrone a buu . Wh<ninh>led
toodeq,lyandlortoolong. • lcohobcancans,•mildhigh
alongwithnaus ,.. _vertigo . wakn,..,,.,,miting . h...daches
lowtomodu:ot<do.,.o/ T CE=grnu:ollyr,,. ·er,;ibl<,but>t and •bdomi nal cra mping . lsopropanol. found in paints
highudOS<>, .. riousn,uropathi<>( >nydOOrdu•ffectingth< rubbing >lcohol,formaldehyd<.•ndp<rfnm,.cmindu ce
CNS)ocrur;!iOm<canbepmrum<nt .' TCEi•p • rtirularly «ver<CNSdqm,.,ion. ' A,m,ntioned,neww , y,tovapor -
toxictoth<liv<r;lt<a<poonofth<,nh<tanc<cancau., in• lroho l•re,xpand ingthi,m<thodo/us,
pot<nti•llyfatallivunecrosio(dathofth,IH<u<)
volatile Nitrites
!Mlexane and Mothyl llulyl Kelona(MBK) N-h<X2I1<io us«I., T h<firstol1h<nitrit<>,am)'lnitri1<.w...di<eovuedinl8 37
> !i0lvrntforgluumdodhe,iv<> . ... • dilurn1lorpa<ticsmd andw..usedtor<li<>'<>ngina(h<artpain,) . Th,,ubsunce,
rubb<r,andintheproductionofWI>in,u<dproduc1> . ).\<1hyl known.,•liphaticn itritesor•lkylnitrit<>canb<modewith
buty!k<ton,i,u.,d u •paintthinnu • nd > !iOh'<ntford~ anycon,.,n i<nt o'l!"nicchemical,,oth<familyofnitrit<,
Thme • r<nulll<l'Ousr<poruofboth,ub,tancucau,ing expanded to includ e ioo•myl, butyl, ioobutyl, ioopropyl,
b,._in dam•g< from occupation•! expo,ur<e u well H From andmostrettntlycyclohvcylnitrit<•.R<mictiono<Xiston
d,rt,n•t<ncr<afm.lus, . R<co,.,ty ·n=r<ecao<•can
>llbu t cydoh<J<)'lnitrit<
tak< u long••thrtty<>.B
Thu<einhalantsdilat<bloodvus,l,. a llowlngth<h<artand
Clllorofl-• (f<Hft ' ) Thes< Oij!anic compounds W<f<
oncewidelyus«1 ... ,.,friger:m1>.prop< lLm1>. md!i0lv<nl5 ~~,!:;~;;i;•;i.: l~~::::~u,.:;;oi:,7;;\~:' ::::;.
but>r<b<ingphas,doutb<c:au5'th<ycontribut<too:ron< :::•-Bloodp~ur< ra:esti:ilow<>tdpo~'\nJO.,cond,
depl<tion . Manyton< >r<<till • ronndinold<rr<frig,r>tof'.'5 1
andothu equ ipm<n l >ndwill <V<ntu.ally <>e:ap<into th< tim<>ca lled "popp,n " b<cau,e a myl nitril< ,....fonnerly
>tmosphrn,.butocc"5il>ilityforinh>lant•bu« is limited packagedinglaM cap,nl<>wr:1ppedincotton.andth,ybrok<
op,nedwith•n•ud iblepop. ' &.ide,contro llin gang!na
AluftnTh<ma,tcommon>lkane,includem<1h2n< . <1h-
am)' ln itrit<isusedtotr<e>tcyanid<poi>oning
>n<,bntan<,andpropan<.Th<laI)!<Tmo lecu luofthiocla"
indud,hexan,mdp<ntmemdar<v<ryn<nrotoxic . Th<
"A""llnitrit<,'l""crocl· , .... ;,,1,,,1,',IW..anJ'l""ar<oif
,1ru1ll<rmoleculeso l thi,cla55ofhydroc2Ibon,b<com<gas,•
atroomt<mp,ntur<•nd • r<inhaledforth<ir,ffects . S<V<r<
• rrhythmW •nd ,ud -
~!:·i~t::"L::j~\::,;1
t.t::~:«L
=:.-:- ~:~1=1~:~:!:tJ,
:~~ : '.~~:"equ<nc<> includ,cardix 00

~.·~

c.,..,_Sniffing go,oline, esp<cially common among wl- """"'"t>.

i,:rlfri,ndsio ;,,~,..,r., ,,,,1~"""IJ""81>1,,,
vent•bn0<rsonA · lnd':mruavat"
variou,compon<ntsmdadditi,.,.ofgasolin<intoth<car
ns,"ntroduce,

dio,cosculor. nuvou,, and r,sp iratoty,y,t<ms , including

- ...-..-.,......,..,_..,
.,.,..._..,""""' .
tl,,,,,p,n<,uio"""'"'/'«I>.

euphoria -produdng!i0lvrnt,(e,p<ei:allytolu,neandb<n -
zen<),m <1at.,•ndch<m icals. Effecl5indudeirnomn i• . 1r<m-
or,, mor,xi:a, md !i0m<time, paralf'H ." JI l,..d<d ga, i,
inhaled,,ymp toms can a lsoindudehallucinotiono,convul -
•iono . •ndthechronicirr<v<nibl,,ffectsoll,adpoOOning
(br>in,liver ,kidn<y . bon<m>rm"smdlungdamag<) . Th<

:::~ '!i~n~:';.;:;;;n•~• 1:,~ ~:::~~",:-~~::::

halfoFallinhala:ntd<>th••"'duetop!i0lin,. '' Worldwid<
go,olinei,thema,tr<adily availab le •ndth<rrloreth<most
~u,ntlyinhal~d .subotanc<;it isc~<aploacquir,c,md
15

AI01l,i!t l<'14,< 4 <,_,i<o l,i.i«<0ll<d._,..._ • .,..4i1,1,1,fo,

...,_, 110 <"'~ - lllt,.;.,1, on r11<1tf1
, onr.:1<;i
!OOM!
y/ oi1ri" , " /u,~
1,-111,g ol. llltl• >Utt; oo<M t ltlu , « ill<4ll<dllu;l,_"''"4o!
<y<lo,\,,;,ryl
ol"i"ond~l • ll<i<tWo,< ofi,. ,dd ,,;4
d,a• l•t flv.l<I
 D'n<Drug,,Othet-... 7.9

lnh.w.tiond,liv=•Fttlingoffulln< .. inth<h<ad.•rush, Ab110<continu<> tod.ay by )-Cung up<rim<nl<" who 110<

hove -rt<d
mild <nphori>.. di.uin<SS. and giddin< ... Fi,,;t-tim< ab=
<><p<rirncingpanic attock>. M th< dfrca wur
off,th<usumightap<rirnc< • -h<,ruoUS<a.vomi ting,
nitrous at rav< and dmc, prn i<>. Some profr .. io1U.ls-
panirulorlyd<nlists . doctOTS. rn<sth <siologi,a. • ndho,piLal
•ndh<aithc>r<work,,.._bus<nitrouso xid,.ba lothrn<,
md • drill a~ by th< dil•tion of blood ,.,..,i.
undu th< •ndoth<r•n<>th< tics ,u ch ., <ther. <thylrn<.<th)·lchlorid<,
,kin.E=Miv<obus,eanau..coxyg,nd<priwtion,fainting md cyclopropan<. " Other an<>th<tics ,uch., pro polol,
OTpusingou~andt<mponry.,phyxiation.Nitrit<abus<n PCP. md kw.min<"" injec ted or ing<>t<d. n.th<r than
bav< • highulif<tim<indd,nceo/headinjuri<>du<tolh<Wl.s inbaled.rndar, • lso•bus<d
they ,uffu .rt<, passing out ." Th< inl<n>< incr= in hun
r>t<>ndpa lpitationsC2I1mak<nitrit<inh.w.tionut=ndy NitrousOxide(N,0)
unpl<2Sant. Fi,,;t aidfo rth<r<>ultingh <adoch,sinclud,s Nitrous oxide W"-' !im ,ynth,siud in 177l by English
•bs tinrnc , _Ov,r&,.,tratm<ntm;iu i=mnovi ngth< abu ,u chemiotDr.J05<phPri<stl,y.Tw<nty -two~a:r,lat<r.Thomas
from apo,ur< md rn,uring that =pintion •nd blood 0ow B«ldo,s and <ngin<u Jam<> W,tt pub lished Co,uidmztiom
•r<moinuin«l . Occasionolly,C2IdiopulmonOiy=u•dtotion on!h<M<dical Vstan.don th<Pm:iucrioneffa£t~io"'Ain
l.s~ . Chron ic •bw<aUS<>m<th<moglobin<IIWl,•condi - (17-H),whichd=rih<dmedic• l= lornitrou ,oxid,,
tionlha tmloce,th<blood's•bilityto e2rryoxygrn includingtuh<rrulo,i , .ndotherlungdis.ea""'(butnot•nes-
Nitrit<,,thoughtto<nh2n<<s,xualactivity.•r<us,dby th<>la) . Th<•=th<tk•nd<uphoric,ffectswm,not<d= -
som<.<>p<d .allyg•ymrn,fOTth<<nphoric a ndph)'siologic • I u;al yan Luu b)' physician Sir Humphry Davy.H< d<>eribed
dF«ts . whkh includ,,-,ln , tionofsmoothmusc le,,u ch u hl.sr«rtttionolu.,ofth<g....,•"pl=urabl,thrillinginth<
th,,phinct<rmuoc le.Nitrit<>aisobringth<usutothepoint ch<>t • ndut=niti<>•longwith•uditorymd,-1.sualdistor -
olpa .. ingout,anothud<>ir>bl<,ffect ." R<p<at<dabus,ma,· tiono." ltv.-..•noth<r+'l)-Uf'.5bdoI<nitrousoxidewaslint
•lt<rbloodc<l l.s•ndimpai rth<immun,,y ,t<m. incrasing usedlormedia! a n,,aJ,..i,during a d,nulprocedut<C>nd
1 mothu 31', , b, ' "' ·au"" b,rc•m< rommon ,rice ...
:~:;: ii~!ri:~~ ~::r:~:r-:~~1:::;1~~i::~t~ In 1869 th, go, wo,rommrn:lally u,ed to ,ff=• or ><n.t<
•lsoronv<rtedtonitrosomin<>inth<body . whkhm,pot<nt drink> ." Medie2lly.nitrousisotill~mostoftrnb)·drn -
ancn-au5ng' i \,. ,. tl.sl5;th<pain -numbingdF<cts•r<shonocting.soth<g:,<
W.aming, bav<h<<nis<uedciti ngth<d • nga.o fusi ngpop- must h< delivered rontinuously during or>! ,urg,ry •nd
p<B, Vi•gr.,.,• an d m<tbamph ,wni n< in combination oth<rdenulprocedur<>.lnth<op,ratingroom .n itrou,o xid<
(som<tim,,;~atrav,dubs•ndg:,)·bathhou,u)btaus, ls ol~<n. ~d t?, ini::« •n<<th<m b,/or, • stronger
thefirsttwo,ubstanc<>lowabloodpr=ur<>ndth,combi -
ruotionolailthr<,drug,anau.,faintingorevrnd <ath. '" Th,ravemdpartyscrnethatb<g:,n inth<l990of<Vived
Tola>n«d<V<lop,r>pidlytoth, ,ff,ctsofni trite, in t<T<>tinnitrou,oxid,.principallyh<e2u""ofitsdramatic
n pidons<t a nd,quillyr.1piddis,olutionofd<,ired,ffects
lnoddition .N ,Oi,,.idtornhan«th<<ffect,of<e,ta>y.th<
mostv.-.ll -knownclubdrug
Th, most common ly •b~ lorm of N,O i., th, ,moll pru-
•nriud metil or pl.a<tic cani,t<r intrnd<d fOThom, 110<to
charg<whipp<d -crambou l<>. Th,.,Whip-11' " OTEZWhip •
: tri c,,am)'l 1 "tri "npan "cuLu,r ,,w,<to' ·when a nridge, ar,,o ld inbou,ol10.ll.orliloubuut'50crna
fruh but• wet-dog or <poiled-baruona >m<ll wh<n ,al<. Amyl <ach . Th,anridg<>oo ntain N,Ound<rgr<Upr<S<unc,•nd
nitrit<is aVllil.ableonlybypr<><ription;•nd • lthoughbutyl th,n.pidvoporiutionoFth<ga.scaus,,tis,u,inth,mouth
mdpropylnitrit<>wer<bo.nnedinth ,U nit<dS Lat<>. w rirna n00<. andlung,tofn,euiFinhil,dd ir«t lyfromth<sonn:<
olth<><lo rmu l.ations>r<<tilloo ld .., roomodori: <f'.5,>nd ron Lain<r. To•vo idth< tis<u,dunog,,u.,,..punctur<th <
,ho,dan<TS( Tabl,7 - l).Stmet,upp li<Softh,drugcom< ron tain<rwith a pinorcnckingd<Vice,infb.t<•billoonwith
fromdiv,nedl,g:,lsourcrsor>T<C<muggl<dfromotharoun - th,ga.s . •ndinh•l•thenitrousfromth,balloon . l.arg<rom -
tri<>. T.. o-third,ofnitrit<abu.,,...admittou,i ng at lust m<rciiltanksn,al,odiv,ttedfromm<die2l,drnul.and
thrttotherinlwana.ont-third•bu0<alrohol,andon<- b•king,mpplimfor • bust(thry•r<paintedblu,rnd•r<
thirdaioo•bus,otherdrug,. " alled"b lu ,nun,")
Nitrou,oxid<is•bus<dforiamood-ilt<ring,ff«a . V>'ithin
Anesthetics
~ghttol0,econd;olinh.ringfrom•balloon.th<l!"PID-
Atth ,<ndolth<<igh tttnthcrntury,newlydi=, -.rulvo lui l<
,ubsWlc<>w<r<foundtohav<<nphoric u v.-.ll u •n«th<tk
• dillin<<S,giddi.n<<S . anddisorirntation.oft<n • ccom -
dF«a . Exp,rim<ntotionb<pnwith,uch,ubston<:<>..,chlo-
paniedby,illylo ught<r
rnform . <th<r. oxygrn . •ndnitrou,oxid,.Ahw<ofnitrou,
oxi.d< (inh>ling•nddrinking) • mongH.arv:ordm<diatlstu - • • throb bingorpu l.s.atingb uuinginth,,an
drnt,v.-..r,poned ._.f.arboc k u th<nin<t«nth«ntury . vi,u.alhilludruitions
 n~r!IJOE•ili<kpt""lry
J.N Wl<t<lif~ri,ltJU,ing
~&<ycP=np<ionfu,
S<ok!ll'lgW,v«,.....,,, ., ,1,,
""'of "l""t'°'l!ia<"
(lllc"""o.nd,Jwqvi«W
""'"lwjf<_!o "'..ti'.i;U
,..,..,..,d"'""''°""l/yoe
"""""""~!<;
.,,.,,..,. ..... u, .,,,a1ea,.....
'-------=====-------'
"ld8"m,d ,oo/.,,J'"'ll,,.,,/P"t...,..Jd,,"tb,tl,,r,ondj!
""'"td.'tb,tl,,,,fo,"-'Utj"""'nd lt=IJ!>tp ,; it""'"ld
b,;,.adm. , tl,,11Jld,1in1<;'f""OI<W>:1bl,toconc, ntm!<
Youliadto,liak,aoff"'"""<thinfr;it ;<stdi<lnt8"""""1.

Am:rnt<1udyatlh,Univ<nityo/Chicogoof36f<mal<>md
7lmal<>foundno,ignificantdiff=ceinth<ir,ubj<c tfre
r<>pc,r=stonitrou,oxideev<nlhoughmxi<>usuollyoutnum -
berl<mxieu«ninm)·gi,-.npopub.tionb)'•ntioof)tol ."'
Continuous long-t<rmapo,ure canc aus,e c,cntnl and
• ronfusionandhn dache
peripheralner.-ec,cllandbnincdl damogeduetoalackof
• •sensetha t oneis•bouttorolla~orpassout suffici<ntm cyg<nh<cau,eN,Orq,lac<>oxygrnintheblood
• imp•ired m otOT Wlb and fxint ing that can r«ul t in For this r<easondentists co-adm inister N,O and mcyg<n while
tr:1umo1· ·; '<>•uch .. abrok<nnos e orum trutingapat irntandcontinu,theoxygenfor•fewminut<,
aftertrn<rnrnltocompl<tdycla rt hega,lromth e blood

-~h,;~J:L=::':~~:.!='::"
l,,,ol'f""'foll.Th«,p,op/,[ oitroo,.,,,,],..,.IJ
"M,and'"'lf,i,.d""nt""o..trowbi"!i'tl,at"""t""
fo,~ltabootthr«"",l;,-W,liad,p,ntm'IBO!ucb,<><h
~t,,oll'Ihit ti,, 8"."""'
fa« ~"land fo,a P'""" wlia onju<toitrow, doin~l,JOOrn ,.. !<uo~.onddidtl,,,1
~6f«ttall.tl,,;t,a~f./1W,l,,,,,,o ,...,b,, of fo,aboottl,,,,...,,l;,-ond,,,,,,;..:,tl,,•r,,l,,,d.l"""'
!.-ok,o"""'ondbrcknt<,tl..ond11J< '-"'"lda!..,I" l,,,!a..c,proN,,.,·
~ito tl,,m.'Ha"'f""~do,:"8,,;trowo:tid,>
O...oo.""·""· ""·""··
Symplmmoflong -l<nn<xpo,ure to N,O include to.. ofba~
antt• nddexl<ri ty. ovaallwnkness, • ndnum bn .. ,inthe
Tht><fedingsquicklyc<a><wh<nth<g:,•le»nlhebody umsandthe leg,:1hereisa1>-o a , igni6c • ntpotrnti•lof
The maximum ,ffect i.,,.
only tw o or three mi nute• .,i,:ure,,cardWCarrhythmias,and .. phyxialeadi ngtocen-
though,xperi<ncedus,n., emtol«lph)-.i calef!ects!iOme - tnlo,-periphenlnerv,<Wrulg,or death.N,rveda~•cm
what longer than do no,ice u,en; this i,; p<>mbly • fonn of occur en nwh entherei , ,ufficientoxyg<n.N,O • bu,ecm
rn-.= toler:mce, wher<el,s,; md lus gas i,; n«ded to pro- l~tophy,icxidepend ence inoomeu«nandmaddiction
duce the <ame effects . Cogn itiv, functioning i, diminiolted Formanyd<nti<llandannthniologi , ll.A lthoughN,Oi ,
d uringth<pe a koFthehighbutmumstononnal wi thin no 1 cl .. ,ified•••con1rolled ,ub5tmce, posse5Sionwith
five min ut,.. Uu<ro more <><l<miv,ly.im?1,imi thinking can int<nltou,ethega,foro1herthonmedical.d<nul,orcom -
Wtromider • blylonger. merc· 1pu~· •mt ' 1 nor· moo1,u«s
 D'n<Drug,,Othet-...

tong-termu..,ofnilrou•wtidecan Sportsand Drugs

cau.., wmulative damage to central and
peript-alnervecellsdueto1 lackol Introduction
sufficientoxygentothebrain.
The twomodem-day ,porufi gunc,whoexemplifyth<prob-
l<ms u,ociat«lwit ht h<ahn>< ol p,rlorm:mc:<c-<nh>ndng
Halothane drugo•ndthe,ubs<qu<n t lo55 ol publictru>l a ncb..,l,aU
Fi,,.tsynth<>iml inl9 31. h•lotlan<is • p=<:ription •urgic •I •t>rAl , xRodrigue,•ndcycli>tt..n«Annstrong.hw a,;no t
an<Sth<ticg,,•"'ldund<rth<trad<nom<Fluoth>n, .• lnth< justth < •ctua l u,,of,t<roids•ndoth< r dru g, to enh>ne<
W<>l it ha,; b<,n most ly rrplx«l with S<Vollur.m< •ntl their a thl<ticp,rlormonceolh>t • li<ruot<dth<publicci 1v.-.,
d<SOur:an<,buti t i,i u.,d ind , vdopingrountri<S•ntlin th elo ngstringof<kni•ls , outrig htli .. ,:mdinvolv<mtn t of
v,taln ,uyprottduu,b<nu11<CoFitslowucost . ltsdT<cts llUilyothuron,pirotorstoh ideth e truth • ndth e dnir<to
•r<<xlnemdyr:,pid a ndpow,rlul , noughtoinduc:< a com.o win at anyroot .
fOT•nrg,ry&c,us,o/itslimit<drn,il•bility,il5 al,n><isn>u -
ln F,bru.oryol 20 H . Al<x Rodrigue,/irl2lly a oceptedhi<
• ll)·c onfin<dto :m<>th,.io logis,.•ntlhospi'2lp<r~nnd 162-g,.m< ' "'J><noion for •l l<g,d Uli<CoF p,rfornunce-
<nluncing drug, duringthe l001 -200J basel,all s,""'n'
Dependence t..1<r h<b<c•m< invoh-«linano 1h<rdrug ,ca nda l wh<nh<
Th, Diagno>ti<and5tarnrica!Manua!efMrnta!Di>ani<n v.-.u ll<g«ltoh>veu,,d,ub,t>nc<S,such"'humangrowth
(D5J.f.j) cb«ifi eo lnhalant -R<la1«l Di50rd<n .. "in h>b nt honnon, (H GH) , supplied by Biogrne,i,ofAmuica, •n
u.,dOO rd<r, inh>b nt intoxic•tion.othuinhalant -induc«l mti -•gingclinicinCoralG•bleo,F lorid.
dOOrdrn;,rnduru:p,dfi«l inhalmt -ncbt<ddOOrdrn; ."T h«< lnthee2><oft..nc,Armstrong,th<b<tT:l)":1l oltru st,eemed
•r<ha>roon•bus,of,u b til< !iOh"<nts (hydrocarbonoroth,r
muchgne•t<r.ln•lOIJ int<rvi<wwi thDpnhV."infrey,h<
,ubti l,compound ,) .DSM -j cb.55ifi,.th<•bu,;,o/n itriteo
•dmittedu , ing,t<roi<l< • ndothup,rfonrutncc-<nhanci ng
and •n<sth,tics "' ·p,yc hoactiv< ,ubstmc< dqxnd<ne< not drug,o v<rtheptriodoFtimtduring whk h he won-,n
othm, i s,,p,dfi«l .""
Tourd,France n ce,.Hi<W2<and • bont<corup incyth>t
Thou ghtol<ranc:<tovo bti l,"'h·<ntswilldev,l op ,th<li•bil - im'Olv<dm:trtyofhist<•mmateoand,uppli<nplu,denia l,,
ityforphy,icalandp,ychologicald<p<nd<n«:mdaddic- voW5of "nnocrnc <,>ndlm'tsto • lrnc:<c "ti . Anru;trong

:::~::::i::i~"'
tiontothtKinlu.bntsisl,,stlunthatforothud , pr,sYnts; v.-., stripp«lof a ll=rn Tourd,F ra nc:<titl,.•ndthebroru<
m«b l v,un at th< 2000 Olympic Ga me,, in Sydne)'. H,
mone lik,ly 10 • hm< inh>.bn,. long -
h2'bc<riisou«l•lif<tim e bo.nlromromp,tition,•pplicabl,
to il l ,po ruthatfollowth<Wor ldAnti -DopingAg,ncy
Br,akingth, labitortratingth, comput.ion c:m b<difficult
(WADA)cod<
btam<m<»t=>r<)"Onng:md immatur,:mdron tin n<d
nKcancau11<Crogn't'n"mp•rm•ntsth> t h 'n ' >mpK- Ther<ea ncthr<<m:tin cat<gori<Sofdrug,u,,din,poru
hension •nducovery. Thrn, ru,,
., bc<rii50bt<d r,poruol • Th<r>p<nticdrug, (<.g .• • nilg<>ie<,mu,c ler<el•nnl5,
withdr:1wal,ymp lmns>f tue<.,.tionoflong -1<rmn><e(hal - :mti-infi•mma1orydrug,, rnd .. th m.o m«l ications) >r<e
lucinotions , chil 1'. cnmp,, •nd occaoiono llydelirium Ir< • u,,d lor ,p,cilic m«lic•l problem, • nd odmin istened
m<m). A cr=•tol<nne<tooth<rdq,,-..,.nts , including withprop<rmedical,upuvioion
•lco hol_ d,--, lop,withlong -t<rmus,.lronical ly, inh • bnt
•hnKi,look< d dmomuponbydrugaddicts"'lowclas, a nd • ~rform:mce-<nh2ncing drug, (PEO., or ugogrnk
inferiortoothahig h, drug,) • nd blood or •y,t<micm2Ilipula1ioM include
steroids . growth honnon<S, blood dop ing . and , timu -
Prevention bna , "'m<l<g,,l:md!iOm<not(most a r,Nnn«lfrom
romp,tition )
Hi,torically . di>mi55ive:mdderogatory>ttitud,.,ov,-.rd"'l •
,-,n1 ahn><ng•v<• lowpriority10,. Lobli>hingeffectiv< • R<crtttionolandmood .. lteringdrug, ,bo thl eg:,l • nd
illeg.al (<.g.,c oca ine,mari j uano ,a lcohol , mdtobo.cco),
~~:-:~~0:0~:::::~:~7;;;:;:~:~~:~::n~~ ar,u,,d toindue<<nphoria,r«lue< pa inOT•nxi<ty,
by• lrohol.tobacco,•ndotherdrug, . A>a re,u lt,par<enl5, lov.u!nhibit ion,,«cap,bor«lom,rq,rodue<theru,h
«lucalo n. the med ia, •ntl law rnforum,nt p,r,onnd >r<e of•non -fi,klp,rfonruone<,e< lebrat<orwinddownfrom
a p,rfonruonc e,OTsimply<nhanc:<th<=

I
unowar<eof th <po t<ntialfor braindamag <OT•udd endeath
a,;50eia1<dwith1hi>h<h>vior.Pr,cvrntionh<gimwith • w•r< ·
n=•ndronsc iouslymonitoringabusable,ubsLoncnrom - lheWorldAnti-DopingAgency,theNatiol\itl

>
moninmo,thon><ehol ds•nd bu,;in<S« • . Reeogni:ingth < CollegiilteAthleticAMoci.rtion(NCAA),•nd
•ign • •ndth<,ymptom,ofinh•l • nt • bnK:mdbri ngprop- theprof-e.,jonal•?Drl!i. INg11e!iaretht!m1in
<rly tr.tined to id<ntify tho... most al ris k ,hould be a watchdogsandsubstancelestentokeep
re,ponoibility• h• redbybw<nF<>K<m<ntoffice n ,h<ilth- performance-enilanangdrug,oulof"l"'rl!i.
car<work<rs . t<och<rs , •ndpn<nt,
 fit ..... .... ,.,,..""""'
,i,.\lttia lll tlwJ911111
,., ....
-,I J'90l. fM I)'•
°"""""'
c-,,.,~ .. _....., .., ............
k lOOlt_,- Jff" fo, M<G.i..t ,,,,.,_ ,
iolo<..,..-.Hi>...,_.l,..t,,.. ,....r
- --~lo<f-...
.,_•fi,.~,,- _._,,,,
-,..r
........i
utl9!111MMlotqotvt'fOULll.o.... J,</
=::-..:wlf </Ml lodw, i.

·11iaw...... ~-.111fflHdl ."

...,._ _..,,ldoln
.. tl,,Soo,,,_r._
S«n:tK"'ndJuryttstimony 1lleg<dth11llondohad lnd<<d
uKd,1trolds,.,,ptt1at!ytttrahydl'O!ltstrinonc(TllG).THG
!.s,onc• -undn ,01abl<otrro !d d...,<lopcdll0ALCO(BayA ru
Labm,,toryCoop,ml"")byltsfound<r,VlctorCont,,w~
wn ,l<o llnk<dto a numbuofp lay<fswho1l leg<dlyenluin«d
theirperf ornunonw! th drug,
S,ame athln<O pt"tc- dru p. oft<n Ulldt one,, u the
qui<kcstYl'lly toput onpou ndo and muKle.tolncrnoe
1wnlna,ton: lk>'e~in,tog,,1"up"(lnopln:dtoa>mpete)
fo1 apm<,01to1<m&lncompt"llll•<wl1holh<rothl,t<Swl>o
U><drup.11«.....,,...nydna
oF ronliden<e and udmn<nt,
p us<din1pon,caU>< f.,.1inp
111<commlUn<nl lo IIOing
the drugs and th< b,lid chat II will h<tp 1h..... • mndt
:,';.!;,:;',;t..;'~nhandft1pot<n11al.cm,-,1i-
History
Tbe11K0Fdnapin1porul11101hln1new.Grttli:Olympic
:athlrtahlthcthltda:ncu,y8.C.M<ia..,.amountsofmiuh
TI>OID5or"""'1tolmptCl"<tlvitpafonnana . Aboulth<,ame
time , athlttnln~nlaprepem!fo,1hci 1 0Y<n1Sby
drinki"II pound donkty hocnu boiled ln oil and pmioh<d
with ,_ ptuls. Roman 1ladlators took ltimulanlS 0,.ltl
DUl>OTq>b<dta) fo,mduranu. " Til< fl lmulantpn,pertia
d.anatl""cact111p<OVld<dAzceclndlon1wtththcenerzy
::.::::•dlttana:sovnsevenllU)'S,111<1,,,.mor,of,
Bythei800.cyd!flS , swlmm<B, 1ndoth<ro thln ul1$«1
opium , morphln<, cocaine, coff<in<, nll"'ll)'C<rin, oupr
cubo..,.ktdin<thtr (Outchcanalswlmm<r,),ondlow
d<>W5oF.uy<hn!n<(mara,honers) . Around 1BnTK<C.....i k-
=lnEIIKl,andch,w<dcoca1, 1vo,10 improv<lheirperfor-
= · Bound<Ell<waterlacedwtth taetl n< betwttn
romw:h.U>ng-distancenmnero,.,.r,/oll.,..<donblcycluby
doctonwhop,·ethtm a milrtutt olbr>.ndyondmychnlr.<. '"
Amphetamin<>(Benndrin , • ),.,.,.dcvelop<dln1l1tl9lOI
ondincru!i<dmalhlt1t's .Jenn =.• n• 'l)',Ondoonfidtn0< .
U.. wa,;/ir,;t=:otdcdal theBer!lnOlympl Olln 1936. Ouri"II
World War ll, •mphn.amine, wm: , dmln l<tefro by many
~:•~:,';" to thtir 1rooJl" to d.lay r.t1gu< and lni:tt ...
Thema.leho rmonet<,t o,t<mne . ltolot<dlnthei9lOl , was
us<dinit>pureformorinrompo<rnchtol>allnjuriu andto
help ,:ona ntntion amp ,u,vivo,. pln wtir,ht 1fttt World
\l/arll.DuringtheColdWu<11,theSo-..1
:,.~·:=!:::..the.:.:5~~:;~:·.:~~
-.mghtliftingroach_theo,gummt.,..mad<thatlhtonly
..._y the U.S.tamcouldmaintainthri,compt'tl'llw<<dJ<ln
int<Tna1ional.athktia .... thmqlrthcm< oFpnformanot-
enhancingdrupAtthcl95601p,q,ico , thcSovln1thi....
and many <>then ~ting Commuo lK bloc cou nuia ,
- ~EastG,rmany , ...,renuoom:ltolur..,us<dottabollc
Oltl'oid,;gr,ingth<mutadvan"Finwti&htloftlngand
..,.ngth ,port>nW<D aommming.
iJ..[£.,,tC.,.,~Ja!lrlru.-~,-.,.,,ar,,j'kll,I
tltat.i-o:ac/,,,..d.Kim!i>IIpt'.d.i-oUlfl ... th,,,._
/w.d,,,,~p<Nlrl,,r,«U>af!l,.,L f -..-tl,wlw,ol!I,
~aft,n- ....Tunr......t.l'--'i<alp,,x,1,,,atlwt
!l,q.o(roorw,...,..i.;,.·1,,,,,.,if>aj , .. !""""1oftlw.....f(,rul
__ _ _,.._,.,,oo,_,_1oo-
fro,.tl.atalot." ,......,
Byl9'Wl,1<1'00, we.-.rudilya ... llablt ,ando bu .. by11h•
ltte,wnwid« p reod,cven lnthe laa:ofgrowlngrvld<ne<
 ·promot<,coordinat< . mdmonito r thefight,pinstdoping
in,ponin a llitsfonns ." WADAworkstew:1rd"avisionof
thewor ldthatva lu,,;•ndfasta>doping-ln,,pon ."" Th<
roderoven,uchtopia • • • nti-dopingrul<S,iolotion,,proof
ofdoping . a listofprohibit<ddrug,,t<>ting>Landords,r<>u ll5
maruogemrnt, .. nctiom . •ppuls . •nd<ducation ...
A,oflOHth<r, • r,sixcat<gori<Sofb • nntdsubs12ncu
• =bolk,t<roidslotherag,nts

• b<ta,•ntagonists
• hormoneandmttabolicmodula1ors
• diur,tic>•ndoth<rmaskinj;ag<nts
• c<TWn techniques, includ ing blood tlUilipuLl.tion,
chemical• ndphy,icaltlUilipuLl.tion,andg<n<dopi ng
In rompdtion, ceru ·n, ,c •fic ,t'muLl.nu . rw ti ;, can -
nabinoid>, md glucocorticost<roid> n< lorllidden . md in
>p,c ific,poru • lcoholmdb<t.a -block<r> • r< bonned.Bath
,..Jt>md,ynth<ticmari j wona•reNilnedundatheh<oding
ofnon -•pprov<d,ub<anc<S
According to the International Olympic Comm itt« (!OC )
andWADA,th<l00401ympic,srecord<dl6dopingvioLl. -
tiom out of mor< thE1 3,667 t<,u . Th.at numb<r dropped to
9 viol•tiom out of 5,Ml l<>l5 eight yun bt<r. T h< lOH
Wint<rOlympic,shad,trict<r•ndmor,«>phist icaledt<>ting

I\, onl1<onr,r:,.,,,,.,,'-'!9!20ly ,npk< l~.l,.<dt,,,. a,,'-' :;"~;:• t;;':1u::C~n~::..:~:~::c~f;:~ ;~:~:ff;~:~

_.,.loo
.fuq,.,l;j,<0<i""(J..,,oo,iu«<1"'1o!<>wtl,""""""''""'" ' ) 0J t'-' tiomw;o,i5outofl, i5 3t<>u

~-
i,,.,...,.
m,:.,,.,1,1,,,;,
.. no.-,.,
,,...,,11a.1...... '"' ond
rl,,d,wl,lon,.i..lt<1>< . H""" "" l,,.u,,,.., ,.,J70,-,. ,. i.,,,.. Comme rcialization o f Sports
lnth< 1970.tde>i><dsportingevenu,pumcdmexplo.h..e
growthof int<=tinprof,><ionol,port> . Athl<tn' .. l,rie,
b<c•m< higher•ndhigher . mdbigmoneylorcommrn:Ll. l
<ndor><mmt> mod< mElY ofth<m millionai=. Th< public \
oftheirnegati,..e,idedfects.lnitially•bus<dbybodybuilder,
attitud<,hiftedfrom=p,ctfora1hletic<xc<ll<ne<tom,yof
andw<ightlift<ntoincru,.ew,ightmd,u-mgth . steroidU><
th<ir,..J,rie,andm<xp<ctationthotforthatkindofmoncy
apandedtoathl<te,"nother,porutooc,' ·,tJ<irtrOn -
thcyhadb<tt<rb<winn<n.Manycoachesadopt<dth<mon -
ing,r,co,..ef}·tim<,mdmu.scl<devdopm<nLTypicaldosag<S
t' ·nn·ngal•nyro,t
incrtt><dfrom301o+omilligr.,ms(mg)dai lyin1hel970.
tol0tim<Sthal•mountbyth<l990s
Ov<rlh<pastSOyan,cyd i,uus«l • wid e vari<tyof,u b-
>Lancn a nd t<chn'qu<> to ' ncr<»< th<'r mdur.rnce md
>lr<ngth : nitroglycerin . c•ff<in<, variou, a mpheumln<> "Ju<tWin&°'j.Wtn"
>1rychnine,cocain<,h<roin . mdmor<r=ntlynythropo i<-
tinandb looddoping . Cy<linghllb<mrif,with,candalslor lult ol <ht ~ • ""'"olAIO.-,,,,o,,"""'"11" """ ' -
ol <ht<»>Ja,d b'7>->0II
many)·nr,_ Jnoddition toth< tr:ansgKMiomoll.ance
Armstrong . finallyr,valedinlOIJ . ther,c.,,medtob<•new
Over t h<pa>t30y<>B . th<,oc ialandlinonciolpr<»nr<>to
sandal "'"f}" ya r. In .!010. Alb<no Conwlor of Spain ini -
winruov<,ncour:agedathl<t<stou.,drug,a,aw:,ytogain
tially won 1h< Tourd, Fr:ance, only 10 b< >1ripp«l of hi> 1itl<
anadvontag,.Do,.·hatyouhav<to,butjust"·inb<cam<,oc i-
aft<r t<>tingpo,itiv,fordenbut<rol.•bann<drnb<unc , ,md
<ty\man1 ra lorprof,.. ionolathl<t<,.A1hl<t<>can<arnmor<
.,. ,,.u ltW:1slormallyandprovi>ionally,usp,nded ."'
from endor><m:t '';: fro~ :mp<ting, ffllling winning
Th<moo t imporuntd<v<lopmmtinprn< ntinJ!ill<galdrui;
u.,in,port>wasthecrea1ioni n l999oftheWOTldAn ti-
DopingAg,ncy( • ndth<WADACod,),•r<<p<et<dl<>ling
andr,gu Ll.tory•g <ncywith••trong a ntidrugpolicy.Th,mi>- Whmmanyp<rfonrumce-,nhancingdrug,w<r<l<gol , u.,
>on of t h" 'ntm,.· · ul 'nd<p<n' · o'&',n· ti, · to ,....,xtr<m<lyhigh . lnthel970.aLl.rg, n um h<rofNation•l
 D'n<Drug,,Othet--.. 1.U

-
' , ,M- 1
Plllffllsof&Flffl(.Dnl&UstinMen'sSports-OmallPffcfflageof UstWith
1 1M 1m 1 ·m·1MU W
inlhePastl2 Month5'"
1-r' M,i WI

FootbaUL<a gu <(NFL)play ersadmi tt ed tousi1lj!amp h<t- Analgesics(painkillers)a ndAnesthetics

•mi n <>r<gu W"ly.
Thi, group indu d,. topical an<'1h<tic• t hot d«ensitize
Accord ingto•nNCAA,urv<yr<l <as<d in2012 . thenumh<T n<rve endi ng,onthe<kin( • lrohol•ndmrntholorlocal
olma!,coll<g< • th l<t«usingp,rformance-<enh>nci"l! an« th<tic>, e .g.,proc•ineand lidocain<)>nd,ys temicanal-
,ubst>nc«ho , dropp,di n mosl<port>bea11><ofincras<d g,.ic< (e .g., a<pirin, ibuprofrn, •nd acru.m inoph <n
drngl<>ling. '° ITylenol " l)fo ,mild -10-mod<r.tt<pai n ornorcotic(op ioid)
an•lge,ic, fo, modent< -to-o.<v<T<pain . The mo<t common
11,,r,i,amt,,:o,,,c,p!iontMtothl,t,,.,,J"'I,' opioid< u«d in ,poru ue hydrorodon< (V",codin~). m<p<ri-
[othtrtMo,1<roid.J..,,,tl.,nthtmtoftht colk9' dine (D<merol') , morph ine, •nd cod<ine . The«drug,n<
,wdtm~ .and tl,.,t",no1r,..,_Tl,,,t.Ji,,,lio.i <ith<Ti1lj!«t<dor inj«1«1 . lnaddiciontoth<irj>Enkilling
tl,.,t,wd,,,1...,fl,l,t,..,, of~U octwl~otal,,,,J dI«ts,opio id,canc:tu«secbt ion,droW>in«o , dullingolthe
!,,,tl,,,ntl,,,,,toftht,wdtnt~- «ns«,moodch>ng« . nau .... . •ndeuphori>
,,..,u.,...
.... ..., ·- . •·c;.,.5«<u1a<=

ln201Ji t v.,.,«timat<dth>t>t lastl '50,000cighth-,t<nth -,

and tw,lf th-grad<r< had U><d staoid< ." Th< good n<W<i<
-:::~=t,:::.:i/,"::!'ti.!~~"'~~t:
1<1~ Wffl<thil\'J.
1jOOlffjimj;, mtal~ dtff,r,ot
o ~!l.!otion
th>tthi<lignr<<haw<• '50% drop from !Oy<n<<>r li<r. Yood,,,,"tp.,mc;p,,t, ~-hrn1101(
r, injur,J ·
Anothur,ponindi cat<< th>t.,co ll,gi>t<t<stingfo,,t<roid.
h<rom«mor<<1ringrnt,you1lj!othl<t<>•r<rncour2g«lto Sitt,w>-
•·""'""""",...,
u.,,,,""~""-
uKthemtobul k upd u ringh ighochoolandthrn,:ocl<>n
Th<Kdrugsblockpainbu t don\r,pai r cbm2g< . Norma lly,
whenth,yg<ttocoll<g <.Thi,i.<cbng,rou,bec•n«•nol>olic
p>ini<th<body ',w.ming,ignolth>t..,m<mu!iCle,organ
,_t<roid•~•u.:bonedeve lopm<ntanddi.<rupthormonol func - OTti<<nei,cbm,ig«lan d ,houldb<prot<ct<d.llth0«sig -
ru,l,•re<hon -drcuit<d,th<"prot<ct"m«Ygeg0<>unhttded
Curr=tly, manycoll,geandprof«<ionol othlet«continue 10 • ndd.mag,continu .. . The ron«qn<nc«loan•thl<te•
u«and •bu«p<rfo rmE1e<-<enhancin g,ubstance,th>tron - bodycanbe«v<r<>nddebilit.ocing.Bec:tu«1ol<ranc:<devd -
taindrug<•ndchemical, • ppropfU.t<inonecont<xtbut op, !iO r:,pidly with opio id,, incm1.<i1lj!•mounts become

::_i:: ::~::,.~::r.~~;~•,:e;;,
~:;,:::~~
p,nsionfrom t h<ir ,pon,bri ngforc«lto,
i;e;~;::
urnndu•t it l<
nee<M.1.rytoach i<>.,pa inr,cli ef, cau,;i"l!ti<<n < d<p<nd<nc,c
Th«efactorsh>v,1hepot<nti•ltol<ad•p<n0nintocom
pul,iv<n«
-

OTworl d rerord,orbri nglook< d uponas•n nnd,oin.bl<

,pok<spuwnFOT p roductendonem<n t
TherapeuticDrugs
Ther:,p,uticdrugs•r<uKdfor,p,cificmedi<•lprobl<m<,
n<u.allyin acco n:bncewith<tandndsolgoodm«lic•
tic<;theyfall intolourmaingroup<
• analg« ics(painkill<r<)and an« th<tic<
• anci-infi•mm ,uorym«lic>tion,•nd,ubstanc<>
Chroni< u«oFopioid,c • n«nsit iutheuO<TSnuve,,..,
th,yFedgrttt< r p•i n thanth<ywouldh>vebeforen>i1lj!the
drugo . Thi,hyp,nlg« i•makesth<u«rmor<d<p<ndrnton
th eop" o'd,mut'm e . Ath l<t,. m n>tl<arntoacc<p t ae<r-
tainl<V< l ofp >inra t huth>ntrytoabo li<h• ll diocomforL
l pr:1c-
Musel< r<W<2Ilt<d <pr< .. n<nra l activi ty wlth in,kdetai
mu!iCl«an d red ucemu!iCleton< . Th<y•reu«dtotrat
mu!iCle m Ons . rg:,mrnt,pr ,."ns , a ndther,c,u ltant«>.,r<
,pa,m> . Th«<>I< a l<ou><dtocontroltremor,;or,h>king in
,poru th.i ruiuire preci.<ion, like markmamhip . Some
nelll•na(neuromu,cubr blocken)>ctperipherallyrnd
inter/en, with th< trrn,mission of signals al th< mu,cles
them«h'es,whuu,othus(,pa,molytics)ar<crntr•llyact -
ing mu,;cle ncbxana that focu, on mu,;cu lo,kel< ul pain rnd
,pnms. !oome •th l<tes ,1,o u.,e them to control performance
anxiety Sk<leul muscl e nelauna include c• ri,oprodol
(Soma • ), methocarlnmol (Robaxin "), cydoben:E>prin<
(Fl<XHil ' ).m<W<•lone(Skebxin °),tiz•nid ine (Z.nafi~).
andbadofen(Lio,.,..,l')inadditiontobenzodi>zepi=
,uch., diuepam (v.Jium • ) md donuepam (Klonopin • ) ."
Theperlornanceenlu.ncementproperti<,ofthe«drugs•ne
minimalbecau,ethedrugsar,dq,,....narndc•nal,ocau«
>Cdation,blurred,ision.decr<.>.,dconc:<cnlration,impairul
memory, ne,piatory depneMion, •nd mild euphoria, <>p<·
ci• lly ifov<rusro . Skel<11lmusclenei>una•reocca,ionolly
abuscdforthrirmentllleffeca,panicubrly=isoprodol
whichisuscdtornlu.ncetheefferuofotherdrug,;whrn
takeninW)!edc,.,s,itcau=giddine55,drow,in<>•,rnd
neW<ation.lnlOlltherewereS0,000,i,itstoem<rg<ncy
roomsduetomuscl ere l:uants,panicubrlyc • ri,oprodol
;:~ :~~prin< . Th<r< hove bttn • number or death, laJ•m:IOLl!ttt>tanond.lopl,lyw ldtl"'in,b.10,l,/tt.llinj,,ry"'
.,.,.,,.,1..,
., J,m".!'"""P"'l"'""'"""-""""•<Mi'I!
inj,,ry. laJ•m:!OLl!ttt,,.i.:,,on,10ww,""'fl<'<0,,•><'1!•M,"f"l''k
dri,g,wowldt<p,,i•=-u,,,,,.,,,O<il<j,,ry.

Belor<an athl <tense• •n•nti -infwnmatorydrug,h<or,h<

Brnrndiuepine, a ndbarbiturat<,hove•high<rdq,endence
li•bilitythmdomusclerebxana.High-do.,andlong
use of mu,cle rebxana cau= tolennc< and tim1< d<p<n-
dence . The brnzodillq,ines •lso •t>y in the body for a long
periodoftime,cau,ingprolonged•ndundesiruleffeca
mustb<carefullyenmin«!toensunetlu.ttheinjuryi>nol
><riou,mdlhatpnctic:<orpbycanoon1inuewithoutriskof
aggra,.,.tingth e damag, . Anti-infwnmatorydrug, • ncnot
d..igned1obeusedsimply1orn•blethe a thl<t<to=ume
-l<Tm
acti,ity bu1a .. part of the ova.II healing procrss. le<. eleva -
tion, r<>l, physic•I ther•py, rnd otha tr<C a tment m,,.,;ur~
mustaccompanyphmn>oologicalr<liefofpainrndinO.m -

Anti-Inflammatory Drugs AsthmaMedications(beta,agoni51s)

Th<r< me twoda,5<>o r drug, that control inO.mmation rnd Atthel008SummerOlymp icoinBeijing,7.2%ofth<ll,Ol8
less<n pain . The fir,;t i, noruteroidal • nt i-infiammotory athlet<swhocompet«!receivedpenni55ionton«•be ta,
drug,(NSAIO.) ,,uch.,aspirin, ibuprofen(Motrin • md agoni>t ror ..,thmo . Thi, i> up from th< ~.7% or •thl<te,
Ad,il ' ), indomelhacin (lndocin • ), phenylbutarone (Bul.0- granted permi5Sion at th< 2000 Summa Olympic,; in S)Un,y
zolidin • ),,ulincbc (Clinori! • ),andc:,lecoxib (Ce lebr<~) :::~ .,!'oorairqn•lityprobablypi>yed•roleinth <
High-d00<useo/..,pirin•ndibuprofencrncauseulcer,rnd
n,ru,l problems . Celebnx • i, =:ommended fOT•nh riti, rnd
0<lro>rth"G',u1notf,orc · ; '<>. •nd'tca ·,.• Asthma.rf<etsl0%oftheg,nenlpopubtion • ndisaggr.,.-
,..t<dbyh<...-y<x<rcisein,ponotlu.trequirecontinuoo,
!~;~:x,.waming a boutpot<nti•lheartrndga,trointe,tinal exertion (e.g.,cycli ng ,rowi ng,•ndmiddl <- tolong -di,unce
runninr,):,,;well:,,;th<<X<:<M5t=thatrom<>fromperlor-
Theotherci...olrnt'
,uch .. roni=andl'r<dnisone
-'nO.mma toies ' ron'cost<roid,
• (rortirost<roids•r<dil -
r<r<nt from•nabolic -• ndrog<nic>leroids). " Th< potential
.i7:1~:::~:~~':!u:
;;;;:;~';;:3;:::
wide,prndina1h l<tics,pennisoiontou.secert.ainasthma
,ideeffectsofconirost<roids>r<•ignifiC2Itt.Pro longeduse m«!ication, i> gnnt<d . Otha beta, ago nisa U>cd to control
cancausew,t<rr<tenti n,boneth'nn'ng,mu ' ,dtrndon asthmoindudedenbut<ro!(bmnedinsporu ) •nd albut<rol
wnkn<>s,,kinproblems,uch><deby«!woundh<.:tling (limited use in ,poru) . Beu , 5timulation •l,.o incre:,s,,
v<rtigo,h<>Wlches,andgi>uroma.Poychoactiveefferu • ne muscleenergy•ndgro"~hbutto a les«rext<ntthrn,teroids
minimal at low de,.,,, but""""' p,ycho,;i, result> from Asthmamedic • tionslikeeph«!rine•ne•timui>na a nd a nc
exce,sivehigh-d0><u« th<r<foreNnnedin,poru . Th<><drug,benefitthe:,,;thmatic
 D'n<Drug,,Othet-... 1.11

by.Jigh tlyin cra.Jngoxygrnintakethroughbronchodib - muscl e-bu ildingproputiesofAA5,lromtheirund<>ir.tbleor

tion . Othu•sthmamedie1tlon,,uch a, throphyllin<•nd dangerou,hormonal,ideeffect5
cromolyn>r< >llowedbybothth<IOC•nd t h<NCAA. M
Tum,nlb,,.,~,/,o,,,,J,1,roid> , ma,t""'"5fttt8i11chn
AllabolicSteroidsandOther a..J",d,, , o..J tht~tnll,Jo °""tli<,..,t"",w,r,thtrwi1<of
Performance-Enhancing(ergogenic)Drugs !h,cl..,andtht98 -poo..J""all"'5atthtb,ocO.S1,,o;J""
;, ""'""~ ti,,~ f,lt ti,,! coofdcw,rom, that ·
"/f,t,n>id,-Jid,i"t~o!hl,t,, ,,, .,td,,"t""t1,,'"·
OooC..ilia ,'4 .D.• """'-.l.laA°')""P'<....,,, .,,,. (ootlllO)
, .... m, of UM AAS u.,rs may ake 20 to 200 times the
Mostp,rfoITn2I1C<-<nluncingdrug,.wbs12nc,c, .• ndttcb- dinicallyprescribeddai lydouge. lnste.odof7~1olOOmg
nique••r<b•nncdbyth<varN>U,,porto-govan ingbod ieo, perweek . w<igh~iftu, , bodybuilder,,WK>tl<rs,•ndother
<>ptti.,.lly th< IOC •nd th< NCAA. Th<« <I)!og<nic •nd •bu.,.ush.ov,1>.krnl,000102.l00mgp<rw«k. ",. Some
rn<rgy -producing drug,. ,ubstanc<>. and tcchniqu<> >r< a1hlel<Sprxticeoteroid,11ekingbyu,ing1hr<,ormor<
u.,dtoboildmusc le,, incr,,.s,,tamina . <nh>nc<5<lf-imag<, kind,ofoalor injecl>.bi<stero id ,orby• lt<matingb<t"'<<n
•ndboostconfu!<nceand•fll!I"<"ion cycle,olu.,•ndnonuS<

Anabolic-AndrogenicSteroids(AAS,o, · roids") "Baoo:,ll.j.18""""°""r10..,,1:,.t1,,nrllaoofffo,a!ittl,

~-'iii,. So 1"""'1..l;Mof,'f'I, itm ~h,r,jt -u,-,.1 ... oor
"/t",o/",fom,.,nu -,.i.,llcin,9""'tJ-lm,oo.that", ,A,otitAf atawtajotiffl<;,,th,.,.,.,,,_·

~t::'1;::,t""/":~~~:f:m't,:,ff;i:::
S"W'~<lr"'8tl,o..JP'-'.· Anotherpa11<rn i,knowno,.,eroidcycling . Wh<n>0m< ·
onecyd<>Sl<roids . thcytakethedrug,for•four - 1018 -w«k
p<riodduringintrn,ivet,.ining;thcythenstopthedrug,for
Anobolic-,ndrog,nic,t<roid• ore dffived from th<TlW< ,evealwuksormonthstogi,.,th<irbod}· • phmruicologic•I

I
hormone t<sto>t<rone or ,ynth<s iud. h1.aboli< means =tmdthrnbeginmoth<rcycle . Some•thl<tescycl< to
"musc lebuilding."aoJroxrni<me.ons"producingmo5CUlin, <>eap<d<t<ctiorL Studies,howthat8l%of•thl<teowho
choract<ri>li<>."• nd,teroidis1h<ch<mi cal cas>ificatlonol uocd "roids " durl ng•tr.oiningcycl<rombinedt hr<eor
theruotora l •nd•ynth<ticcomJ>Ound,resemblinghonnone, mor<different•02boli<oteroid,duringthattime,mdJO%
lik<l<>l"5l<Timeandcortiso n, . AAS.ar,u<rodinical lyto u«<l,evrnormone.Thu,both, tackingandcyding•recom -

I
tr<e>tl<0losl<ro1><imuffici<ncy,del, yedpub<rty,w •sti ngd is- monlyp racticcdtog<therbythooewho•bu, e AASo
<2>a . osl<oporo, " , ceru. ·n t)'J><'of m<m'• - "'me brast

>
cancen.endorrri; " . •nd•'·'' "J,n._ ., Stero iduser.;maytake20lo200time,the
For•n•thl<tetheoedrug,ho,,emorkedb<nefitstha1indud, dinicaHypresuibeddailydosageandcanwst
incr<Hro body wright . Inn muscle mas,. muscular theu..,rupto$20,000or $50,000ayear .
,trength,and.to• le .. ervct<nt.•tamin.a.Psychologicilly,
"ncre:oKS · •ggr<ss"ven<H •nd ro n fidentt nf v..lue "n Pllyl,kalSldoEIIKhlnmenthe!nit ial mo,culinir.:otioneffects
•J>Orulik,lootballandbo,.eba ll. Sbngtmnsfor•nobolic ol•nobolic-androgenicsteroidsindude• n incn,..,;nmu,cle
steroid,include"weigh t tr •inen ."" roids ."" juice, •·A molds. " ~mdtone . Mniyph)~ ici,,nsbeli<vethot•longwithth<><
"gym candy."" pumper,:•nd ",tacker, _" incr=comes•muchhigh<rincidenceoFrupturedtrn-
doru; • ndd•m.oge d ligaments. ).\a,t u«r, •lsorepo n•n

>
initialbloated•pp,1ronce.Long-t<rmuS< inmo l<>cauS<, >
Anabol!c-a.od,°""
. nicsteroids
a"'deriv'l!dfrom lestmteront! ,uppr<»ionofth,body"snotur.tlproductlonoltnlosl<ron<,
orsyntheslI~ whichre,ultsinthe developmrntoff<mininechoracteris-
tic,,ucha,,wdlingbrea,ts[gyn<ro11US tia ).d<cr<ased, iu
Fir,ti>Obt<din 193~. t<stosterone•nd"'m<<>rlydffi, .. . oFKXU•l organs . nipp le ch.orig<>, •nd • n impainnentof
t"v""""'ll ' · ,Gemantroop,to "ncr=th< "rc' t 5<Xualfunctioning. " ln•2002Sporu/11"11mt<Jin1uview,
effectivrne5'.lronically.i1" ... •!>0g!vrntocon=t acion K<nUfflinici. • r<tir<dth irdbas<mE1andlormerma,t, .. lu -
::;e::::;:~,'; :::::~ ,.them r<giln weight md muscle, on •bl<p"',,er(MVP) . .. idhi,heovyuS<ol,uroid,cau.,.edhi,
t<sticle,to,hrinkandretroc1andhis body tostopproducing
M•nyte<n ,. mootlym.ole>,u.,AAS,,olelytoenlunc,cpe,.. it5ownt<sto5t<ron, . AftuheSlopp<du, ing.i t tooklour
month,forhist<>t icl<>tocompl<telydescend ."'
10R1.l>pp<>nne<.Ahigh lev<lofdi.,.ti>lactionwithbody
image(e .g.,f«lingtoom>:l ll orf <>.rof looki ngwe•k)i,com - Fem,tlesderive,im illlpinsinmu.scullldev, lopmrnt . bot
mon inAAS=.np,ci.:l l)· • mong l,odybuild,,.•nd tho>< long-t<rmu.,,,.u ltoinm:uculinllingeffects:f ocial hair,
whodev<lop•dependene<onthedrug, . Tod.t<,nophor- decne...d br,c., t.J,e , low<r<dvoie<, • nd di toal rn!nge -
macologic• l proc,..h•••ucceo,ful ly,q,ar.t tcdth ,de,i,.bl, m<nl . Many oF th,., effects in women >r< irr<>"er,;ibl<
 Wtth""""'"·r.,,,,.aclio"9'i11th<fooalj<>K'li,,,.fh<ir
_,, too. TI,,r, or, ,hfinit,/,j fh"'8'tl,.,l ma""""""- ar, ,-,,t
illij00rfo,orA,dtl,,!a,ti"8""'lt<tooar,,o..rthin,9tl,.,t/
"f"n"""""'~O/""°"C""""'to9"fltotro1<t,'

><Vaalstud i<>r<port<d.,.,.,r,cysticacneinSO%ofusero
ofboth Kxe,.Accel< nt<d bald ingi> alsobe li<V<dtobea
ro~uence ol steroid abus< . AAS, can be 12km or.,lly, by
adhe,ivepatch . Hatopicalgd . orvi aa nimplant,bu t upto
99%0F"roid"nKninjectthedrug.Mostincn ... 1heird os-
age duringth e cour><ofth<irtraining . makingthem,u<eep-
tibletoblood -borneinfection,, indudingHIV/AIDSrnd
hq,atiti,BrndC
Bo.1)-t>.ifdt,-,.,,.,,,.,ld,w,,.~llm=lt;onddtfi.,4<" ·1""~
Cardiova,cularch2ng<>inoteroidabuseroare a l,oofgrttt ob.lomto.V•fe"•"""lyr/,,tfftal-,tdo><L<"'!.,'X' r"'2lpn,l,""""k
concern. Clung<>inKrum lipids(Uain th e blood) a r< ,ldt<ffe,uo,.;,,,.i"1b lt
«Oectedbyinc~inthelev,lsofLDLs(low-demitylipo-
prot<in,or"bad"cholrnerol),d«r<ll<<>inthelevelsofHDL ..-- ·-"''""'
(high-d<mitylipoprol<in,OTcudio -prot<ctive lip id,),rnd
inc=inthecho l«terol -to- HDLratio ." Ther<ar<mElf
Compul-UMOft d Mdi<llon Unlike m"'tP'ychoactivedrug,
ca=ofunexpect<dcmliOVHCUW"probl<ms .i ncluding
AAS, • re notgrnaally u,ed fOTtheir immed U.t< psyc~
h)'J'<rt<mion . throm bo,i> . rndcndiomyopathy.AAS.cause
tive effectbutrathaforlonga -termgain, . Aboutone -third
high blood pr<Mur<, which cou ld b, aggravated by Ouid
ofU«TS,howe>-er,do!nitially,xperiencea><nKoleuphoria
r<t<ntion,m:iuiringdiur<tic,i.Anumberofstudieolu, ..
orwell -b<ingthatconlribut<>tothcirrontinu<drndcom -
linked<=t> incrnCff>to<t<roidUS<CparticulH\yh«>=of
puI,iv, abUS<Co lstero id, ...
theabilityofl«t0<t<ron<to<nrour:1gecellgrowth
Variou,,un~-.olweightliftencitepaniciprna ' comp lainl5
M.....a and €motional fflKII Anaboli<>and"'!lmic ,ltroid,
ofdi.,inctwithdrawalsymptomoindicativeoFtheindivid -
maktu .. rof«lm<>Kronlidrntandaggr<.,iv<,buta,nK
rontinue,theemotionalbalance ,win gofromronlidenceto ual'•d•pendenceandabuse.'.'. "ithdr.tv.-.l,ymplomsinclude
cra,ing,f atigue ,dis<a ti,factionwithbodyimag<,d<J>r<Mion
aggre•sivrn, .. ,to<motion.olinstability,torage,tohypoma -
rutl ... n<>,, insomn U.,headach<>. andalackofappetit<rnd
nU.,todepre .. ion,top•ychotic,ymptom,;,andtopannoi.,.
oau.alde,in,. "T oavoidth<><withdra"-. l ,ymptoms , user,
Thi,rondition,knownH"roidnge,"0Ftrnprogm1•-<>to
rontinuewithlowdo..,b,twerntrainingcycle• . Compul>i,-.
irrationalbeh.ovio r deprndingonwhich,teroid i,, u,ed .'-' ln
uKol,t<roid,mak<>theU«TmOT<likelytotryotherp,;y -
an'mal,iud'<>testostero ne 'ncr<a«~r«s 'on 'n juvrn·1,
and male r.tt, wh=•tanozolo l inhibia aggre,,i on ch"."~'i:'ed;'g,toenlunceperformance . • ••reward,orin
Nandrolone hHminimal dfec,.on~ion ...

-~.!""'~=·;t:'i..:12~~'"; "'1,""1

~,::::r::,~~::
lww.
f:'ol·t!i:E;:,,J
ltlo,i'tl;,-,,.i,efir....,.11,,~o, ifl,,....,.
~ ,tcroZlj· ~:/~=~';; ~:d;o~;t:';i~; ~~~:it::c:.':1:t~:
fidrnceorth,devdopmrntofbiochemicaldependrnc, . In
an 'mal experiment,' :on"'~ ·,•moot, i ·
"Roidr2ge"oocursmostoft<ninp,opl,whoha>-e a ten -
r<Karchusfoundthatdeprndenc,didde,.-elop andthat
dencytowa rdangrybeh.ovi0Torwho tak<,xce,siveam oun"
dopamineblocker,inth e nucl<nsaccumb<n,n egatedthat
ofstero id,.One,tudycompam:!llbodybuild<Bwithacon -
cr.tving ."
trol grouprndfoundthetwogroup,;toh<about<qu.alwith
r<g:ud to abnonruol personality trai"; once steroid, wue
in<roduced,how<Va,theindividu.al,,hov.-edmuchhigh<r
t<ndrncie,towardparrnoid,<ehizoid,antisocial,bordaline,
::ro=
=:i~ i=,~,::::'::
massand,tKngthwhrnrombin«lwithdi<tandaer~
~~ofm':':

histrionic . and pa,,h-e-aggre,,h-e personality profiles .•' Adouble-blindstudybyDf . Slul<nderBha.sino/Chm«R

Violentb<h.oviordonoccurinsomeusenwithnohi>toryof DrewUni,-er>ityinLO<Angel«involving43malevolunt«r,
,uchb<h;"iOT a ndwhoha, .. nori,kfacton.Theaggre.,ion ,howedlargem=urab leinc=-<>in5lttngthrndw<ightdue
U"'-"llydisappea,.,eveninilio,,ewithatendencytoward tostuoids.When,teroidusev.-..rombinedwithexerci,e,th e
viol<nc,c. a Fterceasinguse gaiminmu<ele>iuand,trrngthv.-eresignificantlygr,ater ."
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~iZ.~
....•..,.o/HGHl<io_..,,,.,_,~.,"""""""'
COVlll..:IOtn_ ..,._<tC..,-
Tho side dfotts from kmg-tnm us, of HGH lnduck Jipn·
twn • ..:oomeply(aboonnalbonolfl)wth),pituiwytumon.
ondau:ubolio:and<ndo<rint d--.:lon.~Hilio...,.
elated with .. n1i<n-uciaw d!K.w,ptn , ,.,....tnw d;.o..
dus.ckanK-d~dain,l11tpoK11«,and•dttftm<ln
a ....,r's life,pan by 11p to20ynn. • Boa,..., HGHmu5tbo:
lnjttted,theroar<ahothtlnh<:rtn1rl:sUofn,odkus,
HG!t wa, on« han-...rd from human Cfldaven, but in 1986
1tthn~ua fo• •ynlh<>i> ""'"' d=lopal at Gnle ntech
Cadaverl !Gllu<U• lly ron '2insronumlnanu,u nlik,,y nth<ti<
HGl\,whlch\lpur< . Alhlctoandtttn"&<11g<tthti r •u ppt;,,,
I
fromconucUallf""andinloclinl'OOffllorovnth<lntnn<t.
&lthoughlh<purityofanyllGHpurdVIKdonlin<tlqu,,tion -
abk.Tht: U.S.Olympi<Commltttt(USOC) , thtNCAA_and
,-,pono'g<n"ffllin&bodiot.nl\Gl\ux.ln201J,Majo,-
lag1Xa-t.llapond«litslatift&fortht,uboW><1
Stimulants
ln110mospon,,uchnfootbo.ll , thtuKof,t1m u Wlto,par -
tkularly omph,u.m in< and m,tlumphotamln<, !1 mor, wid, -
spr,ad than 1h<u.,, of ,tern ld,. CNS 1Umul.onta of1<n su. n
D<1 1a1pe rforman«l>ooo t<B,bu t1 hob.ukp harmaeolol)"
ofmoot1tlmulan1> uouallymaknprolong< d US<es,lf.
ddtatlnJ.Tht:IOCalo11&with<"",Y<>lber1poruorpnin,
llont.nnod thtus,ofanyampbo111m.,,.ond mostothu
.,,.,rc.umubnu.Somulantou!i<dbyalhktainclwl<mrth
ampbownina. diet pill,, m<lhylphonltbc,, ,phrori~ af .
ftlr.o, nlo>rir.o,<><asionallyaocair.o, ond,om,rh<rbal.and
dktll,y , upplemrn1>.StimuWml>i>wl•nerxY"-lh<rthan
in<ttU<1trongtho,-muscl,siu,110it! , th<111i,;,rtiv,/«l-
ing, ofunbr!d l«l vig01" and grtattr Klf-conlid,nc, that
<nhanooporlorm.onc<
Amphetlm .-,es (amphetamine 11\dmdl-.mphetamine)
"A.aplld,,r~-l-~~!:i-:'-."'"'!.-.
~--.._
--
~~~~~-,,pi. ...~,.-a<W.
Amphtwnl-oar< rder=l tau1y,npothomimnic:obttauw
theym1mictho•timulationoftht1ympolholic:n<rv<>UO'Y5""
<tm-that portoftht n<rYOU5systtffl that controlo involun-
111,yboclyfuncti<>no.lncludlnJbloodcim,lotlon, =piration.
and dillfflM>tl. Someathln,sus,amph<tamin<s{m<lh.
Adckrall,•ar,d"c,ystal")ua..ayofgntll\llupfo,-oompotl-
tlon.lnllW!J1;ma nyus,rsf« l <nrrgo1!canda l<n.A th1<1<1
olK>toko omph,wn in<>to rnhanoo 1hdr oggrH>in n ao and
ccnfuknce.Som<ta k<lh<m•fttflilCVOnlloc<l<brat<by
IUSlOlni11&thoircomp<titiv,"hl1h.'
S.udla 1howtha1ampbo:wnina••ill1ncrt ... ttrmgthbyJ'II,
,.,..,ondendu~byl .flilnlow......._ " Oth<rstudi<s
.tl0Wthat11tuchoftb<incrn><lnpufonru,ne,..,_,.m,m
1M focutina•fftttsol amph.umlne and 11t<thampb<Umi""
andthtlncttH< in aggno,ivn>Htandconfuw.ttr.,lber
than 111<specific m=W cha113a dortV<dfrom anabolic
st<rold uw . Improved p,rlorm.onoo \1 ><<nin comp lex wlu
lhllr<,lrocon«c ntrri,n
Toloranatoam ph<taml n <0de>-tlop,<1.ul ton pid ly,but
!'01\lllf In diminw>«I brndictol tllocu. Nqoti,-. dl«u
Include anxi<ty; ond lmpatrtd judgmmt. In
som<aisaamph<umin<w.<n(< -a-, loott.ilplay<., ) ov,:r,.
rtKttoplaysar>dliltH!ly<M:rrunthoKtion.Thrin<..-d
~,.....,.Qngrtoutolhand.cautln&lnjurytobotbth<:
..,...ar,dlhoopponm1>.llcnyuKQJtbringonh<artand
blood prusur,,p roblcm!,,u.hauslloa . &ndmal nutrilion.
TI,on, ht,v, olso b«n rq,oru of othl<1a ,uceumbing to fatal
hr111troko. Thisoccur>bet:au><stroni111muWltom:l i,trib -
utob loodowaylromth,,k!n,whi<hcompromi><> th<oodyl
conlint•Y"•mand makadilllpotlnglhoac<Miv< hn.t pro -
dueffl by lncrta><d metabolt<m d1fl>cult.,. Mrntally, hi1h-
dmcuwcanbringcmpon,I>Diaondomplw:wnin<psychoolo.
Amphet,trnines ind methlmphetamine af'I!
u,edinopor15notonlyforlheextr•t..mporaty
ene,gybutforlheinctelseinagg~
1ndconfidence.
Amph<tam!n.. 12I1h<d<1octeduptafourday,al1< r us,bytho
gotchromatagr:aph)tma.ospocuonmrylCSUngpmc«lur,.A
.....a p,vc«June, liquid cluo.,..togn1phy""- spoctmmctry.
- ia11ro.anumh<rofamphnamino,Hk<compound,. "
-
Ottt th, poll dttad<, <n<rgy drlnb loodod orith calf,;...,
ha.-.,~popu!ar"'1tho1hlc1uandodol<=<nu.Thlt
3roupr,gul.orlyeonsumall-or20,ounc,eu,!1ofRocksur, •
R«lllull, • andMoru<tr,•t>oplllj[for o l>i>wlthat willk«p
lhrm1wakoond al<rt. Caffrin<l11l110foundinrn"ll}"tonic,
,uoh11,-bou , ENERGY." cofl«,1n,co l1-0.vo r«l l><vor-
qa, and co,oa . It olsc coma In tablet form (NoDo,. 0
VMlrln.• rnorgypacU)ondcanbo10Xlclnhipdosa
Cafft11Kcaninc:rns,,n.k,lulnt11ar>d..,.ntala.lmn<>0a1
blood i....i. of IO milligraim per m,11,li<tr (mglmL.l by
JdmuWirctht<ttd>ra.lron,,.•ndmcdull.or«n<t
&llat,tlylncru,oaoduruia:dtarlncut•nd«l<=riKand
... h&l.o
lno..,....musckoontrKllon. '° Vorious,tudi<>f"l"ITTtlu.l
 D'n<Drug,,Othet --.. 7.21

theoddedrndurE>ceoomesfromcaffrin e5 •bili1ytoincreao<
thehody5 f.ot- • nd•ugar -bumingefficirncy • ndtom:luc,the
5enseof f.otigue . Negath .,side effrru,uchHinc=ddig es-
tive 5ecretiom (that can cau5e stomKh discomfort) •nd
incre.o«d urination (rn d poosibly d<h)Ur.uion) can •!so
occurrndlimitperformonce "
Tht IOC limit< caffeine to 12 mglm L-.o pproximotdy three
rup,;ol,trongcoff « - bel orecompetition.Some othlet<>in
oompetitionhav•~ • oombina tionofc • ffeine. ephedroo,
ephedrine(sale,have,inceh«n=trieted),and .. pirinto
incre.o5erndurrne<eventhoughthecan:lio~uloreffectsol
the,timulantscanh<risky.

Ephedra(mahuan8)andEphedrin ~
Ephedra (mo hu•ng), • mild stimulant. i, • tradi tion • I
Chine5eherbthatrome,fromtheephedrabu,h.Theactive
ingu dientooreephedrine (abronchodi lotor )• nd.to a
l,,.,,ext<nt.p5eudoephedrine(anas.aldecongestant);
both,uh>,..nc«canh<,ynthesizedinlabor.ttories.Ephedr,.
mn,..im • bou16 % ephedrin e. Ephedr.trndephedrin<w<r<
ingm:!ientsinhundred,o l legalovu -th e- oount<rcold•nd
.. thmomedication ,and in !iOmeherbalt <a>.<n<1ll}"drink,,
rnergyban.<n<rgypill,,•nddietmedication,.Athlet«have
u5edephedrarndephedrin e a loneand inoom binationwith
othermild,timu lm ts(e.g .,ko la nu tandgu•rana . bothol
whichconaincaITeine ) toincre.o,estrength•ndendurE>e<
rndlorpromol<""'ightl0<0
Ephed r>.andephedrine•reu«ddinicallytotreatuthm.o
rndupperre,pir.ttoryinfectiomh< caw.ethey ... ,ebronch i•I
TonyG-..y.,,p!,,.ytd20><d"'"-'f "' W5anDitgoPod,et.He w""8
,pa,m,;andreli<> '<•" "'llinginmuoou,membT:On« . Fordiet -
u,;they,uppr<55>ppetit<•ndstimu b.t<thethyroidglrnd
bat11ogrlt!t~ .,.., ""WAI i >"" Ttam !S ,;,,,,,__aod •·•«lttttd ,o
di,&,;,bollHollofF.,., . Joml.....,,..ll,G•y .. ....,.,'-',-~of
Whrntakrninace>sOTby,usceptibleindividu•ls.theycan WN«bo/l"'""' "' SanDl,g,>SI01eUol-.tt~ ,, ~.,11~e&.1 .. tO<
causetheji tteB,anxiety,hndoche,,highbloodpre"ur •, og,ofSifr--Mll"•rytl.-i< ""' "" M, ~lltd,,,d"f'<dfrr- 111
,
cardiacarrhythmi.a . po<>Tdigestion.andovuheating, " iloMtof"'"ll
'""-"I!'"""""
A ,harpincrnseint he u,eo/ephedrin e in,porucoupl ed
cc..n,-~,,,.._
.,...,..__,
with publicity ova the d<aths of• few othlet<> led the
FoodandDrugAdminis1n. tion (FDA)1owam2~m.onu!.c -
toru,;•gain,toontinuingtomorketto •thlet<> . The FDA
stayofbaseballbecauseitkeptthepbyeralertin•game
•lso prop<><edbh< ls warningtha1ephedr:1can causeh <an
that~longstmchesofinactivity .Th eimageof •bas< ball
ottack, . ,trok<, a ndd ... th . The FDA<>,entu.al lybann ed
playerwith•brgewadof · chew "i nh is ch«k.,pittinginth,
ephedra in dietary , uppl emrnts; • 200 3 ooun decision
revenedthat b. n,buttheFDAmntinued 10,tandbyitsown dug l.w ... common
ruling. '"' The fede flll go,unmrnt rn d many stat< go,,em -
menl5 >lso re,trict the ...Je of ephedrine a nd pseudoephed -
rinebecaUS<itis~ u• prrcur,or o/theillicitm.anufactor<
of meth • mphewnin<>

;!~~i:~~tba;~:id~~ A~A.:,',;',:~;~~~ ~;~h:~<;:~

ephedr>.>ndephedrinein).\inorl<agu•-ll.•ndpl•y -
u,;ar,nowtestedforthedrug.lnaddition.thebasebal l play - Tocb.ytheprocticeofchewingtobaccoisl ... commonthan
'un "on,ent •: ti to't,m emben . 'ng•h< ·th itonce wu du e topbyus,peakingoutaboutth e health
u,e ofthedrug problem>>ssoc iated with iL lt", originalpopubrity cam,
• bout becau,e it w••• , timulant. •nd didn\ cau,e rn)·
reduct io noflungc •pa citynorhinderhTuthing•nd • ndu, -
Thenirotineincigarette,andm,okele55tobacoois•mild rn c, a,; smoking would. All form> o l tobacco ron<ain
stimulant th at increasualertneos. After a mild boo.t.it niootinecom tricl5bloodv=ls cau,;ing a risein blood
ol«n•ctsu•nci.axant.Chewing tobaccoW2Soncea m.ain- pr=ureandh ... tt rate
 Androtlffl«I"""' ti pmch,ttd inoll ,nanunab by lh<g<>nad,,
and1h<odmialalzwl5andb1'MUl>olludbylh<li=into
1HUJSl<..,..lnan<igh1-wttkSNdyoflOhealthymmwith
nonnalta10>ttn>n<icvm,hal£.....t~ion<andhall"
us,,d I ploctbo. and all a>pF<I ln mimna tr,uning £orth<
dura1ionofthe,tudyTherDdt<hersfoundr,odiff==ln

=:~t::::
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~; /::.1::~~
r,moL<h.onnont.inthegrouptho111stdlhcdrugn""'ll"""
In 1994 lhe NCAA banned the...., cl 111toi:-:ro produru lnc,as,cln<hri:hloodl<wbo/HDL "' ll>clop:alooncln>ion
durt111 NCM-<Unction«I. evmu . Today t.et.U M=""' .,...,tu,11bciW>!.lana:in<n-.l~bol...,,,.tcn>1K,
"'"'ly
.. m .,.;.ng ,mokd ... 11,booco11 Major Lague pma; ..-t,lch......,.dln<ffa><mdunntt...Sm""'lc•mcinpa,pk
W)' chew gum , mnlla,,,,cr >tt<k , and btd jerky instrad, to whhlowl......,crnnt,butin,i-.cwich-aln<cb,it
dnolwi1h s1meheoafinactivity . pc,,bably.....,ld-.
Other Performance-EnhancingDrugs Dlll!A, tsimilnhormonc • .,...\11'tdln•Ucmptotoincrus<c
and Techniques JOf'"'dll tnd p,riphcr:,J t<01.001.l1'0ncu ,...,uu-rogrn I"."'
ductionbtctusci1ioaprccurootofthos<hormona.Slud=
AndrostenedioMandDehydroepiandrosterone(DHEA) found llnl, effect from th, subotancc, bul ii did cause
In 1 1996 lnt,rvi<w wi th the fim bu<man for the S<. l.>ui, unwan1<d1ideeffeca,uchnttduotdnaturall<Sloo.tcrone
C.milnals , MMli:McGwire. • rq><>n<raslocdabout• bottle of
mnbclr,e on McGwiffc• locka shelf. Mc(;wl,.,on his~ to
~:i.::i':".~~ liver damage . Ov<cMbc-ccun1er,ale.""'"'
..,...t,ln&lhc )7 -yar-old liom< run fttOl'd.i<kntili<dii n
andrmlmCdion<.1nawnl""'-lhatlsa dirKIPffC""<lr l!fflBiod<er,;{pn,pranobl[lnderol ' l.,,d
1nwbloio,.,.-.or ... -- .wbosicmmhormon<.atenolol{fenonnin'D
A1thttlmelhcoo-call«ldinarywpplm,ent,....lrpllnMajor Btllblod<,nattpracriba:lbyphysicuonslola,,,TTblood
la&11< BueboU bu t bannal by th, lOC, lhc t--'Fl.,the NCAA. J)ffMUtt,decr<a>ebcann1e,prr..,n1anhythmia,,and
andprofeaionaltenni,.McGwir<111d<Ntthtsuppl<mrnt
httptdhlmtr;,lnlong<rby<n<rgai"3mUsclctbuldu '.tl_1<lW
r.su lts amc from the thou.ands of hours he spen t tr.nmng, ""'
~:=~':,7,
~~n~J~~7:.~;\i:;;.~ ~~.~;:;
pm'cnt odrcnol!nefromblndln3iobctarc«j>torson1he
Rtcognlzlng h;,, =ponsiblHty • 1 role modd, McGwltt hur1).Th,1Ta bilityto block ncrvcccl1""1Mtyinthebraln

I
announced ln 1999 that I>< hadOIOpp<dusing tht,uppl,e - .. 1m,ond01codia tb ebody. "
m,n,-1h,,am,yarhehi1Mhomtruno.Sill)"2Hlatnhis
saknct about st,roid U>< briort. romi:m11tt Btllblocken:arealoou1'tdioconuolthe oymp""""o£•
ptlydamagiodlm-lmDl'londcm:libilir,:lt-,,\untll ponlconadorOllg<fri&l,LB«:alw.<1hq-c,.lmlhebnlnand
lOI0<N1hoodmittm.using>tndcls. .......,lrc...,n,mmeathlrtcscomp<tin&inriflny,:m:hery,

f,,,,,.,,,,.,1..,i.-,.
- ,,...............
..,
;~:1:::ii:=/J
___
_
...--
,.,_,,.
1t,u.ol1"""'"1MJ">'>ih'.l"Y
ais<•"'-"""'"""""'
 D'n<Drug,,Othet-... 1.ll

diving, ,kijumping. biathlon. p,ntathlon, and m)·oth<r 5Cnltiyandmo~'ntrn,et<hgcau·" .<t,ototh·nkt 'ce

,ponthatr<l ie,onfin<motor,kill> . 11><them.°' Brt,.block -
u,;arebo.nn<dbyth<IOC•ndmost>1hleticorg:mintionsfor
,pecificevrnts
Beta blocker,canc•nse !.tigue.l<thargy . dmgerouslylow
bloodpr<Mur<.g:,,;tritis.occaslon•I IU.U"'1. >'0miting,•nd
t<mpor:1ryimpotence ." Thesedrug,have thepotrnti.ol to
int<milysomelormsol .. thm.oandcomplicat<h e.:tnprob-
lem,.which=h<fa tal1oth<= -
Erythropoietin(EPO)
EPOis•bloodoxygrnboost<rth.imimic,thehumanpep-
tide hormone that stimul.ot<, bone marrow to produce
more red blood cell, . which carry oxygen to mu,dn. The
drugisin ject edovu•periodoftime;!ttake>twotolhr<<
V.'<<kslorthe effeca tofu llymonifenEPOl>themostwid<ly
u,eddrugincompetiti,.,cycling•ndispopui.orinoth<r
rndur:1ncports
~havedevdopedm<thod,1ote>tbloodandurinefor
useolrecombin :mtprot<in(rhEPO) u wtll .. forEPO:ma -
logu<>... but<><p<rim<nttn:D'<tryingtodevtlop•rtificialral
cell,rndoth<r,uh,tancrsthatwillincruseth<oxygm-carrying
C2J)Obilityolthecirrub.tory5Y5«m ."' Stttttch<rni>t,aretrying
todev,lopnewEPO,•ndbiooimib.rEPO,.WADAhasd~.,1
opedl<St,lor,ome,butthebo.ttl<todetectisongoing
Vnoupuv-EPO•dministn.tionresulain a thickrningol
theblood,whichcanl~todoarndcaw.e,trok<orh<>.n
.itack . Sweating . edema. a ndthe:,ccomponyinginc,.,..,.,in
bloodvisco,itymagnifythepotenti.oldangaofblooddoa
A numbuofEoropeancyclisadiedfrombloodmE1ipub. -
tionovutheP"'l20y<>.n . EPOisbo.nnedbphet-:CAA•nd
th< USOC • nd in moot every oth<upon
BloodDoping
beforeusingany,uppl<mentmdtocar<fullych«ktheingr< •
dientsinth=theych000<to11>< . 0ft<nll0ffl<ingr<dienaare
notli5'<donthel.obelandrouldtriggaapo,itivetestfor
bo.nnedsubstanca.Somet<stsregistuedpo,iti,.,forminimol
<><po>ur<toandro>tenedione , a ,uhs<ancefoundinmany
,upplemenabutnotlistedonthelab<L • Tn<goveming•g<n •
ci<>ofmo,t,portsli>tbo.nnedh<rhal,uhstance> . Th<NFL
V.'<ntone>tepfurther•nd5<tup a productcenification')~t<m
torn,urethatcntifiedh<rbalproduc:av. '<r<frttolanybo.nned
,uhs<ance>. Unfonunot<ly,b<can><olth<complexity•ndthe
co,toftheprocroure . onlyoneromponycomplied ."
AlthoughmE1yprob lem,gounreponed. a ,tudyofllV.S
poi,oncontrolcrnt<r>reportedthattheirhotline,m:<iv<
more than l,300 call, rnnu.ally r<11"rdingdi<tary rnpp l<-
ment,.About'IOOofthecallersha,.,mild -10-,e,u,')mp-
tom,thattheybelie>'<W<r<causedbyth,,upplemena .T h<
')'Inptom>rangelrom><izurernd • rrhythmWtolivud f'"
:::~"';; Fou r death,"'""' thought to b< ,uppl<m<nt
Oneofthemo,tpopubr,upplemrntsiscreotine.anamino
acidtha 1 i, anutrition2lsuppl<m<ntcre•1<dn.otur.tlly in
th<body • nd •lso foundinlishandme.i .Th<useo fcrtttin<
- inmusclernugyme!>.boli,mhasbttnr<>an:hedlorlh<P"'t
IOOyar, .h isusedbya thlet<,tod eby musc le f.otigue. stor<
rnugyforw.ein,honbur,a.ext<ndv.'Orkouttime,mdhdp
mu,;cl,o reoovu f.,l<T. Thrupoundsolmeatrontain 5 gram,
(gm)ofcre•tin, ." Theu 5<ofthi,,uppl emrntbenefits,print
di,ciplinn. ,uch u running . , wimm ing, cycling . and many
powa,ports
A ,tudyolathl<te>engagedinr<>i>!>.nc<tn.iningcompor<d
th < energy level, and the musc le m:overy of on< group
receivinglOgmofcTnlin<o,.,, a ,i.o-w«kperiodwiththo,e
olth<controlgroupthottn.inedwithoutcratine.Thefind -

:::::!°t:!, ;:::;:bee;!~~~ •::::~:.~b'i:': ing, , ugge>tthatth<,uppl<m<nlhdp,

•ndh< lp,muscl,orecovufuter
t h<body,tot<<n<rg)'
. The,ubs!>.nc<i><ff«tiv<
carryo,cygen.Nonruolly,•bonttwouniaof•n
or,omron,el,.e",,blood•rewithdr.twn.frountominimiz<
d<t<riorotion .m dthenreinfusedfiveor,lxv,.,,ks
athlete ",own,

i.ot<r(on<
:hu,7,"!.~::~:•:~,::;t:~
:~;:::;~
!:,:
ncrtt<
to,e,.,ncb, .. befoucompetition) a fterthe•thl<te••blood "ltd ""'f"""'" fl!"''f""' IIUISCl,,do,,"tsrtfired
,..,lumeh:i,;r,tumedtonorrnol . Blooddopingi,practiced atrdjwttal:n"""~"""'o{th,,ow,,,_, fhotmabl,,
inendur•nce,po,nlikecyding . long-di>tancerunning.•nd ip«to,..,,j,ootlone«oodho,J,r.·
crooo-coun1ry,kiing.Te,aindica1<thatblooddopinglowen
perlorrnancetime,for•'l-mileracebym" '<r.tgeof-t3sec-
ond,rnd•3 -milerunby•boutHseconds. " ' ' ltinc,.,...,. Wh<nan athl et<ov eru.,.crtttine .thuei>a ri>kofdeh)'dra -
rndurance•ndperfonruonceinlongarun , tion.>tomxhcr:1mp,withruou,e•anddi.orrhn . andmu,;cl<
pulls . m • im . •ndda m.og,. althoughone>tudydownpby<d
Dopingrrquir<>bloodtr.tmfuslon, a procciurewithinher -
th e •ctwol damage ... Thueis•lso • concemthatcrtttin<
rntrisks,uch upoo rsto~< . viralorb.cl<riolinfection,,
cau.><>undue,tr<Month<kidn<)"'
mdfata l re.actiomduetoml>b.b<ling.~u•ll<5t,,xi,tto
d<t«tblooddoping.butthey•re<><p<miverndpo,itive
11r,yrot«t .d.:r"9"tl,.,tls,,i.ith .. moooal,i,ppl,m,nt,
=ula•rediffirulttoronfinn . Blooddopingi>fOTbiddrnby
;,11.ittl,,,.,th,t<~ofoth!,t,,-tolnjtoo,,,,,.,,tlt,,.
mo,1,pomfrden.tions
tommp,=t,fo,otl,,,thi"B'-fur""'mpl, , efourtoill

Hi>torically. • thl<te,ha,.,u,edh<Th, , • niTrWex1r1ea . vl1>

mins,minenls .pro «ins,andrnyoth<T,uh,w,c,thatth
belie>'<willimpro,.,th<iroompetitiveedge . Today incr=d
:.~r:1..1::;;:~:=.,~k,,":,;t,7,
fhinl;foatwdlfr<tlt,'""""'of"",lf«t"
ey
,._,~,...,,
........ D..d""""ol""""""""""·"""""'Y°'""""'
CW>ifi<d u •nutritional,uppl<mrnt,cr<otinti•,oldov<r we ight.Thefiip,ideof•nor<><iai>•n<wlyddin<ddi50rd<r
thecount<r•ndi,no t b•nnedbyany,poruagency. inmal<Sc>ll«lmu..:ltdy•morphia . • prroccupotionwith

C..mm.t-hyd,oxybutyrate(GI-IB) ::i:t~~!:n~:~~e::,~::u~;:!1~ : i;:;

l~
The,uppl<mrntGH8w:o,;50ldinthel980o a ndtheariy w.akling,,oheoontinue,tolihwrighl5 a ndoft<ntoke,
1990. ua &t bum<r,an • rwKllicagen t. ••l«p aid,• ,uppl<mena a nd,t<roid, ..,

:.~:~.
=.:~t:J~-::~::~
:r:~:::~
~~!:
~~::::~
1om:luceaiabolicot<roidW:1t<r -wrightgain • ndr.ti><l<vel,
Diur<tic,(c .g .. furo,emide lWi x• ]),,1acrynic • cid , h)'dro-
chlorothiazid<,andtor..mid<)•re • OOn>«ltol0«w<
T h<o< drugs incn,..., the rat< of urine formation . which
ight
of HGH. Abuse at rav<> • nd other ,-,enaiswid«pr<od
spe,d.theelim inotionofw,iterfromth<body . Athl<t<>u,e
accountinglo r •nnmbaof, i ,iato<m<rgrncyroom,;lor
th ... drugsto
respiratoryd,pre..ion, •mn<>ia, occa,ionollycomo . and•
dramo1ic.Jowingofth <h< •nrat< . GHBho,•lsob<rnu«<l • Jo.,we ightra p idlyortoqu.alifytoromp<t<in•panicu -
larw<ightclas,
~<~:~ls:!'~°"._.• dat<-r.tp< drug . It is now illegal in
• limitthebloo tingc•n...dby>t<roi<b
• avoidth<d<tectionofillegoldrug,duringtestingby
SodaDop ing increa,ingurinocion
Someathl<t<>believ,1hoting,stingalkal in<sa ll5(•pproxi -
• •wnr th innerormor<oculpt«l
mat<lyl0gmolsodiumbicarbonat<)90minut<,priorto
<>«rci><dd •y•fatigueby decr<Hi ngthedevdopmrntof Exc<MiV<n«ofdiumic,can><>d<h)'dr.ttion . whichwhrn
acidooi,.Theprxtic e cou ldbedfectiv,for,print -typ< roup ledwithexerru<ortheu,eolec,ta')'rndmeth • mph<t -
!po~ with durat:~•. of 3<;s«ond. to 10 m; .ut,sh,abut ;'t amin,crn l<adtohatstrok<•ndorga n damag<

5 gmof a lK>lin, .. l1 is used u •n<Ij!ogrnicdM<;thisdM< "l1«1<,9M'nodwrm<:o""dl,,fo,,/...,,-rocon,prl<.

:;.,.;"': moi: twice th< mnimum reromm~«l dai ly .,;tl,i,utn,ctiom..,ttodrin(..,,,thanohalfCMpo{'""'t"
p,,d.iijiprob,,l,Ljlo,tJ2/!,,of,wt, r thatw,,lll,fttl,,
dormtl,,""'?""8of""!comp,tilion.an.:111!lj"'~bo,acro,s
Weightless
th,o.aildidnt,""9""'""k"""""lf"' • ""'"'J,"""'
Att>ining••p,cificw<ightisnec<>oaryorotronglyd,sir,din lirooldn'tha..plac,d=ondif'tl,,ll'f"'"'""''liodn't
a numbaol,poru,uch • •wrestling,gymna,tics, a ndhor« fi.""""tl,,dii.r,lic"
radng(jockcy,u,u.a!lywrighl=th>nll5lbo.) . Athl<t<0
u .. d 'urfl'cs,W<llt'v<> , <>< ·.,,, · ' ng . ..,lf'nduccivom-
iti ng,andexcuo,w<atingin•,.nno10,hedw,ight.Th,se
pnctie<Scontinuein,pit<ofthe<Vidrncethatdehydr.ttion MWll aneou,PerformanceEnhancingDrugs
,ignificantlydiminish«perlormonc< . Som,athl<t,swilllo,e and Techniques
J%1o 'i% ofth<irtot>lbodywrigh1in•ronpl<ofday, • Adremlineandamylorisobutylnitrit<.Thisoombin •-
tioni,uk<nbyweightliftenjustpriortocompetingto
,\l,c.,ndtfinit,~s,, !hat8'!"'""'"'""wom,Ja000t incr<>«5trnigth . Thedowns ideinclud,sdi,zin<S5(•
thrir""~t.l111ron . """"llarounJi11!rota,Jsand dangerou,condicionwhenholdinga+oolb . Nrl><llo,-.r
"",fiU,.~""."fat. and 11,,,,
·, prol,,,bLj
l>O! on ,x.,..:, one'sh<><l). rapidh<•nbat,rndhypert<n,ion
o{fat"""'"lof""rbodi,,· • 8tt pollen . This ,oppl<m<nt is ,o ld in pellea mad<
fromplrntpo llem . nector,mdbeeoaliv:othotcontoin
JO%prot<in,5~%carboh)'dr.tt<,,50m<bt, a ndminer.tls
lnaddit iontodi<tingmdexuci><,otimulanaar<usedto
Anecdota l r,poraclaimthatbeepoll<nincrtt><><n<rgy
rontrolwe ight,<.g.,di<tpill,(preocriptionmdo,-.r -th <-
kvds a nd perlorm:mce. boooa immunil)', reli<v<>m=
rount<r),ill<!!"l • mph<wnine,,tobacco,rndc•ff<in,.Aft<r
•ndimprov,sdig<>tion . botmost<e i<ncificotudi<>do
a f,wmonth>olrontinuouou«,mostdi<tpilis•nd•mph,1 -
not,how•nyperlorm:mceorrn,rgybrndia . lf50me -
amin<>l0><thcir,ffectiven<S5 . buildingtol<rmc-< a ndtissu<
oneh>••nall,rgytobee,ting, . rninad,-.nrnt,tingeror
d,pendrnce,whichcantrigg,r•l,us,e•ndaddiccion . Mniy
othercontominontcouldbedang<rous . Beepollrnisnot
amph<t>min<•ddict,,ton«lu,ingthedrugtol0«w<igh1
banned by the IOC or th< NCAA ...
Th< NCAA r<crntly changed lnining ru l<> for WK<tl<f'.5 • c.Jciumpongamat<.This,ubotanceisal50call«l"v!ta -
becauseofthenumberolinjuri<,mddeath>duetodehydra - m· B,,.• Pmgam'c 'd · not• ·um·n. no r · ·a ddi -
cion •nd exc=iv< wright lo,s . Wr<oti<rs •re not •!lowed to cirncy linked to any di«.o,e . Testimoni •ls cont<ndthot
u,eanymechani,mforsh<ddingweightduringtr•ining,•nd itkeq,,mu<el<lison<b<tt<roxygrn.al<d ,b utthisdf,ct
a grutufi<Xibilil)'penniaupto•7lb . varianceinthelisted isnotrnpport<dby<eirncificraar,;:h.hisr,port<dly•
weightcat<gori<> carcmogrn
Dulimi•(<ating • ndpurging) andanorexia(•wvation<ot• • Cyprohepwline(Periactin ~). T,k<nlorco ld, a ndaller -
ing)=•l50r< sultfrom•d«ir<to•taythinormok<• glc ract'on,, th ' a nnnswn ·n, (,eroton'n •nd h' ta-
 D'n<Drug,,Othet -... 1.ll

mineant.agonis t)is believedtocaus,eweightgain•nd todrugstohdpthemcopewiththedemandsof • heavy

incrnse,trength.Some11><r,believelha1thispreocrip- ,chedule (practice . tr,vd time, rour,e work ), to m:lu«
tion~rug_•c:tslikea,,,eroid . bu1in,("':'thei:re-:;:; str<M. locompem.,.l<'' nd'ness,or1opass1 ·meon long
roadlrips
by =tonin\ effect on •pprtitr . Side dfec1> include
decre asedperfo nruonce,,wuting , and...btion "/doo"t!hinll""'cooJ<l~nJtoo•«"''l'olJ'9'P"'!f""" -
• Darbepo<tin(Ar.mesp ~).iM>ignedtotrutchronican e- !d:.,tl,allp"'!fa"".footb.U. trocla"'l•po,t - tl,,,ttlieu
mia. thisdrugbooststhtamountofoxygrninthtblood athlet«Jo,i"tdrinl.Andl "'""'" tl,,,tthmar,olot o{
f'<'lf'le,J,osmol:,...,,Jroo·
Ate>ttodetrctthisdruginurin e wa,de>'<lopedfOTthe
lOOlV,,"intrrOlympics.OneSJ>ElishandtwoRu»ian ......
.......,.,
,,.,..,..,..""""
croso-country,ki er, trstedpositi- ,,.,lo n:ingforleitureo l
theirmedaisandexpu l,ionfromthegames ...
Stimu lan ts
• Gent doping. Thisisddined byWADA u" thtnon- Both•thl<t,oandnoruothlet«d<rivethe,ame•~tages
tber.1prutk11>tofgene,;,gmeticdemcnts . :mdlOT«lls •ndexpootthems,lves to the Yme ri,ks when u,ing.,imu -
thllthllvtthtc•pacitytotnhlln«athleticperfo,.. lants r«reatioruolly (su Ch • pt<T J)
=. "Grne then.pie>thllttrutan emiaarulperiph eral
va.,culardi«2>tarepo1rntialmethod,ofincru.singthe Coclne',oneoft'str•A<>' J , lm1>bu1't ' notof
~e:':r°!.~gencnriedbytheblood,mimickingthe u<edH a p<1'rrmi«<nhancubecau«·1 · 50shortact'ng
(J0 1060minut<0)that a n a th let<wouldr<quir<additional
d=throughoutthedur.ttionol•game.Al,.o.therapid
• Human chorionic g~otropin (HCG), HCG, domi -
r,bounddepr<Mionis50int<ns,thatunl<Mthedrugi,us,d
phrne . OTtamoxifrn is occaoionally u«d to n,t2rt the
everyJOm "nutrso r ,o't"mpa"r,pe1'cmE1«
-y\ownt<.,0>1tTOntproduction a fteran•b-olicste -
roidu«.Toxicd!ec1>ontheli,.,,andthereproductive
,ystrmha,,.beenreponed
• Modafinil(Provigil ' ).Thisp=criptiondrug,U><dto
trutrarro lq,sy, acts :,,;a>ti mulant . U,er,b, lievedthat
modafinilwouldmaskthe11><ofthebanneddrug TH G
(1<tnhydrogestrinone)
• Non-•pprov,dsubstancu.Thes,aredrugs50ldonthe
bl • ckmHketbefoneapprev>.lbyth eFDA(e .g .. CERA
[« ti .ou, erythropkt"n receptor ti otorl, an
advancedver,iono/EPO) Sedative-Hypnotic,
• Omithintand arginine. Th<>< •mino acid.ar, taken Some athletes u« drug, ,uch"' alpra,ol•m (X..~). barbi -
1oincra«mu<eleRa>Sbecau«1hey•nepurportedto tur,te,, oropioid.•s a r<w.trd for enduring th< ,tres,of
caus,there l<a«colgrowthhormone . Highdo«scan performingbe/or,50manyprople.They•l,.on..,th<S<drugs
ludtokidneydamag< t' :~; /'\;~tthwu::i '>t~eul·~::nu,ed f':nh~.-
• VitaminB 11.This vitamini,injectedortakenOTil! lyto perf ran« . Depre.,.nts•recount<, 'ti : u a perl
wmloffillne55 andprovideatr.trnergy.ltis•OOU><d fflEl«<nlu.netr,•lthoughtheirpainkillingd!«l>can • llow
1omitigatrthedfec1>0/he avydrinking
an athletetorontinuetocompetrwhilein j ur«l
AthleteUse of Recreational/
Mood-AlteringDrugs
lnl 009• photool14 -time0lympicgoldmedalistMichad
Phelps,mokingmarijuanafrom•b-ongat a partyw:,,;posted
onthelntrmeLltwasfivemonth , aftutheOlympics,and
Phelps wa, no t in tr ,i ning . M•rijuana is not romidem:l
•per/onruonce -enhancingdrug,andPhelpswuu,;ingit
recneatioruollyEverydrugusedbyathletesi,notautomoti -
cally•perlorm:mce-enhancing,ubstance . Phdpswunot
lngener.t l,alcoholntgativ<lyaffectsr<:1ctiontime,coordi-
charged, and he apologized to the publ ic,>ayl ng he hm ru,tion . andbalanct . although,tudies,ugge,tthatlow-dos,
:::-:::iru : :~mportant les>on and would be mor< r«pomible •lco ho! oon,umption dO<S not imp;air ""'}'One • perlor -
fflEl« . TheNFLdrugpolicy,tate,that•lcoholis"without
Manyoommonpsych oacti,,.drug,ar<usedbyathltt<>to qu<>tionthemostabu«ddruginour,port ."T heclu.ll eng<
•dju,;tmood ,, helptbemfitinto,ocial , ituations , comply isronvincing a thletr,tha1thereareser:iou,hulth andper -
withpttrpru,ur<e,imitat<thtbehllvioroFolduroltmod- formancecon"'l"<ncnlinked1o • drugthath"',ocial,legal,
ds . orconformtotheirownself-im •ge.Athlet<> al50 turn andmoral acc,p tance ·noursoc ·ety.
 :!~mat~:;-
• i<•bonntd,ubotancethatwillresuit inaone -ya r ,u,;-
!;Yoo·U~,~~;:"21:7
d,dilv
a Yoo
~::t=
J,d., "'''lj·
in otlilmc, . ;i,,t ~, a in
pension from any NCAA <pon
. i, illep l mde1nd .. 1roymathlet<~e1re<r
t'9!.A.dw,~, j!a,co,xl,,, _o.dtl,,pb,'f'""''t.oo"" Marijuonai<f at-!iOlublemdrnruoin,!nthebodyfor•long
trljtood.Jr,.,jtri(j,t""-"'j" cim,cimpairmen t canpersi<tFor-eralda)-saft<rc .. uol

:;~;~~=
n«•ndlon gerafterc,cs,.tionoFchronicuse.Athl<teswho
admitu,;i ngmari juanabe lievethcyareperf ormingwell;but

~o~:a~:':~!;ot~:Z 1
::i::i:: e
anobjectivestudyofth<irperformanc,,how,tho
,mok< marij=
t thosewho
perfonn pooriy - th,y drop more~
perfonrumce.Akoholi,usedHa~ rdforperforn12Itcr
.. away t ounwind , a nd .. aron!iOlationpriu,and itcau .. ,
romm't monc = - •nd ,uff more · ;u ·,. du 'ng tl<i ·
rollegecarttn
the~eproblemsfo r a1hle1n .. itdo«forthegene.-.l
population . A,urwyby1h<NCAAfoundthatdrinking lev- Curren tly. theNCAAb•ns a llmarij uamu«forethicaland
el,olstudrn1 -a1hlet<oar< the <ame utho«o fth e grneW monlreasonsr.otherth2nforperformancernh2ncem<nt
population . One<1udyfoundthattheincidenceolacquain -
1>.ne<r>p< im-ohingathl<teswufi,.,timesgra1<rthan1hat
Testing
:;:;:!~:!,'";',ru"h let .. . andalroholwa,;involvedinmostof Each,poruorgoni:E> tionh2s itsownli<tofbann«lperfor-
Tr12ItC<-<enluncingdrug,andtechni que•Hwdl .. polki<•
T<gord ingth< consequ ence , for use. In 1986the NCAA
"\.lbovnar,"""'"'1,,,,ab/,,~~~•l,,nth<rj·,.1,,,Jroo bepnl<sting at allNCAAch • mpiomhip, a nd inl990initi -
,..,:1,
to <trialri,,~-,,"""'
!¼ to 1,, rnp«Ld.:ttt-,op.-d •t<daya r-ro und •nabo lic,t<roidt<,cingprogram .Ba nned
dru g,--i ncluding m•bolic <t<roids, HGH, diur<ecie<,be11
"'"'"""""- Sr.J~afrait"diji.., .ho..,, !hat ,1.1,,1,
athl,t,,_111l,,ntl,,~·.,1t.,Jroonuochtodrinl:.tt.dtol,,rom, blocker<, alcohol, amphetamin« , most m«t drug, . md
<>fraordinari~alfl""iw. high level, ol caffeine-ca n be th<r.tpeutic , perfonrume<
enhancing,andlorrecrutional.Thelir,1po,itivet .. treoull5
Atbkll<- . C,ll ionwSw, U"'w"'< < Soc" "' "'°
in a los,ofeligibilityforon<)=rcthe><rondpermanrntly
Alroholi,gen,.-.llynott<ot edforun l<Mthe•thlet<uhib il5 elim iruote,anathl<telrom•llNCAArompetition.ln••nrvcy
aim>< a nd addiction problem, . Unfonunat< ly, studen1 - ofNCAA>ehool,,only36%ofth<=pondenl5hadmalco-
athle1<, ar<l«<l ikdy1hanothercolleg estudrn l5to., , k hoVdrug tducacion progr:,m lor <1udent-athl<t<o. Three -
fourth>oltherespondrnl5,aidthcyrelerstudent -athi<t,.to
hdplo r ,ub.1.mcr-•bu>eprob lemslromtratmrntprof,._.
"oruol,'nth 'run·v, 't, :ommun ·, rommun ·ty, 0 .,., couru" ~andlratmrnt
Olympicdrugt<<ti ngreachedanewlndof""Phi<tication
Marij uan~ aftertheWorldAnti-DopingAgencybeganroordina ting
drug-t<ot inJ!progr.tms,in1rn,i lyingre ..._rch,cnca1in gedu -
Althoughmarijuanai<lega l inWa,hingtonandColor>do, il5
c,tion•lprograms,andannuollypub li<hing a li<1ofbmn,d
u«isgenenllyforbid drninmost,poru.Anecdo 11lly,how -
,ub.tanc-n. " -"' Th ' proacfveen 'ronmrnl '«red mor<e-
<V<r,theu«of1hedrugforrecnca1ionalpurpo«•(notlor
acrur.tl< t<ol5 for HGH, EPO, blood doping. and oth<B
perfonrumceenhancemrnt)i<muchmorewide,pradthon
Othert<>ting ogrnci<>are taking ad,-.n12ge of WAD& prog -
pr<>-iouslythought . M•rijuanacm<ithu<1imu lot<ord<pr<55
th<=,d<pendingonth,,tttngthofthedrugandthemood "'" 10 impro,.,e their °"" prognm,. T«ting programs in
prof<Miona l ,portsvnyfromo,ganizationtompniution
ftheus,Th,mostron<t<nt, ~ '~;anau .. · m
incra>< inpul>< r>t< of about 20% duringex<rc~ ... TheMajorL<•gueBaseballdrugpolicyi<basedona n agr<<·
Mariju•rut can lo wer anxiety , but it hinder, .-.thu tlun
hdpoperfornunc,c ~~•mi;::::,~;
~~t7."'i:~;::!:e
~=~~;f
oth<rill<g • ldrug,andrequireor>ndomt<ocingduringth <
Thedrug
><a!iOn. Ploy<r<can be tested on ly one<. A pl ayer t<oting
• Jowmbloodpreos u re, causlngl aintinginc<rtain,itu - po,ith,elor<tuoidsrec-<h,e,•30-game,u,pem ionlorthe
ation, (e .g .. lootball linemrn moving quickly lrom a /ir,1 off,,,.., a 100.pme ,u,pemion for the o«ond offrn><
crouchto a runn ·ngpo, ·t"ond ,nsoffmeso,-.rthe and•lif<timebanfrompb.)inginM•jorL<aguepm«lor
cour><ofapme)
~: ~hii:~:tth:~~~rogr.tm i, not "' thorough ., tho« of
• inhibi15,w<oting,cau,;ingh<>tpro,tr.ttionmd,trok<
• d imini,h«h2ndleyeroord ination TheNa tionolFootballleagu<ha•••lricl<rpoliq,lnl007
• imp•irsth<abilitytofollowamovingobj<ctlik<aball theNFLandi15pbyen'unionogr«dto<v<nmore-ext<nsh,e
inpb) ·(d«~t racking•bility )
• hindenthe•bilitytodocompla t2>ks. ,ucha,hittinga
1
t<ocing,addingEPOt<ocingandincre.o,ingfrom

:!::.~~l;,~~~1~
r"i~~~~~~::.:r:::~~~l
.... -.ntolO

golfball alour -gam,,u,pemionlorth,fimoff,,,..and•on<-yar

• decre....,oxygenintak<beausethedrugi<,moked ,u,prn,ionforthe><rond
 D'n<Drug,,Othet-... 1.21

TheNationalBask<tballAssociation testspla)'er>lourtim« covn -upshavelo,t<redanasoumpcion inlhepublic >mind

P<T"'a<on. Su,;pemiono in clu de 10 g:,m«for the /ir,;toff,no e, ol guilt yun tilproveninnottnt
f;;::~:u~;;nd, one year for th< third. md di,q_u.alificacion There is • thr<Catthatf>nowill tum aW>yfrom,portoifthcy
perceivewinningtobether .. ultofaecrs,tothelateot
Th,Nation21Hock<yl<•guerar.dom lyt estsev,ryplaya phar=logyandochem .. toevadedet<ction.Thi<ha,
twice •nnually. with prn.altin of • 10-g:,me ,u,pemion for
thefir<tviolationand60g:,mnfOTthesecond : ~;;~~n•~~~::";_,7.1:7i":1:.'':v~•
for u lrn,ksonanyrerord<thatoccuITroaft<rl987lha1•re
As,trtttchemi<aberomemoreknow ledg <able.lh,yneb<t •
in question . Drug, •lso roh m athlete of • ,en,e of,elf .
ter•bl<tod e,;elop<rgog<n icdru gs(,uch.,t<tr.thydrogu -
ocrompl i,hment andt>rni<hlhe prid eolwinning. &au ..
tr!non<) before th<r< >r< t«ts to d<tect them . THG H a our,oci<tytrem,portofigures u heroesmdrolemodel,,
bo.nned,t<ro id (modefamou,bylh,l,a,,,balldrug5canda[s)
drug -abU<ing>thl<t«dimini,h a llofu,;
thatwutweakedbychemi«<atth<BALCOdinictomok<it
undet<ct>bl< . The development of• reliable t<st lorTHG
"/fl""'ldtak,adruaand.,ttlt,,..,,l.1,w,,Jootof"'xh(u
prompted!iOme,poru•g<ncintot<<t a lhl<t« " .. mpl .. pre -
~njl,od~andtl,,tmd,oif"""'1dl,,/wooldl,,d,,d u, ~
,..,_.,d lrom previous Olympics •nd world championship<
ij<On./d,ji,,it,!lj""'"ld,,'tdoil/..,.n . tom<. .. l.jio
, OffiW><
EthicalIssues ~ooi"'f'OO'ln!' l"""'1tolia.,ochanc,to8"""oldondpkllj
.,;d,""1/l'andW,and""lll''alifondW,"
lnadditiontotheph)'.ic•l • r.demotionoldang<r> >lhl<t«
Allt,_-.,-oty..,,.,pi.....,_, ,ll O-...,u h""'1<s
upo,e lhemselws to when they u,e perform:mc<-<nhancing
drugs,thriru,ecompromi<«theintegrityofth<comp<ti -
tion . U,ingillegaldrug,orU<ingdrugs illeg:,llytoimprove
ath l<ticperformanc<i<,byddin ition . •g:,inotlh <ru l«in•ll MiscellaneousDrugs
,poru a r.disilleg:,linma,tstat«.Drugu,.,undermine,the
unwav · nas,umpt"ono''ri rompet"t"on"n•porto,>nd
Strtttch,mi"5 provid < oth<r p,yc~th-. ,ub,t>nce, by
itvio lat«1h<,uyruotureol,port,which., inc elhecimeol
'}nlh«izingdrug<thatwueoncel,gally»-.ibbl,.,uch••
themden1Gr«ks.i • •m ... ,meofpenonri,xcellence,lhe
Qu W ud"® •nd ph<ncydidin< (PCP). or by producing
r«ultol•!iOnndmindmd•h<rithybody.Thepublicupeca
,emi -leg:,lorilleg:,ldrugs.lik<'}nlh<1icmoriju•ruo•ndbath
the outcome ofev=t • lhl<ticrontestto bed<t<rmined b)'
,alts(,ynth<tickhat). Tha< >r<nomanufacturingrontrols
di<cipline . tr>ining,mdeffort - notchemistry
"""rtttdrug< . •ndthcya r<nn<rt<sted .lnegu lud""'5,
Th,r.ctlhat!iOm>nyacrused>th l<t«vehem<n tlypro- incompl<l< ~lion,, uruontidpat<d toxic <id<
cbimedlhririnnocenceonlytob<foundguilty~<roded dfects,>ndcontamiruonts inth emanuf acturingproc,..•ll
theb<liefintheintegrityandthehon«tyof•llathl<t« . The canhav,di<>strou,dfectsonanumu,pe<tingn>a .
UnusualSubstances liquidrnd,wallowro. Th is mil kyexudo 1< ol th,rootcon -
Th< numh<r oF ,ubs12ne<• and mtthod• people use to tainsa1 l<.0stsix ch,micals , including•lpha -P,wn .. . tho,
produc,c•drunk<n•tat< . , imilartothll t oFalrohol.wh<n
inducep•ychoactin eff«t>>n d gethighboggleothem ind
u«di n lorg,quant iti<,. U.,nc l.oimthatth<<ffecaof.,,..n
Thcy include<mokingasp irin ; drinkinggasoline , rubbing
q1Urttities•r,mor,p le .. u rabl< • ndr<b.xingthmth,,ffec1,
alcohol ,o r hydrogmperoxide;putting Ambtoo la (to pic>l
of•kohol•ndi1doe,no1r,,ultin • hmgo,u . l<ovoi, u«d
an .. th<tic)inth<ire,~;md,mokingtoad>ttr,tions
uan mti.mxi<ty druglike alcoh olin r<>thome,tor,b.x
Therttl ity TV, howMy5trange Addiction fr a1u=mil ,ld<rlycli<n" . On,,it<of • ctio ninth ,bniinist h< ,a m,one
p<0plewho•r,addict<dto1hemostunu<U.alsuhs1.mceo aff«tfflbyb<ruodiuepines . Antl.orud<ty<ff<el5>I< lound al
includingea1ingwood ,d in , gWO. uce .. , ugor. ca1fu r,ice th,70mg l,vd , wh<rusll5to2 '50 mginduc<><i«pmd
andpillowstuffing.Oth<rs•r,addict<dtoodd behavior, 500 mgo r mor,canindue<drunk<nn<> • •ndstupor.
,uchashoarding,hairpulling,ac<>,rnrgery,tanning . eur -
c',e, • r.dtattoo ,. l<avais<0ldH anhubal,uppl<mmttor<li<V<•nxi<ty,Slr<>0
andifl!IOmnia . Th,r,hav,bttn•fewr<poruofli,,ercb.mog<
Wtth ,,.,., ,W>lw.:na.J l,,O<l>ior>
that b,rom, ..dktit< <>p<eiallyinindhidlWSwithprttxi,tinglim · prob l,m,
j!;,pos,jbletos,,~""1t tl,,pe,,on8'!>fromtl,,"'f'<ri<nu - ln1h<Fij i l,land,, kavais«TVffli ncoconut,h<ll,a,;•w<l -
=" '"f!l· """'"li,fl,,,ll.c j..,tiom.0<p<rl,,,p,a"" "t ol rom<lib.ationfOTvisitor,_Th<<h, ll is pa,sed • round . mdno
<>a1p<.&ain>r,oct""!"""'OOJ!Ljto"npl,-,otaper.,n«> bu,in=isdi,cu5Srountilth<r<b.xingeff,ruofth,drink
,,,,Jifanaclmlijcanc"""9-ap,"""''..,.,,:(it.lonOtha.·, mak< en: , n< m ><nobl, 10 .... ,on
to I,, a pkasant ""™Ii/°' trltfl'ra hw,or .,J,,u ..,.., otli,r
pk<=ntape,,;,nufo,"""'°"'ro"'''°""'tl,,I,,"""°'_ Kratom(m~ragyna)
Add.:hon 5adis<m, ca""d&jonalt<r,d!,,,.;,,.anJa This tropi caltrttisnati, ,eto lndo1><>ia,M•l.oy,ia,T hailand
::::.i:.t~~
,,.~
:::~!1ur":"·""'°""·
,.,.,,,,~ andoth<r•rtt•of>OUth<.0stA,ia . l"la.v<>•r,chewfflby
l.obor<rsinTha ilandto <as< th<irburd<n. A1 highdooe,i 1
,,.,,..
,,......_....,
,._D_
,.....,"""""""="""'
'_, """-Of. d,livusopioid -lik<,ffects , inh ibil5,moothmu•d•contrac-
tion , andreduc<0p•in.Addictio n r<Sult< inopioidwlth -
Camel Dung dr.owal ,ymptom,. At low d<>«> it ha, • ,tlmul.ont <ff«t
incr<a<ing• l<Ttrt... . talkati, ., n,.. , •nd50cia ble behavi or .
ln!i0m<Arobcounlri<,ruo5hi,hi,produc<dbyforc, -f«ding
ripe marij uana p!.onl5 to cam,! , . Th, ir four -ch• mb<rffl stom - Long-termu«T><xhibit,ignsof•norvria,,l<in da rk<nin g
lr<qurnturi n.ation,mdronstipation.Long -t<rmu.,.usin
aclts ronvrn th, morijuano int o has hish cam<l dung, and
withdro wol , xperi <ne< ochymuscl<••ndbon<smduhibit
y<>. p<epl,,mokeit
hos tility•nd j<rl<)'mo, ., mrnl5ofthellTI15.Tho«addict<d
EmbalmingFluid(forma ldehyde) chew lor l 5 tolOyarsOTmOT<.lnth, Uni t<dS tat.. . kn tom
Fonna ld<h)'d<is • known carcinog<nron tai ningm<thanol is u,u•llyobtain ,d overth,lntun<trnd is mostlikdytob<
<thanol,ando ther!i0lvrnl5. This ,ubstanc <,!i0m<tim<>Slo- abu«d u• t<a OTocc»io nallych<wffl . hisnot•rontroll«I

~:!:::rr:'C-::~~:.;~;!
'.:~:r!::•;:::i,-;:\~:;
drug,.Som,abu«rs !iO:lkmorijuan.o jo inl50Tcigm ,tt<>i n
,uhstanceinth,Unit<dStat<>butisill<g:, l toJ>O"<"in
T hail• nd, Aum •li• . M•l.oy,ia, •nd Myanmar. H,ad and
smokeshop••lso«Ul<ratomutracts;th,conc:entm,i,
7-h)'droxymitra.g;nin<•ndoth<r>ctiv,chemical , ,=ultlng

:w:::~
;1z: ~~•
::::.i
th, fluid •nd•mok< them . Callffl "click<r,," "dickem ,,"
m::•~:: d,livers • l'CP -lik< <ff«t
indfecl5,imil.ortoopioidslik<Vicod

Raid,• Kairspraya ndlr.,o l•

in .•

fiuidinth,joint . Effecainclud,
visua l md•uditoryh.alludnations
• !« ling of imincibility. pain
tol,rance . •nger ,para noia, • nd
m, moryprobl , m,. Th< ,ffeca la,;1
fromoixhmm lo t hr<<cb.y,. '°" "'
Fonna ld<h)'d< ruo5•lso b<,nllsroin
ofm<thamph<tamin<
Abu 5<rspunctur,•<rosolcanscontaini ngth<.., p roducn ,
d r.oinoutth<liquid,and•wa llowit . m.ainlylorth<•kohol
ron t<nl. Th<S<products>r< r.,r, ly • bu«d by th,grn<Till
popul.otion; • bus<occurs inrural,001.ot<d•ra,wh<r,acc<>•
--- to> lcoholislimit<d . Rec,ntly,i n nu -dtyyo uthsh"'"'"krn
th<illid t manu factur, 10,pny ingRaid " on tomarij u•n.orndrolling itinto • joint
Thisro mb inationisc>l lffl"cm•id"mditiss.aidto!ntrn,ily
th,,ffecl5olmarij=

lnspit<ofth<toxicityolkad<d•r.dunGdedgasolin<th<r<•r< Sarpa S.l pa

~molpropl<drinking•mixolgo,olin<>ndorvig,juic, Thisli,h,••peci<>ofhr<a m loundoff th<ro.,tsolSo uth
Known., "Monta nagin,"itis • panicub.rlyl<thalb<v<rag, Afric•,Cypru, . •ndM• lta. becom<>toxicil it <.0l5• certain
a!g:,,; ifth,fi,hi,th<n<.0trnby • human,hallucination,cm
occur . ltwa,;r,ponffllyu«dduringRomEttim<>.,•recr, -
• tion.oldrug . ll5p<)'chooctiv,,ffecaha,.,bemdescrib<d
~:h\"':!n'.iro: ~:,':~nt '~i' ,~:"s:,::;~ th;,.:~itn . ~~~ uoi milortoth0« callsrob)' tr}"ptamin<>found in•)'•h=•
South Am,ric• . Th,roo15>r<c h<W<dorcru<hffl into • ""'PY orcoh obo . li,rum,ntnotori<tygr,wlrom • n • nicl<in •
 D'n<Drug,,Othet -... 1.29

tmcicology journal about two diner, who Ole th e fuh at • byhealer> , med icinemen.rarandtTW,andth epowaolfa ith
).ledi<nr>ne .:rnr<staurm t andthen,ufferrdaud itoryand ThefirsteditionoltheU.S.P,1o:m1tacopriaintheear lynin <•
,-i,ua l halluciruotiomlasting.36hour,. '"' ternth century contained mostly herbal medicine, •nd
prepamiom . Proololtheeffecti,.,ne,softh<S<pn,puations
Strychnine wa,notrequ ired.Th<FederalFood , Drug,andCosmeticAct
Thi, oolorle,. cry,L>lline alkaloid is U>ro u • p<<ticide and o/1938,theKefam.,r-H•rrisAmrndmenl5, a ndtheNutrition
Labeling•ndEducation Actof\99()soughttoprove1hedli -
~~n;~g :..:-;,•:::::chc:~:1;;:;:1,!i~;.~
cacyol medka1iommdtopro,idetruthfu l lab<ling. '°'
osphyxla.lnverylowdOS«,!tcaw.es,timulation,,imiln10
that of methamphru.min e. l's, lor it, stimu lant effecl.5 is Asthe,cknceolph.mn•cologyadv:onced•longwiththesd -
uceedingly cbngaous. "' th e dOK need ed to produce • rnc,olt<sting(clin icalst udie,10d<1<rmin<thedlicacyof
stimub nth ighisthe<Ene>5aletha l doseofthedrug th < drug,or herbs),,ome ofth< ffl)'<tique • nd "plac ebo
power"ofth<><,ubstance,diminished.Anunintendedcon -
ToadSeaetions (bufotenine) "'!U<nc:<cofth<><advanceswuthek,..of!. ithintraditionol
TheBuJogrnu,oftoods(ColorodoRhu,SonoranD=rt, herbalmedidn<> . ~bcedbymover -uvermceonthe!iCi •
Cane,andothers )<<<:r•«• • l"'Ychedelic,ubstance,bufotrn - rntific approoch , evrnthoughmanymodemmedi cations • re
ine . frompor,slocatedonth<b.ckofit,neck . Thi,,ub- ba><donherba l preporations(e .g., .. pirinfromthebarkof
,tance i,collected . ,prinkledontocig:urtt<s,and,mokedto th< wil~ _w •~d dietal:ilrom the :~xgl;:'< pl•i:::\~me mod -
induce•p,ychedelicexp<rience.EluFotenineisaS,chedul<J
illegolsubotanceunder t heContro lledSubstance,Act drnt on ly after • long period of u« and were downpby ed by
themanu!.cturu . Tod.oyha balmed icineisrrwdng •• trong
Herbal Preparations and Smart Drugs comebo.ck inth eW« t . .. monymedica l !iChoolsanddinic,
integrot<herl>almedicin<,acupunctur, , andancienthealing
and Drinks techniq_ue,intoth<ir,tandndcurriculum
He,balPreparations
Forthou<and,ofyun , h<rbalpr<pualionsand"n.otural
rure,"weretheonlymedicin«anilabl<. Theireffecti,., .
~=~
\:::~:.-:..~;; ::t::::.7!:r::Jd:':io~:!:1:::
m.orkrting and ..:t« <kporlmmts thal overpromot< th<
ne,s wu rttl md highly v:olued, but ,ome of thos e c1uati ve
,upplements ' h<alingprop<rti«muchtothedismayolth<
dlect5c•mefrom1he,piritua l powugiventothe,ubswico
~•rchdepanment . lnrecmtyursrigorouste,tingofmon)·
herbal,upplemenu,how,dth.ot a numbuofthe • d,..,rtiKd
prom~out5trippedthe>ctualbrnefil5.Prq,amiom,uch
"'"" in1-John's-won , fchinacea,,..wpalmet10,gluc05.l.m in<,
chondroit in , ginkgobi loba,ar.devrn,-itamim>r<notth<
ponoca,they>r<touted1obe .10,.,oo
,1o,;

Anothuconcemisthed i!iCov<rythat,omeherbo.lprq,an. -
tiomcontainpincriptiondrug,,ucha,Xann •• OOindo-
mrthacin(lndocin ° ).Unbb<ledfiller,canhavede leteriou,
," · somet"me,theyconta"nknowncarc'n . Internet
,it<sh.oveexpondedthepublic'sacce55tosubstanc«that•re
subject to lit~< or r.o qu.ality control. To »uid regulat ion,
::: . ;:t'!,;;;:n•~::::; m~~~:~;:. ~roduc,. "food •deli-

"Smart" Drugs ~nd Drinks

"Srn.rt " drug, a r<thedrug,,nutrim,. , drink> . vitamin,,
utnc,.,:rnd hubo. l potion,(, .g.,gin«ng,g!ngko biloba,
• ndcaff<ine) thot manufactum~.distributon.•ndpropo-
nen,. believe will boost intelligence. improve memory,
,harprnattention,incrtt><concentration,drtoxifythebody
(<>pecially a ftaakoholorotherdrug a bu><),andenergi,<

(
__
th eus, r. Th<«•reilwp romot<dHnal u ral,h<althy,and
l<galsubotitute,forclubdrug,andoth<rill<gol, ub•tonc«
Popularm10rtdrug,h.oveinc ludedOoud9, 0 Brain Tonix.•
"They must work. I've never had a BroinBooster, 0 Nirv:ma, 0 !.AMe0 (S-Adrna,y l methion ine),
,. repeat customer.~ Helicon ,• andS<ntion. • Proponrnt,ofthes,produrur:tng<
"'""'"""'
___ ,,,
_ "'_L.--..1'--. from AIDS •ctivis ,. , to he.:tlth laddi,,. , 10 New Ager,, to
member,:o/thetechnoculturewhob<lieveth ey•reo nth<
cutt ingedgeof • newfie ldofmrntaldevelopmrn t
Anumberof51ru1ndrinksar,nonalcoholic,fruit-ba.sromix -
tur<Sol,iwnins,powd<m:lnutrirnt> . •nd•minoocid,mdm ,
• vailableinr<tail<Stablishmrntsknown.,·,mmbar, " /or$4
10$6 . Combin.otiomofm<dicatiomusuallypr=ribed for
Puldn,o ni,m ,A lzheim<ndi,a,, , andd<m<nti>h :m,b<rn
loundin,martdrug, . lt isbel i<V«llh>tth<><drugsmor< <ffec-
th1'lyn,baW>C,lh<bfllin•fo,r • busingolh<rdrug,.'flt<r<>r<
claimsthatthe..,drinkswill,lowOTr<V<rKth<"!lingpro-
c,.,. Th,ronsum<TS>I<typicallyyou ng(•g "l7tol3)urban
>tud<nt>OTprof=iona!, looklnglor•nint<llectu.l!«lg,or
mo«.,.minatoWOTkorpartyhardu.
Critic>ofth<S<productsrnribut<th<ir,ucc=to<ithu•
placebo,ffect(>n<xp<ctationof,ff«tiv<n<50rathuthanm
actl.Weff<et )o rt o t h<C21£<in<. <ph<da(m.ohuang),md
,ug:,rth<yconu·n . S.Om,,mand ~•ronu'n>t' ulmtsthat
rould l<ad toprobl=islori ndividu•lswithhighblood pra.-
•ur<orah,..ncond'J 1 • r.d'nth0><pron,1ostrok<
Nootropics
rontro l dOOrd<TS(<.g.,kl<ptomani>•ndhairpulling),md
Aninv<Sig:,tionofN,wAg,,mandrug,,uch..,hydergint
oth<rshaveth<irownci....ification(< .g, ui ng<merd,rs)
«l<gHin<, va.op=•in , SHT, mod>linil, pinc,wn,:and oxi-
~m l«l to • n<w cW,i6c•6on of th,s, drug,., noot - Mmypeopl< ronfu.e impuls<-rontrol di,o~ 005<Ssi,.,
with .
ropics.Subsunc ,. inthi,drugcllls•r,thos,thotimprov< rompulsiv,di50rd<n . Th,hallmarko l•nim pulsc-control
cognition, l<ami ng, memory ron,oli d>tion . and m<mory dOOrd<ris•fa ilunto=istanimp uls,et h>t ish•rmfulto
mri<Vlliwithou 1CNS,ff«tsandwithlowto xicit y,<>1'not th<individuolOToth<rsbutoftrn,tan<doutHpl<Hnr,.
<Xtr<m<lyhighd= ."' ·~ Nootropic,swor kbyincTUSing ablt.Th,othumajo rc haract<ristici,ari,ing"'""'olt<n •
thebrain's,upp lyofceru.inneurotrm,mit«n,uch..,ac<ty! - >ionor•rou,. J b<for<committingth <ac t,0F1rnfollow<dby
cholin< by incr...,ingth< hr.tin's ,uppl)·ofmcyg<n or by grati fie1tion,p l=un,,r,lid , •ndth<nr<mOT>t•ndguil10,u
,.. ul•fngn,r,,..,growth. On, ma·n mechan',mofnoot - thecon""l"rncnofth<act. "·" •
ropicsandothu>m>rtdrugsisto<nlanc<th<conv<T>ionof Th<hallmar kofmobsu,iv<-rompulsiv<di50r<kr(hmd
,hort -l<nnm<m 'e,tolong -l<nnm<m ·,,. •"'
wo,;hing,ch<eklngthing,,ord<ring,rouning,pr.t)ing)i,
Nootr opicdrug,th ot u<not)1't >ppro,'«lbyth,FDA • r< <ngog!ng!n a r<p<titiv<activitynottoprovidepl<Hu r< or
import«lfromEurop, . CriJc,softh,.,•ndothupr<>erip- gr;,t ilicationbuttor<duc,anxi<tyordistr<Hcan>«lby
io ndrug,includ ,th<FDA,r=•rch<r> . •ndphy,id.1.n ,__. 11 obsu,iv,thoughts. " Addictiveb<havior,al t<rbrainch<m-
ofwhomclaimthatth<dlicacyofth,drug,ha.snotb<rn istry in much th< sam< way,., psychoactiv< drug>do
,ubsta nti.l.ted. Advocat<,ngu<thotth<5<>ndothu,mart Eith<re>nougmrn t or d,pl<t<nrurotr>Mmillus . d.l.mog,
drupimprov<>p,r,on'sm<nt>lc•pacity•nd<nhanceth < r<cq,tors,•ndoveracti,-.t<th<"go",witch(th<nucl<u,
m<nt>l •bilityolp,op l,,uIT,ringfromd,bilitatingmrnt>I acrumb<m)•nddamag<lh<"Slop",witch
dOOrder, ,uch u Al,h,imer's. Nootropic drugs includ e
thOS<Cprncrih<dlorw111tm<nt>landm<dicald i,orders

CompulsiveBehaviors

"lf,l"'/r,oJn.i;oJ.JJct.o,ofooda.Mict.0<0llolcohok0<0
,aoddict ,i t',oo1oboottl,,odd.:i;,,.,,;(,o bootallth<oth<,
Th<r<uonswhyp<opk<ngag<inarompul,i~<bthavior
t~in 'l""' lif,that 'I""'"~- artthesam,re:uon,; wh ythcyrn!l"g<incompul,iv,dru g
u5<: ta~· n 'ns1>n 1ru,h,toov<n:o mebor<dom ,10',!«
R<p<titiv,oomput.iveb<ha,-ion,uch u pathologicalgam- p~er,,.~ocontro:•md':y•nddepr=ion,•nd.•bov< >ll
bling,rompulsiwbuying,hoording,<atingdOOrd<n . 005<,-
,iv,~ilh<havior . prolong<dlnt<m<t1H<C,ga111tployi ng FunctioruolMRl,cansofth,b raint> k<nbyth,D,partmrnt
orTVwlllching , .. wdlHpathologicallying , ,hoplifting. ofRadiology a1).l, .,. chu5<ttsGrn, alHospi ul,how<dth ot
hairpulling,mdlir<.,,tingdonotinvolv,substanc<S,just th <u m , ar<Hofthebrainactiv ,u,dbyabu,ingdrug, • r<
behavion.Som,ofth,.,dOOrd<n•r<classili<d u impu ls<- also actint<d whik gambling or anticipa1ing • d<>ir«l
 D'n<Drug,,Othet--.. 7.]1

Wh<n the word u,inx i>~lac«I with<ating.~ombiin X, .. ,fing

th< ln t<rn<'I,slt"J'Pinx. >«nchinx or h,ning sa. it i> <a<y to
s«thatrompulsionisr,otlimitedtopsychoactiv<substmces.
Compul<i,.,gamblenc
• playpokumxhin<>,buylotterytick<ts,trytorm<money,
orthink•boutgamblingm0>1ofth<tim,(rom pulsion)
• mU<lincras,th e ,izeolth<betwh<th<ritisat••lot
mxhineor•pokerabl<{tolenntt)
• l«l=tb<anddiocon<mtwhmnotgmibling(withdr2w:d)
• rontinu<gamblingr,gardl<Molhowmuchtheyloseto
slotlpokermxhine,,lott<ri<> . orcardgam,s(abn><C)
• believe th<yca n rontro l th<irgamb ling•nd that their
onlyru l prob lems a recashfiowand luck(drnW)
• willg•mb leagain,<V<n>ft< r "'<<ksol•bstin<nc< . pu -
ticu lorlyil1heyhov<mon,y inth<irpock<t(reb1"')
lnrttli1y,th<•pecificbehavionladdiction(rompu1'iv<gam •
~'.:g..°\1::~:i:!;~ ~i::.::tom of the addiction, not th<

Dv,u.:uu,; AnonymoU< borro"" concepts dir«:t ly from

Alcoholics Anonymou , . Th, structunc ofth< m«ting,is

food.Th<regionsol•gamb ler'sbnin(i.e .• nucl<n> accum -
ben,, at<nded •mrncb l• . •nd orbi1olrontal cort< x) th>t
=pondedtoth<pro>pecaofwinningand losingmoney
"""''h,,.meregions a cocaineoddict'sbroinr<>pond«lto
whenth<prospectofcocaineus,waspres,nt«I "'
:::i~•d:::~:!~!7:p:Zk~tc~~l=:~:n::.:'::
•ndeneour-.g,.themto!ittthenece .. ityofch.ongingtheir
liFn t yleandbdid,
"/l,,,.,10,..,.,j,onmi&."""'"".Ho..>dol""twith"'ljlic.,i,.,,,J'>
Howdo/oct"1id,Olljclti!J,,n>Ho..><l<llo>ctinr<kitionship<>
M~ ddictiono,mff .,.,, to olt tl,,,t - airri« om to "'I

>
Thereasonswhyonebecorn<!!iaddicted "'-,I, lij', Sol I..J ro,Mng,d><...,~I tr,atpropktl,,""lj
toanon--dru.gt>ehaviorarethesame ltuot~f -"
rNsonswhyonebecomesaddictedto
apsydtoactrvesubstance.

Th<followingnet h< h.ollmarksofdrug•ddictionrom- Heredity,Environment

, and
pned withthos,ofcompul•iv<bdw ,ior-.l•ddiction
CompulsiveBehaviors
Druj!u,en
• us,•ndthi n k•boutu,ingmos1of1h<tim,(compul,ion) Lik<,ubstanc,c•bu,e,rompul,ivebehoviorocanbetrig -
• nttd~•t<ramounaolthedrugasu.secontinues g<r<dbyg<n<ti c p r<di,pos ition.byenvironmenal,tr, .. ,.
(tol<nnc,c) •ndby th <r<p<tit ivebeh>vioritsdf.lncre...cldopam in<,
• aperirnce,ymplom,whenabstin<ncebegins giuam.o«, and GABA l<v<l• that ov<r>etiv:u, the "go "
(withdr.owal) switchesinrompulsi>'<gam blu,; , o,u<at<f'.'5,md,hoppers
,ugg<>l>commonbioch<mic•lthr<ad
• rontinu<tous,d,spit<adv.,..medical,<motional,
social,family,firuoncial,rndlega l con"<!"<ne:<>(•bnli<C) Heredity
• donotacc:q,1that1h<yhov<•probl<m( drnW) Familyandtwin'1udie,h>v<ron clu,i,., Jyid<ntified a grn<tic
• h•v<>strongtrndencytoU<<>g> inaft<rqultting ronnectio n to • lroho lismandtodrug•ddiction . Dtherfam-
(rel>!"') ilyandtwi n otudi« h...-. foundag<n<ticronntctio n to
rompul,ive b<h.ovion that don\ involv< poychoacth'< pl<.a,ur<. a nd, ,uia tionbyr< laoingdopamin,donotprovid<
drugs. "' m Twinotudi<0usingth<Viruu.m TwinR,gi>try thatSEI><•urg,forp,opl<withth<A,•ll<l<g<n<b<cau,<
loundthat>g<n<ticvuln<r>bilityacoountsfor'50%to60% th,y l•ckth..,1te<pt0Tsit<s . Th<><Cindividllll,anm0r<
of• compuW,., g:,mbl,r', •=•ptibility. In this otudy • lik<lyto5<<krnbstmc,s:mdoctiviti<>thatr<ka«ac<>•
grn<1icinh<riunc, >l50 oonn<cud>lcohold,p,nd <ne<md dopamin< (e .g .. • lrohol, drug,, or r<p<titiv< compuW,.,
majordqmc.,iv,di50M<rtorompu1'iv,g:,mbling "' b<havioa).Th,ul,...,of,x t radopamin<cans,dbyn,p<t•
itiv< rompul,ive b<h.oviors otimubt<, th< ,urvivaVttin-
Compul,iv< ovctuting wa,; th< fim h<havior>l addiction
forc<m<ntp,.thwayto a grttt<rd<grttthannOT11L1.I.Allof
drt<rmir.«ltob<panlyhm,diury.Astudybyth<N ation>l
a, udd<n,th<><Cpropl<lttlpl<>Sur<thatth<}·nonruollydo
lnstitut<0ofHe>ltholi00twin<oV<r > p<riodo/Hyar,
no t <,q><ri<nc<
loundthat "cumubtiv,grnrticeffects,xpbinmostofth,
tracking in ob<,ity owr time. " Thi, mans that • much Dop•m ·n, ·• not th< only n<urotr:msm 'tt,r 'm '' 'n
high<r-t han-norm.olp,=tag<oftwinsbomtoob<«pu - cravingandaddiction.Th,urin<•ndth<,pino l fluidof
<nl5but,ub.<qu,ntiyr>i>.<dinto l11lydiITm,nthou«hold, pathologicalg•mblersha,.,high<r -than -normall<>'<1'ofnor -
<ndMupob<,, . Th< r=>n:h<rs•OOfound that"olu.rci <,i1<ph 'n,,lh<n<uro tran, m 'tt<rthalJ ducu tinu lat"on
<n 'ronllltllt21, uruw<r<not i.;nilicant " ·n.i, "L~
th<twino'w<igh t pin. "' Fiv,studi,sofodopl<dchildrrn :1...7.u":•:~\t:':!\d;,~~thSc~:':~:~r>d~!;!~ :~:~
,upport<dth<condll>ionthatth<family,nvironm<nt - th< =tonin a r>d nor,pin<phrin,in acut<ly ill bulimic md
•iZ<>ndth,f=iurncyolm<>1' . th<•mountoffoodinth < :morvic'c1 ti ts .' "
hou«, m dth,r.mily'sl,v<lofa,rc i>c-pb y,littl < orno
rol,ind<t<rminingwh<th<r•childwillb<com<OO<S<.Th< Environment
otudi<>loundthatonlydI2maticrnvimnmrntoldiffm,nc,, lti,fairly<>,;·tound,mandhow,nvironmrntcouldint<n •
rouldmitig,.t<th<inOurnc,cof•g<n<ticprofil,thotllWl<• ,ifymostoompul,iv,b<h0>ior,;
one•n=ptibl,toob<oi ty. • Th<acc<>•to•tat<lott,ri<,,,,lotandpok<r11W:hint,,
Byth,mid -l\l90o,p,cificg<nrticconn<ctions•mong>lco - lnt<m<tb<tting,l,galoff -trxkb<tting,andAm,rican
hol •bu« . compul,iv,drugu« . mdoth<TcompuW, ., lndiangamblingca,inos,•longwithmajOTg:,mingd<S-
b<haviors"""'b<ingconfirm,d.Monthan90diffm,nt tiruotion,lik< AtianticCity,New J<™Y.:mdth<<ntir<
g<n<0haveb<rn identificd.,having•ninOu,ne<onon<'s ,ut<ofN<v.tda . ,,er,.,.,,.rongtrigg,rsfor•compuW,.,
,usc,p tihility to addiction ; dozrn , of oth<r, "" und<r gambl<r
inv<>tigation • A pl<lhon ol fast-food u,taurants, • diminishtd

~:~~1B~~~\!';'~~~!:::::i
valueplac,donphy,icalactivity . :m• bundanc<offm
~!~~!ii';:\~~ ..~o~d •nd,ug,.ainfoodthat caninduc ,crav! ng, par,cntsov<r -
f,,djng th <irchildr<n . and th< r.,,d toov<trom< th<
:m< xt=n<lyhighincid,n«ofthi,g<n <i n « v<r<>lcoholic,
d<pf<SOionmdth<mxirtybroughtaboutby•chootic
l.ot<r<tudi,s,how<dthatth<g<n<w:o,•OO=iot<dwith
drugaddiction•ndmynumbaoladdictiv,b<haviors ."~ "' ~~:.ii::r<btionshipwithlood-allaggmr.u,nting
Th,yfoundthatth,DRD,A, a ll<l< g,n npp,a rsinonlyl9%
to21%olnonolroholic,nonaddicl<d . •nd noncompuW, ., • Th< IT«jU<nt pr<S<ntation of ,om•l oituation, •nd octiv-
,ubj<cl5but<ristsin ity in th, m<dia, H "'<ll :l5 th< a« ol acc... to md
th<>'Olum,of<roticmdpomog raphicm.o t<ri.olonth<
•
•
•
76%ofpathologic• l g,,mbl,rswithdrugprobl,ms
69%of•lroholic,ubj,ctswith«v<r<>lroholism
~2%of cocain<•ddiru
~:';'~
·::t~t==~
ht'!,
~;:-'~,~;r,n.~:
mal ." Afragm<ntcdfamilylifr!nwhichchildr<nha,.,
• ~1%of pathologic•lg:,mbl,rs lit~ < ,up,rvision, f«l <motioruolly disronn<et<d, • r>d
• i8%of,mok= =:,iv,noguidanc,r,gardingwhatis•ndwhatisnot
• i~% of compuW,., ov<r<at<rs •ppropri•«=lllloctivityrouid!nt<nsify«,rualcom -
• -t'Yl.ofp,opl, with Tour<tte's,;ndrom< pui,ion,orbringth<TI1toth<•urlac ,
• An <xplooion of onlin< multipby<r gam«, gambling,
lnaddition, a otudyofchildr=withrn,ntion-d,ficitdisor -
andoocialn< tworking,it<,,uch .. Fac,bookand
d<rfoundthati9%hadlh<m.ork<rg<n<compu<dwithonly
l7%ofth,controlgroup .11• Twitt<r mok< compui,iv< lnt<m<t us,•
mous, click

I • ;:n;~,;t:~;;,g
c::;~~.:r:i'i:.~~/:t
.:::·:::
> lhefirstaddictiongen e di= ered.in1990,
wa,theDR_D,A \ allele_gene.Atleast88other,
havebeen1dent1fied.,ncethen.
Th< r<snrch<rs th<orin that curius of t hi, A, a ll<l< grn<
have a d,licimcyofdop • min<r,c<ptorsinth<
rrinfon:<m<ntcircuitofth,addictionpathway.
thotoctivit i<>thatnonruollyd,liv<ra,n'll<of,
, urvivaV
Thism,rn,
,uhlac tion
Wha,!hav,i,who/am-4ll•r<f<rtikgroundstonunur<
•ohoppingcompuWon
• Ahistoryofphy,ical , ,motionol , ands,xu>l•buo,in
thtliv, , ofmanywhop.-.ctic,th<s<rompul
·or, a t.o ,ugi, ts th< 'mi>
, inb<h.v
:, of ,n\ronm,ntal
-

conditioning•r>dr,cinforc<TI1<nt
 D'n<Drug,,Othet-... 1.»

"Al"""talladk:t. - anJ/",,tnll:,Jtothou,,,,,J,;oftl,,111in
if""l"andindi,-iJw!Lj- lia.. ,,,iJtliatth<ljlia"obacl -
!J""'Min wliid ,tl,"jf,/ tinf <tior, i,ia.l,'!""t, , auJtij. .,liam,,l

Z~'-E': ti.ir:!::.::::+
::J.::"J.:ri -~
"""'"nt
_,,,_"'-D
."""""""'- """',;,<cial"'-
•°"L«"•""
R«<n tad= c,.i nund er, tanding epigrneticproc esscs link
theherrdiwypropens iti,.withthe<nv!ronmrntalacti,,. .
tionor <uppressionofaddic tioni n m individu•l

PracticingCompulsiveBehaviors
Engaginginthe>ctivityiuelfcanactintethehered
•ndrnvironmrnUl<n«<pt ibiliti«andleadtorompul<ive
beh>vior . • bu« . •ndaddiction
• Winningbigearlyinone l<gamblingcarttrimprint<the
br:lininmuchthe <amewayu •potentdo<e ol heroi nor
cocaine don<>. rlyinone~drug-U>ingcaneer ."'
• Compul,iveealenwill«nrintheirdige<tive<y,temwith
exce,, lood , partiru lorly ,.1 1. l• 1<. and<ug,.r,; , andch>nge
~~~~~~~:• 1;;,;sothey e>t tochang e mood rather
• Acompu l,iv eoh opper cal l>theHom<>hopping Netwo rk
lor m expensfr e, bejeweled 1n .. ure•ndimprin1<the
br:linwithth<anticipa tionofov,nmhip . kindling•
<urg,ofple .. unwithoutregardforth,finoncialron
"'qu<nttoftheactionort hen eedfortheitem U 1
• Repea.ted,xpo,uretopomogr,phy,fruiurntiruo,turba
tion,mdpmidpa tioninothercompu b iv<<01uolbeh>v-
ior,; C2I1make somron< with sexual rompul<ive behav -
ior,; •void nonnal «xual o r ,motio n • l nlationship<
CompulsiveGambling
Scope of Gambling
JnlOllAm<ric2ns betS900billionalgamblingvenu,.,
itary
ln2 0!J,)o,W.,,/d>M«ofPol<t,<00<«ttd of M""' ' """'"""
lm ol,i"SJl) ,OOOplaytt1 ..J""'"'Wl•llOOMIIMftl n F <t<""""J'
Jl,,""1 iOM "1 of ,lll,J.tri«•·"'"'1d! ~ Ll;li'pli . Illttr• ·ttr •1,.,,
WI06 ,J.l21'"'Y=•·ls:,l"'«lll0.00tJ<"'~'°'""<12.,,..,-,ojl;,,
t>rood<a,,in&"""" V Wr,J:,,ofS8,J6l,.lTO. '" Ill<<xpi"'I•<
,...,.......ojp,0,,(<. 1.. fo>1</lol,u,o,O,,,,,M,a.J«>,_-<ao!<twd}i1
a "1lt<t""1of W""' "'" "·idrand...,,IJ,,!.l,l""' 'h of1<1ml>i,'I!"'"
WJ'4"2.lY"'"
,.,__,,"'_"""'
3. "To1aO<art, Ointh<hop,of gaininxana,h- antag,1>ra
orn<[i,•
- i . "Torn gag,tnrrdl «,o,'1,wirdau<brho,ii,r "
- The autho B prrferthe lollowingd efinition
0
Anyl ,ruinx1>rwaxmng.Jor,rlfo,o<h<1, . wh<1h"Jormonry
ornOl , rrga,,U,.,oJ-,,,,wdightorinsignifican<,whrrrth<ow -
,om, · uncma "nord<prnd<uportchanc<1>r>.-llcon<1·tu1«
xornbling. ""'
G•mblingindud«
• poker . bt.ckj•ck,cr•p<,roul<tte . andp•igow
• •tandord<lotmachin<> . vidropokert1W:hin<> . and
otherVLT ,(, id eo !otterytmninal> )

=
r<>ulting in• loss of $96 .3 billion. It i, rnimated that by • tntemetgambling•ndmassivemultipl•)""ll"Ill"
l013 • bou110%ofgamblingrevenues"illoom<fromNorth • •tat<-runlotterie, • ndkenog,.mn

~~i:n::;,~ : ;;;;;,,M;:e!~ !:!u:~::,~: • ho = • nddograce,•nd j• i • lai

omyre,ult edin • dedin e ing,.mblingrcvenu«incntain • bin goandraffie>
venue< (but not <>'<rywhere). N<>..da~ gambling .,, ..,nu es • •port<b<tti ng(bothle gal • ndillega l),olfi <:<pool>, •nd
dedin edov erthe ~ tfewy<>.n alt he,a me tim e th< <tate • wog<r>onthegolfcmu>,<
unemploym<nt •nd horn< loreclo,ur, rates beam< among • schooJ7,.rdg:,me,;md lmgame,(e.g,liar~dice)
the h;gh est~n the:tion. In .7,['"'<> : ~ottery ;:, ..,nu es • <tock<peculotion <nch .. daytrad ing.oommoditie,, • nd
option,
erybeoom«morerobu5t,='<nU<S>r<incn .. ing
• '.5'lling•nd;r.1dingd<rivotiv<> • ndoth<r speculative
G•mblingisnotconfined tothegame,•nd themochines
rn,it.bleinc .. inos . Modemtechnoiogyh .. vastlyexpn,d<d
th<numberofgamblingopportunit i«,•ndlegalWnionh>s
~,gambli ngOCC<S<ibletoneryone.Som, defin<gam •
blin g .. follow,
I. •--:• ~ onanU11c<rta"noutc om,. asof oco n1<<1
"
l . "Top layagam,ofchan«Jo r<la• « •
Thrnear,mor<opportunitie,fOTgamblingtodaylhane,.u
be/or,, Th< rons,q urntt< assoc U.t<dwithproblemand
:~i:;:calgamblingauas-<r< .. withanydrug-baocd

· t.,1..,!L/l'l""tl,,tlt "'l/'tl,., til,,ow fo,,w ,_ r.,, p,otm 1

dlJIJfl,t,(,roll,!J<""""'l
l".,<p<nt"lljda,,rj,!Lr',(«tw,.
Yoowantaoa"""'"ttoj!~llnow"lljhi,,1,,,,./1,.,,p,""""llij
...-i!!L
od1,d;,.m,l,,dclwds fo,owrS JOO,OOOi11tl,,1J
'1"'"1,,',b«,,..,;tl,,,., _//.-tha tp,""""llij /ha ,,lf""
t"""'9h
..lcoo ldn't"'t1"to!LU 'l""li.:.. "'"d ,·

Anybettingorwagering.for...ttorothers,
wh~her for money or no~ no matter hw,
, light or in,igificant, where th e outwme
i!iuncertainordependsonchanceor,kill
const~utesgambfing.

History Ill,jit"pa,:lt ,"OO"""ltUl«wrn,b.illl•fa!r,•"'''"U,ml"')'<I><

Gambling in Ancient Civilization•
Gambling by Homo .. pi<ns pr<dot<• recorded hiotory.
Archrologi> I> ha,., un <>.rthe<I pr<hi>toric g•m bling bo n<>
::.~,;,~t!:n:!·:1::r~~i::",.~:•::i«l,t.::!~
d«i , iomonmatt<r,b<lie,.-,dtob<inth,handsolth<
gods kg., rain or drough t) . Six-side<! die, mad, from
po tl<r)'. wood, or ivory ,.-,r, U>ro a, <>.rl)' •• 3000 B.C. in
M<>opoumia . Th<cao tingof lo1>ismrn1ion<din1h<B ibl,
a, • m<>.n,o l rndingdi,put< , ordistributingprop<rt)lAft<r
th ey cruciliedJ<Suo, Roman ,oldie.-. cas t Joi> For his
doth ,. ."' Th< kn ight< of th< Crusad<> l? mbl«l whil e
playingan,arlyv<n ionofbackgammonthatthcy l<>.rn«l
lromth eArabs,w hol earneditfro mth <PasU.n>
Alongwiththed<0ir<etogambltcameprohih itionsagoinst
it . An ,.. rlylndiml'«i,(ul<)olgamblingwo,,,Th<Gam!tl,ri
Lamrnt, writt<ninS..n, krit•bo u tlOOOB .C.,toldolaking
:!:=~:: -~,~-r,·a ll ofhi, wal th •• ,.-,lla,hiswif,
rMJ 920..By ,NJ9.JO,..i.h-«t<d"""li lot<w,n,n·•llable,b.cil
,. ..,.,.,,.,,.il-f~Wo,-ld\½,/11/wp,><lilnlw"'1""'widcipmld
p,,rulori1yl•J"P"" - Ill,!(ffi!t.:tll,1lwpl,lytncoll<t1•tt=lw,ig<d
jo,r,1,,.,.,,,,,,Mt<,o,li_Ill,r,1ttu"'""""'""',.,u"I"' '"'
""lw,i!"Jo,,o,li_Af...,,..,Jlo/clwl6,00Jwl7,00Jp,><lil,W,
Wl!"•"'"""'dO,,K""""-'lin•ti•fa!r,•
cmlg:,m,haruifudau.,.cardswithpictur<>ofchrysanth< -
mum,,stork,,andoth<r notiorui l ,ymbols
Th, mo,tcommonfonnof l? mbling!n Japanispachi nko.a
v<rtic•lpinballgamelhatisa,;popularthrneas,iotmxh in<S
are inth,Unit«!Stat,s . ln lnd i•be ttingoncrick<t ma tch<,
is bigbusin<M
Th, fir,t,lo tmach in<>w<r<inv,nt«linSan Fra nciscoi n
190~ by Charl,s Fey The orlgiruil ,ymbol> W<T< h,aru
,pad,s,andd i•monds . Thcylot<r<>-olve<ltoth< familiar
du e to fruit< (<.g. , cherri<> and or:,ng<>). andtoday th<r< areh un -
drul,of ,y mbo1' . includ ing 1h<facnofcd ,briti<s. '"

In th < Middle Ag,s .churchm<n 5<mloni,«l against gam -
bling , and Louis IX of Fra nc, mad, die, illegal in ll ~~
England'sHrnry Vllloutlowedpub licga mingho= b<caus<
heb<lie,.-e<lthey distract<dyoungmrn lromth<•rtofwu.At
theb<ginningoFthetwrn titthcen tury ,gam blingwHron -
•ideredtheleadingvic<inEngla.nd
Th<< arli<stplayingcardsd.t<from t h,e levrnthcenturyin
Chi.....,Turk<,tan.ltwasth,Fnnch,inth,lourt<enthcrn
tury, who introduce<! mod,m -clayplayin gcards . Other lorm,
ofg,mblingoft<nr<lkct<darountry'scultur<.lnJ•panth<
Gambling intheUnitedStates
Thr«w;aw ,o fgamblingh....,,we ptth eU nit<dSt> t<S.Th<
fim,pann<dtheytt rs Fromth, , arly-tl <m<nt<u n tilth<
mid -lSOO..Lott<ri<>,popu b.rfOTcrn turi,o inbothA,i •m d
Europe . " " "' import«! to the Ameri can colonic, in th<
1700. c th < proce<d>wer<u «dtobu ild road ,,sc hool>( <.g.,
Harvard and Yale), hospital> . a nd othu public works. 1"'
B,1tingonhorner:1c<S,cockfights,anddogfigh1<wa,popular
among gentry and farmen •lik<. Gambling , along with
wh i,k,y, rum, tobacco, and hemp . hdp<d firuinc< th<
Revolutionary War. An tiga mbling law, W<T< <>1'ntu.ally
pa...d by a numb<roftheorigina!Ucoloni<>a,rorruption
andsc•ndolbrought loll<ri<>to a n ,nd .1"
- Th<li«Ondwa,, ·eb<l?n atth<rndofth,Civi l Warin 186~
withth<e,q,an,ionofth,W<>t<rnlronti<T . Riwrboatgambling
ontheMississippi,roul<tt<wh«ls,andsalooncardanddic<
 D'n<Drug,,Othet-... 1.n

gamesw<r<partolth,lot<Cofth,V>'ildW«t . Victori>nmor.i.l- ~hin«. or wag<r<d on ktno numb,,,. i, • dollar tha t i,;

ity•ndpuhlic!iClndal.scaU>roth<ird,mi.,•round l910. 1"
Th,thirdwav,b<goninthtl9JO.withth,l<gali=tionof
gamblinginN<viid•mdth<op,ningofrac,t=k>inll
s1>.t,,;,N,wfumpsh ir<m!OCOV<Iroth,,ut<lott,ryinl964,
butitWHr,otuntilth,bt<l970.thatg:,mblingrullytookolf,
withth<op<ningofCI.SinosinAl.b.nt icCit;; th<e,rpansionol
lott<ri<>to38.ut« . off-trackb<tting.n<Wriv<rboatcasino,i,
mdl<galizationo/c.,,i"""onAm,ric2nlndWlbnds
For much of th< nin<tttnth and twmti<th crnturi«. gam -
bling r<mained popubr. though it w... consid<m:l immorol
h<a11«itpr,;'roonhumonwnkn<>,.Gambl,nw<r<con - byH•rryEst,,_,eon,ut<
,id,mld,cad,nt.i=-ponsibl,.•ndinsan,.Buto,uth<p,.t
25 yan, g:,mbling~ h<oom, • ltgol, rup,cl>.b l, pastim<
By th< mid -1990, <V<ty 51at< <><e<ptH•w•ii •nd Uah hm
«ubli,hed!i0m<kindofgambling
Th, Indian G• ming R<gubtory Act. •pproved in 1988,
~~';!o•~
:~"'~;:fr~:;~;n ~~=;;"~n=~rii!:
inth<Unit<dSt>t«rolltttivdyhad-t70gamblingf•ciliti«
inlll,ut ... lndi>ngamingr,v,nu«from\98Btol0llw,nt
fromSllOmill ionto$30b illion. "~"'
St>t<<Suppon,dlott,ri,oron tinu,dtob<,.l>.bliohed
through th< 1980,and l990sto,uppl<mrntWI dollar,
•nd grn,n.t< job,. Som< argu, that l<galiud gambling
iml"""'••r<gr<ssiv<tnonkrw-inromtgambl,rs
onlyportlyr<cycl<dintoth<localcommunity.Grinol,rd<n
to t hiomon,y u "cmnibaliz,ddo l!no;rathuthanulnsh
infu,iomofmon,yintoth,local<eonomy.D,spit<th<><
figu=.politiciam>r<drowntogamb lingmon ,yh<au,,th<
r,v,nu«bringin<Xtn.inrom,withoutth<politicalli>bility
of aio ing t>x<,. Contributions by gambling int<r<sl5 to
:::::it:::::!;',,;m;c:,:;-;-n~",:,.Lug<><th,rontribu -
The Oregon Research
lnlOlJ th,Po rtlanJOr,gonian , in • brilli>ntfiv <•port5'ri«
-•pomor<dgambling . r<ponedon •
studycommi55ion<dbyth,Dr<gonlott,ry '" Gamblingr,v -
rnu<>wrn,d,dining.prompting t h<,ut<lott<cytohir< •
team of ronsulWH< to study th< gambling habit, of
Dr<gonian5.Th,informotiongath<mlwastob<u.,dtocnft
::~<:~"'th:i'7:~i=~~~Ju:~ni:•~:.:::to~h;';~'."'r::
u urml5. md gambling "d,li , " r<valed som< ,urpl"Hu
• 86%ofot•t<=<nu,.($737million)rom,fromvidco
slot•ndpokamachinu;th,oth<rl 0%($119 million )
romn from loll<ri<>, scratch tick<15, • nd k<no game,
Aft,,- ovuhad cost>. 5'500 million is •dd<d to <111<wt
mon<},.
• M<><tofth< r<V<nu< rom,o from 3%oF th< play<B
&cau.,-1%ol>llgamb l<r>>r<<ith<rp>thologicalor
probl,m gambl,,., th< implication is that 80% of • U
gambling r,v,nu,o romt from rompul,iv< pmbl<n

"/tf"'IItl,,9""'m111<otinthr!x.su,,,,-of>i<:,
W,pbjfh"""''"d:,,.rohr/p••f""jowta=·

I
>
Mmycountrin•ndtravdd«tinationsha,.,,xpand,dth<ir
gamblingfaciliti<,to lur<,i,itor,; . M.acaoonth<SouthChin.a . e maj.orify
Th . of gambli"8 revenue (a.round BO'!b)
oomesfroma/r;tWOnoftheptay,n(about5 '!b
routioth,numb<ron<gamblingmuk<tinth<world.with mastatelikeOregon) . Withalcoho(IIO'!bofthe
lOllr<v<nu«ofH 3.lbillion.upfromS6 .9b illionin akohol1sdrunkby20'lbofthepubhc.
l006. 1" ltd raw, ma,tofi15VHitor>fromM•ini>ndChin.a,
butgambl,nfromoth<rAsiancountri<>•r<m.akingth<ir To soft<n th< implication, ofth<ir own ,un'<}·. th < •t>t<
pr=n«f<lt. 1" 1nconflictwithth,d«ir<toupandr<Y<nu< Lott<ryCommission r<mind<d th < public tha t hallof•ll
from gambling i, th < conc<rn ol citizrn• that th< grm<~h in Dr<gonim,hodponicipot<din,ut~pon!iOTedgam<Sof
<2>in<><•ndgamblingwillalsobringmor<crim< •ndmorol chane<inth<postyt2r . Th, f.allacyi,;tho tm<>0tofthos,
disruption propl,pl.oy,donly • f,w tim«. Ju5110%o fth,toal•ctually
pl.oyedolo15 >ndpok<rmKhin«.and3%ofO,-,gonU.m
Politicsof Gambling playcd,lot> • ndpok<rmuhinn<V<rymonth
Eu l LGrinol.sinhi,fin<bookGambiinginAm<rica : Cost,
onJ&n,_/it< "' diop<lsmE1yolth,myth<r<gardingth<<eo-
nomicb<n,fit>ofg:,mblingto>rommunity•nd••Ut<.lti,;
th<po,itionolgamblingint=l5thatmon<ywillflowinto
•communityfrom,isitoror.tth<rthant<C>id,nt> . thatjobo
will b, CT<C>ted. md ux r<V<nU<>will fund gov,mm<nt bud -
g<t>. lniti•lly. th, romtruction ol • ca>ino do,,; bring in out -
,id,r,,,enu,.but500nth<n<tflowolmon,yr,vu= . ln • To incr<li< r<v<nu<>. th< Lott,ry Commission •pprov,d
,tudyollllinoi,co.sin0>
35mil<>olth,ca.,;ino•ndonly
. >bout 73%olvioi toroliv,dwithin
• m,.allp<rc<ntag<liv<dmor<
thanlOOmil<>•w:ay.E:achdol!or,p,ntot•ca> ino.u«dto
;r~'!:!~~:~:~~~~~~::r'.::
...
".!'~:i:~~g-~J
• ttn.ctyoungacustom,rs .•gro up • lr<adypmli<po,edto
pure~, ,ut< lott<rytick<t>. F,d to ,ut<-ov. ncd ,lot pl.oyingvid ,oga m<>
Online Gambling lh<><w<>.lthymenla,tdidnotprevrntth<mlromco,.,ring
lheba,icn<c<»iti,soflifr;butwhrncompulsi,·,g•mb ler,in
Asth<numbe r ofprop l<withac=tolh<lnt<m<tgrewin
lhel990smd:WOO.,on lin<pmblini;,xplod,d.Revrnu,s a lov.uinromeb rack<tk,.. a paych<ck , they•truggl<topay
ncnt, putfoodonth<Loble,orbuygutog, t towork
from • wri<tyofg:,m<> . indudingpoku . rou l<tt<. dice,md
onl in< ,lot machin<>, went from s,4~3 million in 1997 to
alm0>1$l 3.BbillionWOTklwideinl009-S 3.,billionoftbat
from th< Unit<d Sl.Ol« . 1'°·1., In Octobn 1006, Cong« ..
P"'"' d • l•w criminaliai ng th< proc<Hing oF onlin< gam-
bllllJ! t ransactionoby U.S. lnnksandCKditcardrompani<>
so much of the onlin< gambling g<>« throug h off,hor<
accounts and i,thuefore no t ,ubject to much ocrut iny.
Asandalronr.ect<dto.,ven l onlineg:,mingsit<•caU>-<da
Theottitudetow:,n:lpmblingby,porufiguresandpmbling
t<mporaryslowdownofonlin<pmbling,but ... u,;ual,th<
promi.<ofprivat<•ndpublicrev<nu<>ledtorrroru;ider a- ingrn<Tlllh .. ch:,ng,dovulh<pasl15yeansincethe•ll -
tion.BytherndoflOU . Dd•war< . Neffdo, • ndNewJu.,y tim<l<odinghitterinbasebol l. P<t<Ros<,w .. bann<dp<m11.-
nrntlyfrombaseballlorbettingon,poru,•ll egedlyonhi,
h•d lepliudlnt<m<tgambling . andatle .. t<ightothu
sat<,m.aysoonfollow . own l<am. More significontly , the>ttitude h"5cbanged
becou.,ofthehugetar<v<nu<>invoh,ed
lnth e ar!y.ZOOO. . mo,tstote,hodnot•d,quat<lystudied
rompulsive p mblingnorhadlhcy<>Ublish<dpreventionor
trutm<nl programs . On ly Louisirn • . Minn<>et:,, Oregon
andW • •hingtonhadfundedtratmrn t progr;ams . Tod:,)·th<
prolifrationolpmblingoutletsh"-'r<>u ltedinmorelhan
J0,11t<,funding,omekindolg•mblingttte atm<ntbu11he
amounts•r<>'<f}'>mallcomparedwithpublicfundingof
othuaddictiontrutm<ntprogr;ams.Someargu<lhatgov<m-
mrnn tbat enrounge gambling •nd legit imiu it ,ltould
bnr,omeofth<fuuncialcostsoFtre:,tmrnt.Theg • mbling
Problem and PathologicalGambling 'ndu,;tf}· • 'ens«sace .. roncernovucomp 'h,egam -
G•mblingbebaviorisd,sigruitedotfourl<ve l, bling .. animp<dimrnltoil5growthb<causethemajori ty
• A problem gambluis on< whose gambling behavior ohu«,• and cninO>' gambling income deriv<> From prob-
"'""" problems in any na of his or her lif~ P'Y<ho- lemand p:,thologicalgambl<r, . One>1udyby Hrnf}'L<sieur .
logical, ph)'sical, 50Ciological. or vocotional a pion«rinthefield , foundth.atprohl<mmdpathological
• Apathologicalgambl<r:odd, lheelementofobses,i,·e pm bl<B lose 10 10 20 tim<> ._.much., nonprobl<m g:,m-
::~~::~t~: :;~;;:1, • nd signific•nt disruption
blu,;. '" ln • stndy in Connecticu1, H% of casino patron,
wer<rompulsiv< orproblempmbl<r><Vrnthoughth,y
• An at-riokgambler . a nocca,ionally u,ed d<>ignation rompos, 1,.. tban 3% of the o,,erall popu la1ion. " ' In
•ppli«lothos,who•r<>USC<plibl,tobrttingth<irway Minn<>et:, l"I', of th< pmbkr, generated 63% of th<•'-""'
intoproblemorpathologic• l g:,mbling
• A rom pulsi>-e gamblu c•n be a prob l<m gambler or
pathologicalgombler ""'B"""''~""d"",~"""""'~in'l""'"'indo ..J ,.i
thocoo/dlj<"'l,,thi,,wpitl>thocoo!dij00o,()f"'7Y<o'llj
ll<can><compulsivegamblingis a progr=iv,dis<OS<, th < inklini;of wliat...,1.,pf'<Nljto'l""'thocoo!dljOOI,,"'
maindiff<T<ntt>betw«nprobl emandpathologicalgam- briehtill=d,.. ;.,.,,J,o,tupid ill'l""'""llj~lif,''"
blini;aretimeandmoncy . Acron:lingto,.timal<5 . th< typi-
calproblemgambl<rlo..,•navengeofSJ.OOOperyear . ·-- .. po>,,-..... ,
whans th< pathological pmblu to.., an awnge of
$11 .000pery,ar ."' Th,gambl,rsda.,ified .. bav!ng a g:,m- Epidemiology
blingproblemoft<n,uffu)-...rsoflo...,before..,kingh<lp Deniali,panicuLulywide,pradamongrompulsiv< gam -
The av,ng< indebtedn<S5 of gambler, rnt<ring G•mbler, blu,;_ Forth ' mdoth<rra,ons , :ocrurat<,ut',t'c,onth<
Anonymou,i,$60,000forwomen•ndSIOO,OOOlormen numb<nofthosecons iduedp>thologic•lorprobl,mg:,m -
M0>1h.aveio>1tnckoftheirlif<tim e lO<S<s , which•tteoftrn blu,;,-.f}·widely Abou t I to l%ofAm,ric • nscoul d be
ronsidendp:,thologicalgambl ersand lto i %roul d be
ronsidend problem pmblm . In • new Geffll2It study, the
l.oso<>•rerelativedeprndingontheg:,mb ler',incomemd
r=urc e, _ Fonner drug czar V>'illiam Brnn<tt •dmits to los-
ing $8 million; golfu John Daly admit, 10 losing more than
:~::~~~~~~::1i!.~~~~::: combi n ed was

$SOmillion;and,upers1.0rMich.adJcm:bntalk, • bon1th e T h<avail•bilityoFgamblingopponuni ti<>hasadramatic

million,helo, t whi lestillp l•yingba,k<tba ll. Th<mon,y effectonthenumberoF p robl <m•ndp•thologicalgambl<ro

c:?4ve
~1'/WIIJ>
States like West Virginia, Rhode Island, and Delaware, New
York, and Oregon earn the most money, per capita, from gam-
blers and have the greatest variety and number of gambling
opportunities. In Oregon, the percentage of compulsive and
problem gamblers jumped dramatically as more and more
outlets provided a chance to place a bet. 137 In 2011, Oregon
had 11,000 poker machines, thousands of keno games,
scratch-offs were sold in every convenience store, and nine
American Indian casinos were in operation. The number of
gamblers in Utah, a state without gambling, is a fraction of
that of states with gambling.
At one time male compulsive gamblers outnumbered female
compulsive gamblers 2 or 3 to 1, but that ratio changed due
to the proliferation of slot machines (women play slots more
than men do). In the U.S. minorities have higher rates of
pathological and problem gambling than Whites_l47
The similarity of gambling to substance addictions is evi-
denced by the high rate of other addictions among patho-
logical gamblers both male and female; other behavioral and
substance addictions occur in 25% to 63% of pathological
gamblers. 14
The availabilityof gamblingoutlets,suchas
casinos,card rooms,barswith slot machines,
and state lotteries,leadsto drasticincreases
in the number of compulsivegamblers.
"I didn't see that one wasjust makingthe otherworse.
The moredrugsand alcoholI did, it seemedthat I wantedto
gamblemore.The moreI gambled,if I lostespeciallq,then I
wantedto do moredrugs."
24-year-old recovering compulsive gambler
OtherDrugs,OtherAddictions 7.37
The desire to build a gambling casino on
a tribe'sown land has encouragedsome
American tribes to buy land and have it
declaredIndian land, thereby making it
eligiblefor consideration.In Oregon
some senators as well as tribal leaders
,,. . fear a glut of casinos and arefighting the
idea of establishingnew Indian lands.
© 2013 DaveGrunland. Reprinted by permission.
All rightsreserved.
© www.davegranlund
.com
Another major study of co-occurring disorders found that
among pathological gamblers 73% had an alcohol problem,
60% had a personality disorder, 60% smoked, 50% had a
mood disorder, 41 % had an anxiety disorder, and 38% had a
drug problem. 149 -' 50 One curious footnote regarding co-
occurring drug and gambling addictions is that gambling
I
often becomes a problem when a person abstains from his or
her other addiction.
"Inour GamblersAnonqmousgroups,manqmembershave
eight,10, or moreqearsof sobrietqfromalcohol,but theq
replacedthe drinkingwithheavqgambling.A smallerpercentage
practicedbothaddictionssimultaneouslq.I knewI wantedto
staqsoberwhengambling,so I'd drinktonsof coffee."
45 -year-old recovering pathological gambler
A recent trend has been the increase in the number of older
gamblers . One survey of residential and assisted-care facili-
ties found that 16% of their seniors visit casinos at least once
a month on facility-sponsored trips. 151 Many casinos offer
weekly day trips, providing transportation, snacks, and
"players club" discounts. Senior day is often the busiest day
at casinos.
'The greatestthingthat compelledme towardgambling
wasthe fact that I had lostall structurein mq life. I just
felt likelifehas cometo an end. I am no longerimportant.
I am no longerneeded.I haveretired.The worldis running
on just finewithoutme."
67-year -old female recovering compulsive gambler
College students have a higher rate of problem and patho-
logical gambling than the general population . In particular,
Internet gambling is growing in part because electronic
devices have become an ubiquitous part of that generation's
 7.38 CHAPTER 7
culture. 152 In a major study, 42% of 10,765 students in 119
different colleges said they had gambled in the past year, and
2.6% said they gambled weekly or more frequently. 153 In a
study of students in Connecticut, a state with more gambling
outlets than most other states, 4% of female students and
18% of male students said gambling led to at least three
negative life consequences (e.g., gambled more than intended
and couldn't pay bills). Students who were problem gamblers
were more likely to smoke, drink heavily, and use mari-
juana_ 1s4
Among college students, pathological gamblers were absent
more often and got lower grades than other students. Even
high-school students can get caught up in gambling. A
Canadian study of students in grades 7 through 13 found that
5.8% met the criteria for past-year problem gambling and an
additional 7.5% met the criteria for at-risk gambling. 155
Characteristics
In addition to problem and pathological gamblers, there are
several other types.
• Recreational/social gamblers. These are the majority of
gamblers; they are able to separate gambling from the
rest of their lives but generate only 10% to 20% of gam-
bling revenues.
• Professional gamblers. Gambling is a business for these
people. They make a living at it, and they take losses as
part of the game. Professionals were once few and far
between, but with the advent of extensive TV coverage,
dramatic increases in prize money, more-frequent tour-
I
naments, and lucrative sponsorships (e.g., online gam-
bling Web sites), their numbers are growing.
• Antisocial gamblers. These individuals have no con-
science. They perpetrate shams, and they cheat and gam-
ble to steal (loaded dice, marked cards), not to win; some
are compulsive gamblers as well.
Two subtypes of problem/pathological gamblers are the
action-seeker and the escape-seeker. Action-seeking gam-
blers are often male, frenetic, excited, and always in
action-behaviors that are contradictory to their inner
desire to escape .
"More than an~thin9, I just wanted to be a bi9 shot. I didn't
care if I was winnin9or losin9or if ~ou saw me 90 back to the
same place da~a~er da~ a~er da~. Somebod~ was 9oin9 to
think, 'God, this kid is a hi9h rolleror somethin9 becausehe's
here ever~sin9leda~."'
23-year-old recovering action-seeking compulsive gambler
Escape-seeking gamblers are often drawn to slot machines;
they are also called machine gamblers . Unlike many action-
seekers, machine gamblers were once responsible people
with good jobs who for a variety of reasons (e.g., children left
home ["empty nest syndrome"], loss of purpose, divorce,
retirement, death of a loved one) began gambling to escape
their emotions or just to escape boredom. Many experience
the equivalent of a blackout while gambling, where hours
pass without conscious awareness.
"/ was an escape9ambler... I was escapin9boredom; I wasn't
escapin9problemsat home or problemsat work."
58-year-old retired serviceman
The DSM-5 Classification
for a GamblingDisorder
Like other addictions, pathological gambling is a progressive
disorder requiring more gambling episodes and larger bets
to engender excitement and relieve anxiety. The 2014 DSM-5
categorizes pathological gambling as a Non-Substance-
Related Disorder simply called "Gambling Disorder." The
manual finally recognized that gambling is indeed an addic-
tion like drug and alcohol addictions. 156 Like other addic-
tions in the DSM-5, gambling disorders are rated as mild (4
to 5 symptoms met), moderate (6 to 7 symptoms met), and
severe (8 to 9 symptoms met). This is meant to replace the
current wording of at-risk gamblers (mild), problem gam-
blers (moderate), and pathological gamblers (severe), how-
ever many in the treatment community feel that the new
terminology uses too broad a brush in defining those who
have a problem with some compulsive activity.
The nine symptoms used to assess gambling severity are:
• gambling with ever-increasing amounts of money
• restlessness and irritability when attempting to con-
trol, cut back, or stop
• repeated unsuccessful efforts to control, cut back, or
stop
• preoccupation with gambling (reliving past and plan-
ning future gambling experiences)
• often gambling when feeling distressed (e.g., helpless,
guilty, anxious, depressed, bored)
• chasing (attempting to recoup previous losses)
• lying to conceal the extent of involvement with gambling
• jeopardizing a job, relationship, or educational or career
opportunity
• relying on others to relieve desperate financial situations
• craving43
A male with severe gambling disorder often begins gambling
as a young adolescent. Female pathological gamblers typi-
cally begin later in life. Both are more likely than the general
population to have a parent who had moderate to severe
gambling disorder. One study found that an individual's risk
of heavy or compulsive gambling was 65% if the father
gambled, 30% if the mother gambled, and 40% if a sibling
gambled. 157
Dr. Robert Custer, a clinician at the Veterans Administration
hospital treatment unit in Brecksville, Ohio-the first unit
for compulsive gamblers-described three phases of gam-
bling: winning phase, losing phase, and desperation phase .
To these three, researchers Henry Lesieur and Robert
Rosenthal added a fourth: a giving-up phase.
WinningPhase
Initially, gambling is recreational and pleasurable . Bets are
small and consequences are negligible. The feelings that
 Other Drugs,Other Addictions 7.39

come from playing and winning or breaking even seem to

satisfy the gambler.
for
"I had a winnin9phase that lastedme probablq12to 15
qears,and I actuallqlivedon mq9amblin9. I thou9ht I was
a semiprofes
sional,but I still did it in the closet."
"Forme it wasa rush,qou know, nothin9likealcohol,nothin9
42-year-old male recovering co mpulsive gambler
likeanqthin9I'veeverexperienced.It wasnervousness qet
excitement
; and if qou won, qou know,the excitementturned
A gambler who is susceptible to addiction will devote increas-
into happiness.If qou lost, qou didn't feeltoo aood unless
ing amounts of time and money betting. Poker stakes increase
therewasanotherraceto bet on and qou had moremoneq."
from nickel-and-dime , to $5 or $10, to table-stake games;
23-year-old recovering sports gambler
blackjack goes from $2 a hand to $20 on two different hands ;
sports bets escalate from $5 on the Super Bowl to $100 on 10
As skills improve, the action-seeking gambler becomes more
different games each weekend. A $2 bet on the favorite at the
confident , often overconfident, of his or her abilities. The
racetrack spirals to a $20 wager on the trifecta and $ 100 on
winning phase can last a year or 10 years. A similar winning
every other race. Day traders stan by depositing $500 to cover
phase does not really exist for escape-seeking gamblers (e.g.,
their trades and soon up it to tens of thousands of dollars if
poker machine , slot machine , keno, bingo , and lottery play-
they have a run of luck. Over time the player depends on the
ers) if they play on a regular basis. Sometimes they win , but
high to deal with undesired moods or relationship problems .
overall they lose. A good day is breaking even while staying
in action for hours at a time. For both action and escape
'The lon9erqou could staq in action, for
me anqwaqs,
gamblers, the goal is to stay in action and escape reality for
the moreI couldescapefromthe realitqof what mq life
as long as possible-winning is secondary .
reallqhad become."
Early on for most action and escape gamblers, a big win 43 -year-old recovering action-seeking gambler
fueled the craving to gamble. The amount is incidental; the
win could have been a few hundred to tens of thousands of Gamblers believe in luck to solve their problems. They
dollars, but it has the same effect as the first intense rush remember their wins and minimize their losses . Their self-
experienced by a cocaine or heroin user-never forgotten esteem is boosted by their gambling ability and , for action-
and forever chased. seekers, by the camaraderie of other gamblers. Gambling
increases heart rate significantly, and it remains elevated dur-
ing the activity ; cortisol (the stress hormone) also increases. 158
e-mo;l :CLOSETOHOME@COMPUSERVE .COM

LosingPhase

"I wouldtalk lessand lessto the peoplearoundme.

I wouldplaq for hoursand hoursand hours'ti/ I was
practicallqin a stupor. We don't stop to eat; we don't stop
to drinkanqthin9;we don't stop to 90 to the bathroom;
we don't leavethe machinefor an instant."
63-year-old female recov ering escape-seeking compulsiv e gambler
I
The losing phas e for both action and escape gamblers often
stans when the law of averages catches up to a lucky streak.
If their tolerance has increased and they are betting large
sums , the suddenness of heavy indebtedness can be startling.
They try to recoup losses and begin chasing their money,
becoming impatient and making bad decisions. A sports
gambler may listen to three or four games simultaneously ,
whereas a compulsive stock or commodities speculator may
call for price quotes every hour and be glued to an online
quote screen. Poker machine players will refuse to leave a
machine they have fed hundreds of dollars to because they
"just know the machine is ready to pay off." The online gam-
bler will play all night , hoping for a lucky run. The point of
llJ:t::j::5,~--- ~ all this activity is to stay in action.
. .. . ' :www
'.cioiiohome
.com
t
While social, job , and family tensions multiply, a gambler
Researchers at MIT study the effects of may deny that there is a problem and lie about the amount of
casino gambling on laboratory rats. money involved or the frequency of the gambling. The magic
is gone and, for the action gambler, the emotional anguish of
Cl 1999 JohnMcPhers on. By permission of AmericanUniversal
Uclic
k.
All rightsreserved. appearing to be a loser can be overwhelming. For the escape
gambler, the humiliation of staggering losses and engaging in
 7.40 CHAPTER 7

questionable behavior can devastate an already fragile ego. NO EXIT © Andy Singer
Chasing the money brings other changes in the gambler:
depression , deception , isolation, and irritability . But even
when they lose , gamblers still rely on gambling for their
emotional satisfaction.

"Mqmindtold me, Yes, qou're9oin9to lose'; but qourmind

alsotellsqou, 'But if qoudo this,qoudon't haveto feeleither.'
Aslon9as qoudon't haveto feelthe priceqou'repaqin9,
whetherit be wei9ht9ainor whetherit be for the moneq,it is
almostworthit at that point."
44 -ye ar-old recovering escape-seeking compulsive gambl er

As losses multiply, gamb lers try to recover financially by

gambling more, try unsuccessfully to cut back , vow never to
gamble again (a vow always broken), often look to others to
bail them out of trouble, but yet they relapse and lose even
more money. One reason was found in 2012 when research-
ers in Japan discovered that pathological gamblers had less
norepinephrine transporters in their limbic survival/rein-
forcement brain cells that made them less aroused by losses
and less sensitive to the pain of losing money than were non-
pathological gamblers. 1ssA

DesperationPhase
In the end stages, which could take a year or several decades
to develop , pathological gamblers often lose their jobs, lose
their homes, become alienated from people they owe money © Andy Singer. Courtesy of Cagle Cartoons.
to, destroy their credit, and sometimes turn to illegal activ-
ities like theft, embezzlement, and drug dealing. Desperation

I
causes pathological gamblers to play more and more; and
because the laws of chance are finite, the two key factors
necessary to preventing damaging losses-patience and com-
mon sense-are ignored. They play too many poker hands;
they direct their anger at a slot machine and swear not to let
the machine beat them; and their former sense of being lucky
turns into the sad lament that they are the unluckiest people
in the world.
"A~er 15qearsit 9ot reallqbad in dollars-hundredsof
thousandsof dollarslost, lossof mq marria9e,mqself-esteem,
mq vehicles
, mq homes.At oneotherpointin time, I lostmq
mother'shome. I don't evenknowhow I 9ot mqparentsto si9n
on the dotted line."
43 -year-old recovering gambler
Gamblers often bankrupt their families and suffer divorce
or separation because of deteriorating family relationships ,
long absences from home, arguments over money, and indif-
ference to the welfare of family members and others. This
desperation creates a curious sense of optimism, a belief that
tomorrow will be a lucky day. Many fantasize about leaving
it all behind and starting over; this thinking often includes
thoughts or attempts at suicide.
Giving-UpPhase
At this stage pathological gamblers stop believing they will
win it all back, and they stay in action so that they don't
have to think. Gamblers can experience elated moods when
they win and mania, depression , panic attacks, insomnia,
health problems, and suicidal thoughts or actual attempts
when they lose. They become more mechanical in their play-
ing and often are in dissociative or trancelike states. One
study of Gamblers Anonymous members found severe
depression in 72% of those who said they hit bottom; 17% to
24% attempted suicide. 159 Gamblers who committed suicide
were twice as likely to have personality disorders as non-
gamblers who committed suicide. 160 Another study found an
80% incidence of at least one psychiatric illness in a group of
problem/pathological gamblers. 161
"EverqtimeI 9et out fromthe casino,I wantto killmqself
Then it's 9oin9to be over. Then it's 9oin9to end. I tried
to killmqselftwice.I tookmqcarto the mountains.I just
wantedto-I decidedI didn't wantthe painanqmore."
38-year -old recovering compulsive gambler
Often the problems become so overwhelming that they pre-
cipitate the final crisis (e.g., loss of house, car, spouse), which
hopefully leads the compulsive gambler into treatment rather
than to suicide .
Understandingthe CompulsiveGambler
'Therewereno feelin9s . That'swhq I plaqed.Therewereno
feelin9s;blockedall the feelin9s;blockedall the stress;blocked
all the anxietq.Therewereno feelin9s."
42 -year-old recovering es cape -seeking compulsive slot machin e player

It is hard for people who never gamble or for social gamblers
to understand the compulsive gambler. The phrase It's not
about the money says it all . Compulsive gamblers seek the
rush from a win or the peace of zoning out while gambling
more than achieving some financial goal. Even when there
is a win, its value to the compulsive gambler is that it allows
him to continue gambling.
"I wouldget a biggerrushfromstartingout the eveningbeing
down$1,000 and then fightingm~wa~backto beingon/~
stuckfor $100 than I wouldfromgettingaheada few hundred
dollarsand endingthe eveningaheadb~aboutthe same
amount;that'snot exciting.Peopledon'tget that."
38 -year-old Texas Holdem player
Gambling is a binge activity-compulsive gamblers will
keep gambling until they have depleted every access to
money and have run out of people from whom to borrow.
'Towardthe end of m~card-plafngcareer,I usedto lose
deliberate/~
so I couldleavethe Holdempokertable.As long
as I had mone~,I couldn'tleave,literall~.I just had to keep
going.At leastwhen I drank,I wouldpassout beforeI totall~
destro~edm~finances."
55 -year-old male recovering compulsive gambler
One study on recovery found that more than one-third of the
compulsive gamblers recovered on their own, often precipi-
tated by a devastating financial loss. 162 For others options for
recovery range from pharmacotherapy adjuncts such as anti-
depressants and anticraving drugs to gambling groups such
as Gamblers Anonymous, a 12-step recovery program with
chapters in every state and in 45 countries worldwide, and
the state-sponsored Gamblers Awareness program in Oregon
(one of the few states to have an extensive treatment pro-
gram), which treats upward of 1,500 gamblers each year.
MagicalThinkingand the Gambler'sFallacy
(Adaptedfrom Richatd]ohnson, Ron Fisher,and Tom Teneyck)
Cognitive distortions are common in compulsive gamblers;
researchers believe that about 70% of their gambling-
related thoughts are illogical. It is these mistaken beliefs that
lead to the behavior that is so baffling to non-gamblers as well
as to the gamblers themselves.
"It wasn'tlikebeforewhen I wassinJJle, I couldgo out and sta~
27 hoursat one table, I wentlessfrequent/~. So in m~mind
I thought,'Wh~don't I bettwiceas muchand sta~half the
time...then it'[[workfor me. And that theor~is a ver~good
theor~and sometimesit worked,but mostof the timeit didn't."
43-year-old male recovering compulsive gambler
"Magical thinking"-the main cognitive distortion-is the
belief that thinking equates with doing . It ignores cause
and effect and denies the validity of the laws of chance.
Magical thinking allows someone to live in a fantasy or dream
world rather than the reality of a situation, which enables
them to continue to gamble. It is also a way to avoid dealing
with painful issues in the present because gamblers live in the
Other Drugs,Other Addictions 7.41
© KasiaBialasiewicz bypermission of l 23RF
future, where all things will work out, where a big win will
solve all financial and personal problems.
"I figuredI waslosing$500 hereand there,~ouknow,a week.
neverthoughtthat it wasa bigdealbecauseI alwa~sthoughtof
m~selfas goingto be success{
ul, goingto get a betterjob down
the roadwhereI'll makeall this mone~back.It'sgoingto be a
week'spa~checksomewheredownthe road,so wh~quit now?"
22 -year-old recovering compulsive gambler
Gamblers never completely escape the past; along with the
memories of past wins and past pleasures come those of past
I
injuries, past losses, past resentments, past abuse, and emo-
tional pain .
"You'restafng awa~fromthe realdeepinsidepainfor a super-
ficialfinancialpain. I mean,for the mostpart what I felt was
the lossof dollarswhichI couldrecoupagainthe nextda~, but
it wasbetterthangoinghomeand facingthe painof seeingm~
motherwithsleepingpillsor thingslikethat-fights, drinking."
24 -year-old compulsive sports gambler
Magical thinking leads to the "gambler's fallacy," which in
its simplest form is the belief that one can predict random
events. To a gambler that means previous events can be used
to predict future events-that it is possible to predict a win
even when the game involves totally random events, for
example:
• If a slot machine loses 10 times in a row, the chances that
a winning array will come up soon are increased.
• If a roulette wheel comes up red five times in a row, black
is more likely to come up next.
• If someone plays their lucky numbers, the chances of
winning are increased.
In all three cases the reasoning is incorrect because the odds
are the same as if there were no streak or the person simply
picked random numbers. These erroneous thoughts coupled
with the belief that continuing to play will eventually and
inevitably result in a win keeps compulsive gamblers gam-
bling and inevitably losing.
 7.42 CHAPTER 7

"I don't thinkaboutodds. What enticesme to staq is GamblersAnonymous

I'llseeotherpeoplewinnin9and I'll think, 'Well, mq
machinehasn'tpaid out. It's about timethat it will." 'The onlqrequirement
for membership[in Gamblers
41-year-old female gamb ler
Anonqmous]is a desireto stop9amblin9."
Gamblers Anonymous

The "gambler'sfallacy"is the beliefthan one
can predictrandomeventssuchas a slot
machinepayingoff, a pair of dice rollinga
pass,or the rivercardfillingan insidestraight.
For most forms of gambling, it takes an average of three and
a half years of steady play to slide from social gambling into
pathological gambling . For those who focus on video lot-
tery terminals such as video poker, the time from first bet
to addiction is only one year. 137
Video slot machines are designed with "the gambler's fallacy"
in mind, and the machines are programm ed to feed this cog-
nitive distortion . "Virtual reel mapping " technology manipu-
lates the symbols so that an extremely high proportion of
winning combinations will appear just above or just below
the win line, prompting compulsive gamblers to say, "Darn,
I almost won; I'd better keep playing; this machine is
due ." 163, 164, 165 The average social gambler who gets an "almost
win " does not get nearly as excited and realizes, "Darn, I lost
again. I'd better quit ."
Gamblers Anonymous (GA) was formed in 1957 on the
model of Alcoholics Anonymous. Its basic concept is to let
compulsive gamblers help themselves by changing the way
they live so that they can stop gambling, develop spiritual-
ity, and help other compulsive gamblers recover. At present
it is the primary stopgap for compu lsive gamblers and their
only hope for recovery. Study after study found that gamblers
who participate in Gamblers Anonymous have a stronger
chance of recovery than those who enter therapy with a
counselor or psychologist or go it alone. A few states provide
free gambling treatment, but most compulsive gamblers must
find treatment on their own.
, The20Questions
ofGamblers
Anonymous
1. Didyouever lose timefromworkor schooldueto gambling?
2. Hasgambling
evermadeyourhomelifeunhappy?
3. Didgambl
ing affectyour reputation?

Recovery 4. Haveyoueverfelt remorseaftergambling?

Recovery comes from correcting those cognitive distortions . 5. Didyou ever gambleto get moneywithwhichto pay debtsor otherwise
Brain scans of compulsive gamblers actually show their solvefinancial difficulties?

I
intens e excitement when they get an almost-win on a slot 6. Didgambling
causea decrea
sein yourambrtion
or efficiency?
machine .167, 168 "I need to gamble to make money to pay the 7. Afterlosingdidyoufeelyoumustreturnassoonaspossible
andwin back
bills" must be changed to "I've rarely paid any bill with gam- yourlosses?
bling winnings because I can't stop until I lose everything." 8. Afterawindidyouhavea strongurgeto returnandwinmore?
Most gambling therapists and counselors recognize the 9. Didyouoftengambleuntilyourlastdollarwasgone?
strong similarity between gambling treatment and alcohol/ 10. Didyoueverborrowto financeyourgambling?
drug treatment except for two differences: the compulsive
11. Haveyoueversold anything
to financegambling?
gambler's egotism and sense of entitlement. 166
12. Wereyoureluctant
to use"gamblingmoney"for normalexpenditures?
"I wouldstep on anqbodq.I was rudeto people. I wouldcall 13. Didgambling
makeyoucarele
ssof thewelfareof yourse~
andyour
qou namesthat qou wouldwant to crushme for. I don't care fami~?
aboutanqone.I'm the mostimportantpersonhere." 14. Didyou evergamblelonger thanyou hadplanned?
45-year-old male action-seeki ng gambler 15. Haveyouever gamble
d to escape
worryor trouble?
16. Haveyouever committed
or considered
committing
anillegalactto
"I wasso absolutelqcertainthat I could controlit. I was financegambling?
supremelqe9otistical.I didn't haveto keeplosin9;it was9onna 17. Didgamblingcauseyouto havedifficu
lty sleeping?
turnaround.I could9amblelikeotherpeople.I could rational-
18. Doarguments,
disappointme
nts,or frustrations
createwithinyouanurge
izea thousandreasonswhq it wasokaqfor me to keepon to gamble?
9amblin9. I'd had a crappqlife. I deservedit. I had the moneq;
19. Didyouever haveanurgeto celebrate
anygoodfortunebya fewhours
it wasmq moneq, and I could do what I want to with it." of gambling?
55-year-old female recovering gambler
20. Haveyoueverconside
redself-destr
uctionor suicideasa result of your
gambling?
"It's likeit's mq machinenow. I'vepaid for it. I've investedin
it, and it's mq machine; and ifanqbodq's9oin9to win on this Mostcompulsive
gamblers
will answer yesto at leastsevenof thesequestions.
machine, it's9oin9to beme and so I'm hooked. I'm just 9oin9
to staq thereuntileitherit paqsout or I runout of moneq." © 20 lo GamblersAnonymous
52-year-old female recovering pathological gambler
 0,.,°""S'ONo_,. l .4l

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.. 1ts d<rli, · m u.k,, Ill" ralhff than afler th< KIIW >Clof
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Compulsive Shopping and Buying

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~holdslntheUNta!Stalts(l.!19proplep,rhomchold)
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ond the SH0.000 In .,.,.rnmmt deb< that Lt°""""
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::;;:1:;; ;::. ~""u~•=~!nioc~IISI~~:
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ondtospmdtobendi1thttcnN>m,cForoomcp,apk,
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andth<Uruta!Kingdomputthenumbaofrompulm-<buy •
ns,omewh< nc bie<..-ttnl1oand\O'!loof1h<popub.t1on. ''"
~=~~~~~~~~.~e-,;nc;;"th:"°~~==~~
pt0plt who.<deb uaremeuured inthe1t mol thousmd< or
hundrtdsofthouoandsofdollars ."'CJ<1 rl)\cltl:emo£poor
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 7.44 CHAPTER 7
© 2013 Fernando
Gregory.Bypermis
sion of 123RF.
The roots of compulsive shopping/buying parallel many
aspects associated with pathological gambling. Pathological
gamblers believe that their wonh and self-esteem come from
gambling because they believe they have control-the casino
brings them free drinks, and if they lose big, they are treated like
royalty. Casinos and clubs issue membership cards to gamblers,
who are treated, if not with respect, at least with acceptance.
Shoppers/buyers are also treated well; the more they spend,
the better the service. That is just good business. For most,
shopping is a pleasant outing, a chance to buy needed or
desired items; but to some a store is one of the few places
they can get acceptance or get lost in a dream world, much
like action-seeking and escape-seeking gamblers. All they
I
need is cash, a credit card, or some checks.
One small study of 25 compulsive shoppers/buyers found a
number of commonalties . Buying urges occur from a few
times a week to once a week; and though they try to fight the
urges, they give in 74% of the time. Compulsive shoppers
often don't have specific items in mind when they shop and
frequently purchase on impulse . About 50% of their house-
hold income goes toward paying debts.178
In preliminary studies by the Economic and Social Research
Council in the United Kingdom, researchers found a large
discrepancy between the way shopping/buying addicts see
themselves (their actual selO and the way they wish to be
(their ideal selO. They believe that buying and acquiring
things will bring them closer to their ideal self. Others with
the same problem might tum to drugs or compulsive eating.
Women tend to buy things that enhance their uniqueness,
like jewelry, clothes, and cosmetics, whereas men prefer
high-tech, electronic, and sports equipment. 179 Debt coun-
seling is only a stopgap measure until the roots of the con-
dition have been addressed, much like a temporary bailout
for a pathological gambler.
Most consumers incur 40% of their actual debt during the
winter months. Holidays can trigger old resentments and
magnify feelings of loneliness and depression, and depres-
sion is one of the major motivations for compulsive shop-
ping.180In one study 10 of 13 compulsive shoppers received
antidepressants and reported a complete or at least panial
reduction in their compulsive-buying behavior. 110 Dr. Eric
Hollander, director of the Compulsive, Impulsive, and
Autism Spectrum Disorder Program at Montefiore Medical
Center in New York, believes that low serotonin levels (which
cause depression) are the reason why some women become
compulsive shoppers or develop eating disorders whereas
men with low serotonin levels become risk takers and some-
times turn to violence. 175
Research has established that the neurotransmitter dopamine
activates the brain's "go switch." This activation is more exag-
gerated in people who are vulnerable to developing an addic-
tion. The relationship of dopamine to addiction can be
observed in gambling addicts who also suffer from Parkinson's
Disease . Medications used to treat Parkinson's activate the
brain's dopamine receptors which results in relapse in indi-
viduals prone to impulse control disorders such as gambling
and shopping. 181
The use of cognitive behavioral therapy to treat compulsive
buyers showed marked improvement in patients which
resulted in fewer buying episodes after six months. 182Weekly
therapy to help interrupt the cycle of compulsive buying,
committing to a budget, working on the inner issues regard-
ing self-image and self-esteem, and attending a self-help
group for support-all are positive steps toward recovery.
There are more than 400 Debtors Anonymous groups in the
United States.
Hoarding
Collecting, accumulating, and hoarding are offshoots of com-
pulsive shopping and are rooted in an individual's belief that
his or her worth and self-esteem come from objects and the
ability to acquire them. They avoid getting rid of anything
because of the anxiety that removing it from their lives
produces. The belief in the hidden value of anything they
acquire makes them believe that throwing it away is akin to
dashing some of their dreams (similar to the magical think-
ing of compulsive gamblers). 183The objects vary from use-
less items to antiques and other items of true value and
beauty to pop-culture and hobby-related items that have
gained desirability among certain segments of the population
(e.g., baseball cards, action figures, Barbie® dolls, and thou-
sands of collectibles).
for
"I'm into baseballcards. I'm bidding these boxesof cards on
for
eBaq $50 and aboveand hoping the more valuablecards
will be in the boxes.So mq plan was to buq and sell these and
make some moneq, but I have qet to sell anq. I have tens of
thousandsof cards."
28-year-old recovering collector
"Hoarding Disorder" is included in the DSM-5, with these
diagnostic criteria:
• Persistent difficulty discarding or parring with posses-
sions
• A perceived need to save the items and distress if they are
discarded

• A resulting accumulation that impairs living
• Significant distress in social situations, work situations,
and mainta ining a safe environment
• Not attributable to anot h er medical cond ition (e.g. , brain
injury)
• Not explainable by another mental disorder
When someone 's desire to accumulate th ings becomes a det-
riment to every other aspect of their life, their behavior cou ld
be classified as hoarding. The news reports of peop le hoard-
ing relatively valueless objects like decades' worth of news-
papers and magazines, plastic takeout containers, cardboard
boxes , and junk mail are the tip of the iceberg . There are
people who hoa rd spoiled food, cats and other live animals,
and, in one case in San Francisco , thousands of rats .184 Often
the objects collected are connected to memories of enjoyable
childhood experiences and feelings, and the individual has a
need to re-create those feelings; th is behavior is similar to a
hero in addict chasing that first high .
The number of hoarders is estimated at more than 1 million,
and many more are considered borderline hoarders . Hoarding
is a hidden disease, especially among the elderly, but several
TV reality shows have created an awareness of this disease by
chronicling the lives of people whose inability to pan with
their belongings is so out of control that they are on the verge
of a personal crisis, such as losing thei r children, their pets,
or their home.
EatingDisorders
Overview
In 2013 the American Medical Association (AMA) finally
identified obesity as a physical disease, not just a risk factor
for other disorders such as heart disease . The AMA concluded
that this true illness warrants far more attention and respect
from patients, docto rs, and health insurers and a concerted
effort to treat it. It is estimated that obesity adds an addi-
tional $150 billion to healthcare costs in the Un ited states
and leads to 300,000 premature deaths, second only to mor-
tality from smoking (490,000) .185
In the DSM-5 , under the heading of "Feeding and Eating
Disorders, " are th ree uncommon disorders:
• pica-ingesting nonnutritive substances such as plaster,
gum , wool, or string
• rumination disorder-repeated regurgitation of food
• avoidant/restrictive food intake disorder-a lack of
interest in eating and the avoidance of many foods,
result ing in weight loss and bad nutritiona l problems
The DSM-5 also includes three more well-known disorders:
• anorexia nervosa-an addiction to weight loss, fasting,
and minim ization of body size
• bulimia nervosa-an addiction to binge-eating large
quantities of food, often followed by purges using self-
induced vomiting, fasting, or excessive exercise; body
weight is on the low side of normal
OtherDrugs,OtherAddictions 7.45
• binge-eating disorder-recurrent episodes of binge eat-
ing where more than norma l is eaten and a sense of lack
of contro l grows strong 43
Those with binge-eating disorder compose a much larger
group than those with anorexia or bulimia . To reflect the
reality of modern society, the DSM-5 changed the descr iption
found in earlier editions by specifying the frequency of
episodes of binge eating and the severity of the disease.
"WhenI got up to 328 pounds, I wouldlookin a mirror
and saq, 'Not too bad.'Talkaboutdelusion.As I wentto
more OvereatersA11011qmous meetingsand lost 123pounds
in eightmonths,I thoughtabouthow I neverleft anq food
011 the plate. Once I startedeatinganq food, particularlq
carbohqdrates , mq addictedlizardbrainsaid, 'Eat it again;
get somemore;eat it again.''
53 -year-old not -so -obese compulsive overeater
Sometimes the line between anorexia and bulim ia is blurred .
Bulimic symptoms appear in 30% to 80% of all anorexics. 187
The major difference between the two is that bulimics purge
to maintain a low weight whereas anorexics usually starve
themselves though they may occasionally binge . This is the
reason why anorexics are severely underweight and bulimics
are not. Female bulimics are also less likely to suffer men-
strual irregu larities and mo re likely to admit to having an
eating disorder than are anorexics.
SchoolLunches
Eating disorders have been around for centuries, but the per-
I
centage of the popu lation affected in the United States was
very low until the middle of the twentieth century. During
World War II, the armed forces had to reject 40% of enlistees
because they were too small and too malnourished to carry
the backpacks and the weapons needed to fight. After the war
ended, in 1946 the government responded by creating the
National School Lunch Program, supplying milk, cheese,
and other high-calorie nutritional foods to build up
America's youth for future wars. 186 Americans were eating
more, mov ing from rural areas to urban centers, making
more money, driving instead of walking, and, with the advent
of fast-food restaurants, consuming more fats and refined
carbohydrates. All of these factors cont ributed to a culture
that viewed eating as recreation rather than for survival and
a population with ever-expanding waistlines.
Today 27% of potential recruits would be rejected by the
Armed Forces because they exceed the weight standards.
The recommendation presented in a report on the readiness
of our armed forces, "Too Fat to Fight ," encouraged the adop-
tion of higher nutrition standards that will eliminate high-
calorie, low-value foods from our schools and from our
child ren's lives. 186
Demographics
As the standard of living rises worldw ide, the rate of obesity
increases. Globally, 12% of the world's population is obese
compared with 35 .3% of the U.S. population. The U.S . rate
of extreme obesity is 6.6%. In 1980 the obesity rate was less
 7.46 CHAPTER7
[ RECRUITING or:s:,cE ..
© 2010 DaveGranlund. Reprinted by
permission. All rights reserved.
\/A~f:Gl2AN O©
L\JN
than half that percentage. The number of Americans who are
overweight (including obese Americans) is 68.8%-more
than two-thirds of the population. 188 .189 •190 In 2013 about 17%
of all children and adolescents in the United States are
considered obese .191
The current obesity rate is 22% in England, 13% in Spain, 9%
I
in France, and 9% in Italy. Recently, the obesity rate has
begun to level off in developed countries, though it is rising
in developing ones.
Certainly, genetic susceptibility plays a significant role in
weight gain, but according to the World Health Organization,
environment (mostly cultural factors and the availability of
food) is the key reason for the rise of obesity worldwide,
particularly in developing countries . WHO estimates that
more than 300 million people worldwide are obese and
1 billion are overweight. 191
In a survey of 43,000 adults in China, it was found that more
than 11% of people age 20 to 39 were obese, an increase of 2
percentage points since the previous survey in 2010. Children
have an even higher rate: another survey by China's General
Administration of Sport found that 34.4% are overweight, up
from 25% four years earlier. 192 This is ironic because 50 some
years ago, during the three years of China's great famine
(1959-1961), up to 45 million people died from starvation.
Globally,12% of the world's population
is consideredobese comparedwith 35%
of the U.S. population.
In the United States, the percentage of young people in the
6-to-19 age group considered obese is almost 17%, and
those considered overweight make up 32% of that demo-
graphic. Even children age two to five have an overweight
www.daveg ranlund.com
rate of 10%.193 Excess weight leads to a number of illnesses
in children, such as diabetes. 194
"Duringqourlife, mq child, seewhat suitsqourconstitution,
do not giveit what qou find disasreeswith it;
for not everqthing
is900d for everqbodq,
or doeseverqbodq likeeverqthing.
Do not be insatiablefor anq delicacq,
do not besreedqfor food;
for overeatingleadsto illness,
and excessleadsto liverattacks.
Manq peoplehavedied fromovereating;
controlqourself,and so prolon9qourlife."
Sirach 37: 27- 31, second century, B.C.
History
Over the past 5,000 or 6,000 years, the concept of beauty has
changed from generation to generation and from culture to
culture . Thinness was once a sign of poverty and lower-
class status, and plumpness was a sign of wealth and mem-
bership in the upper class because the wealthy had the
means to access plentiful amounts of food. At the beginning
of the twentieth century, with the growth of middle classes
and moderate wealth, the full-figured grand dame of the
Victorian era gave way to the svelte, fun-loving flappers of the
twenties.
Following the Depression and World War II, the voluptuous
woman typified in the 1940s and 1950s by Jane Russell,
Marilyn Monroe, and Jayne Mansfield gave way in the sixties
to the slight, boyish figures of Audrey Hepburn and British
model Twiggy. Wallis Simpson's famous quote, "You can
never be too rich or too thin," is reinforced in fashion
magazines and television ads featuring waiflike models and
in an entertainment world populated with slender stars.

Today the paparazzi mercilessly hound young starlets, often
focusing on their weight gain or loss.
"I'vebeen on this insanediet for almost 17 qearsto maintain
the weight that was demanded of me when I was modeling.
Mq diet was reallqstarvation.I am not naturallqthat thin."
Carre Otis, model, actress and recovered anorexic
There is a wide discrepancy between what is presented as the
"ideal body" in ads and on the fashion runway and the reality
of most female bodies worldwide . The average woman in the
United States is 5 ft. 4 in. tall and weighs 140 to 164 lbs. The
average fashion model is 5 ft. 11 in . and weighs 117 lbs . 195
Our society strives to emulate the youth, beauty, and perfect
bodies presented in the media, and yet the number and the
frequency of television spots selling beer, soft drinks, candy,
and fast food create a curious paradox. Children see 10,000
advertisements for food each year, and 95% of those are for
sugared cereals, candy, fast food, and soft drinks. 196 Individuals
who are overweight or obese are often subjected to social isola-
tion, job discrimination, and ridicule that foster feelings of
inferiority and guilt. A common compliment in our society is
"You've lost weight-you look good. "
The diet and fitness industries reap the financial bounty of our
desire for a perfect body, as Americans spend $40 billion to
$100 billion per year on weight loss programs and products.
The desire for the ideal body sometimes moves people beyond
a healthy weight-loss program into a serious eating disorder. 197
"I went to this eating disorderclinic for mq bulimia.There were
also anorexicsand overeatersthere. At the meal table, the
staff kept an eqe on everqone.Theq made sure the anorexics
ate somethingand didn't give it to the overeatersor bulimics,
or go to the bathroom immediatelqa~er to throw up, or start
exercisingto incredibleexcess.Theq also checked under the
table for thrown-awaqfood. We bulimics,theq just had to keep
us awaq from the bathroom, so everqonehad to staq in the
meal room for at least a half hour a~er eating. A qeara~er
I stopped throwingup becauseof health reasons,I ballooned
up to 360 lbs. Now I'm just a plain old compulsiveovereater
or, as theq call it now, 'binge-eatingdisorder."'
35-year-old male recovering bulimic, former college wrestler
Eating disorders involve obsession with thoughts of food ,
use of food to escape undesirable feelings (e.g., depression,
anxiety, or boredom), secretive behavior, guilt, denial, and
continued overeating or fasting regardless of the harm done.
These symptoms can be applied to people who are moder-
ately overweight or obese.
"It's not just a phqsicaladdiction. It's a spiritualand emotional
problem,too. It just doesn't encompassqour bodq. Your mind is
totallq off keq.You'rejust so involvedin whateverthe addiction
is, qou'renot livingqour life. You're livingfor the addiction."
45 -year-old female recovering compulsive overeater
Like other addicts, people with an eating disorder feel a
sense of powerlessness when dealing with food, even
Other Drugs,Other Addictions 7.47
A society'sattitude toward weight can vary greatly.Japanese Sumo
wrestlers can weigh 300 to 400 pounds and it is acceptedbecauseit
has a purpose. In the United States, wrestlers are praisedfor their
abnormal muscularity rather than their girth and weight.
© 201D StanislawTorarski.Permission by l 23RF.
though it is often a desire for mastery and control over their
life that led to their developing an eating disorder.
"Mq mom had schizophrenia,mq dad drank, and I felt I
couldn't help or change anqthing in mq life. One of the onlq
things I could control was and still is what I eat. I could choose
anqthingin that refrigerator.I can go to a restaurantand order
anqthing. Nobodq can tell me what to eat."
43-year-old male compulsive overeater
I
"When qou'rea drug addict or an alcoholicor a food addict,
there'sthe assumptionthat since qou'rethe one putting it into
qour mouth, or smokingit, or mainliningit, or whateverqou're
doing, qou somehowhave a senseof control. You don't get anq
kind of senseof control until qou'rein recoverq."
45-year -old recovering compulsive eater
Genetic, Environmental,and
Neurochemical Factors
Some regard eating disorders as learned behaviors that can be
unlearned with treatment. Others believe that they are phys-
iological and psychological addictions, often formed by sex-
ual, physical, and emotional traumas suffered during infancy
and early childhood. 198 Some cite genetics as the main cause
of eating disorders. Evidence suggests that eating disorders,
like all addictions, are a combination of genetic, environ-
mental, and neurochemical factors. 199 ,200
Genetic Factors
There is a very strong genetic component to compulsive
overeating and, to a lesser extent, anorexia and bulimia. The
genes that have the greatest impact are those that affect
hunger, satiety, and food intake rather than metabolic rates.
One of the genes that signal a tendency to alcohol and drug
addiction also signals a susceptibility to compulsive overeat-
ing. The DRD2 A1 allele gene, found in 70% of alcoholics but
 7.48 CHAPTER 7
in only 30% of social drinkers, is often found in compulsive
overeaters. This gene signals a lack of dopamine receptors
(pleasure receptors) in the nucleus accumbens in the sur-
vival/reinforcement circuit of the addiction pathway, which
encourages overeating to obtain satiation and a modest
high. 117-201Recent research found that high-fat, high-sugar
diets decrease the number of D 1 and D2 dopamine receptors
(down-regulation), which further increases craving. 202This
research showed that after ceasing an overly rich diet, the
craving and the desire to overeat was still there 18 days later
partly because the receptor shortage had not reversed itself.
Some other genes that affect obesity are those that affect
leptin and melanocortin, two hormones that control hun-
ger.203-204
Other genes that affect obesity control fatty acid and
cholesterol synthesis. 205
EnvironmentalFactors
Nutritional biologist Hans-Rudolf Berthoud suggests that in
a restrictive food environment where feast and famine are
cyclical, the body's homeostatic control system regulates
body weight quite well. 206In other words, when food is
scarce, the body alters its metabolism to get the maximum
nutrition and energy out of limited supplies. When food is
abundant, it also stores fat to be released when famine takes
its turn. In a society where rich food is readily available and
where the need to do extended physical activity for most of
the day no longer exists, obesity does occur and the natural
subconscious control of appetite and metabolism becomes
ineffective .207Cognitive control of one's eating habits is nec-
essary to make choices based on intake rather than appetite
I
and craving. Excessive loss of control occurs in those who are
already genetically predisposed to retaining every morsel
that's put into their body.206-208In any other situation, this
ability to alter metabolism to maximize one's intake is a
survival trait. In a modern, upwardly mobile society, it is
often injurious to individual and societal health.
NeurochemicalFactors
Researchers, including Nora Volkow, director of the National
Institute on Drug Abuse, believe that compulsive overeating
could also be called "food addiction" because certain foods
alter the brain in ways that intensify craving and promote
eating disorders . The alterations are very similar to the neu-
rochemical changes caused by psychoactive drugs.
Normally, an empty stomach releases ghrelin, which affects
the hypothalamus, the area of the brain that controls metabo-
lism and appetite . The hypothalamus then triggers dopamine,
which stimulates the nucleus accumbens ("go" switch),
encouraging the conscious brain to search for food. 210 -211
Eventually, the hormone leptin, released by fat cells, counter-
acts the ghrelin and tells the hypothalamus to stop eating. 213
Even the endocannabinoid CB1receptor is involved (the same
one that causes the munchies when stimulated by marijuana).
>
High-fatand high-sugardiets decreasethe
number of dopamine receptors,which in turn
further increasescravingfor these foods.
Another neuropeptide, orexin, will increase the saliency or
importance of a psychoactive food (e.g., one high in sugar or
other refined carbohydrate) over-activating the dopamine and
the nucleus accumbens and thereby increasing craving, par-
ticularly in susceptible individuals. Interestingly, orexin will
do the same (increase saliency) for cocaine and possibly other
psychoactive drugs. Researchers have found a drug (SB33486 7)
which helps block orexin, reducing craving for psychoactive
food and cocaine, as possible treatment for obesity.217
The various mechanisms that control appetite and satiation
can be overwhelmed by large amounts of food, particu-
larly high-energy foods like fats and refined carbo-
hydrates (e.g., pure sugar, high-fructose corn
syrup, and refined flour). These foods raise
and reset the body's natural appetite, increas-
ing craving and intake. 214Positron emis-
sion tomography (PET) scans reveal that
20% fewer dopamine D2 receptors are
found in compulsive overeaters' nucleus
accumbens, implying that much greater-
than-normal amounts of food are
needed to stimulate the survival path-
Even though this genetically manipulated
mouse eats the same amount as nonnal
mice, it is still two to three times as heavy.
While genetic influence in humans is not
nearly as dramatic, it is still a strong factor.
Courtesyof the AssociatedPress

Study: Th.ose atOUnd youcanmaKeyou
© 2012 DaveGranlund. Reprinted by permission. All rightsreserved.
way to raise their mood and make them feel satisfied. 215
These large concentrations of high-calorie, high-energy foods
also impair the compulsive eater's ability to stop eating by
disabling the brain's "stop" switch.
Food manufacturers and fast-food restaurants in particular
are aware of this distortion of normal mechanisms of the
human palate and often add com syrup or other refined car-
bohydrat es to make products more attractiv e to consumers '
taste. This distortion makes people want to eat for the taste
rather than the nutrition involved , believing that it is crucial
to their survival. 216
Over the past few years , fast-food restaurants have begun
posting nutritional information about their offerings.
Consider how the concentration of psychoactive substances
through refinement and synthesis increased their addiction
liability over the centuries and then compare that with how the
concentration of high-calorie, high-energy foods, particularly
refined carbohydrates, increased compulsive overeating.
The onset of obesity
often predicts the
onset of diabetes.
Medical Consequencesof Obesity
With the exception of cigarettes and alcohol, compulsive
overeating causes more health problems than do most psy-
choactive drugs. Compulsive overeaters-those with severe
bing e-eating disorder-are usually overweight and often suf-
fer from medical conditions associated with obesity:
• high blood pressure, high cholesterol , circulatory prob-
lems, and heart disease
• type 2 diabetes (adult-onset diabet es)
• sleep apnea
• gall bladder disease, gout , and arthritis
• according to some studies, a 15% to 60% greater risk of
cancer, including breast cancer in women 220
Other Drugs, Other Addicti
ons 7.49
fat ... The American Heart Association reclassified obesity as a
major modifiable risk factor for coronary heart disease .
Obesity (80 or more pounds overweight) shortens a per-
son 's life span by up to 12 years .221 Those who are less than
30 pounds overweight live a normal life span, possibly due
to the medications that are available to lower cholest erol and
blood pressure.
Diabetes
Diabetes has become epidemic in the United States over the
past two or three generations and is spreading to other
countries as they strive to emulate the American standard
of living. The two major factors that lead to type 2 diabet es
are genetics and the type plus the amount of food ingested .
Excess intake of fat and high-carbohydrate food coupled
with a sedentary lifestyle strains the body's ability to produc e
insulin, which is necessary to metabolize sugar and other
carboh ydrates . Often the body becomes insulin resistant , the
liver produc es too much sugar, and blood sugar rises to prob-
lematic levels.
One study found that approximately 25.8 million Americans
(8.3% of the population) had diabetes, while 79 million
more were prediabetic .222 The number of actual cases is
predicted to reach 44 million in 25 years .223 Anoth er study
projected that one-third of U.S. adults will have diabetes by
2050. 224 Costs to manage this disease are expected to triple
to $336 billion by 2034. As people worldwid e gain easy
access to unh ealthy food, the number of cases will continue
to grow. The onset of obesity often predicts the onset of
diabetes ; when an overeater becomes obese, type 2 diabetes
I
is likely to occur. 225 In a study of individuals with diagnosed
type 2 diabetes, 86% were overweight or obese; 58% of the
entire study population was obese_22 6
There is a strong racial
and nationality component to diabetes: American Indians ,
Each day, one in f our Americans visits a fast -food restaurant , where
spending totals $110 billion a y ear. McDonald's alone operates more
than 30,000 restaurants in 100 countries. ln the United Stat es
McDonald's controls 43 % of the fast-food market. There are 160,000
fast -food restaurants in Am erica_ll'
© 2012 CNS Productions, Inc
 7.50 CHAPTER 7
14.2%; Blacks, 12.6%; Hispanics, 11.8%; Asian Americans,
8.4%; and Whites, 7.1%. High rates are particularly prevalent
in those 60 and older (12 .2%). 193 -222
In the United States,
8.3% are diabetic and
another 25% are prediabetic.
PsychologicalProblemsand
Co-OccurringDisorders
People who are overweight or obese often develop psycho-
logical problems:
• They exhibit higher rates of depression than the popu-
lation at large.
• They develop a negative body image and avoid social-
izing and going out in public.
• They have issues of self-esteem because of their
appearance .
There is also a high incidence of major or clinical depres-
sion, anxiety, substance abuse, and personality disorders
among people with eating disorders. 226 From 12% to 18% of
those with anorexia and between 30% and 70% of those with
bulimia abuse tobacco, alcohol, amphetamines, prescription
drugs, or over-the-counter substances.
Recent research on genetic and biochemical factors suggests
that the brain is unable to differentiate between the euphoric
feelings generated by bingeing and those generated by fast-
I
ing.200 Some bulimics report feeling a rush while purging,
followed by a sense of peace . Anorexic women describe feel-
ings of powerfulness, blissfulness, and even a floating sensa-
tion. Starvation releases endorphins that in turn release
dopamine in the survival/reinforcement pathway, similar to
an endorphin or opioid high. 227 Overeaters say that when
they load up on carbohydrates, they feel like they 're loaded
on alcohol and it relaxes them. Neurochemically, high levels
of sugar have been found to reduce the levels of certain
corticosteroids, the body's stress hormones, thus calming
the eater. 227
Epidemiologyof Anorexia,Bulimia, and
Binge-EatingDisorders
Although it is easy to identify both overweight and grossly
underweight individuals, research suggests that more than
half of all eating disorders go undetected .228Often physical
symptoms such as shortness of breath, dizziness, and edema
(excess fluid under the skin) are not mentioned during doc-
tor visits or they are simply ignored.229 Denial of an eating
disorder in spite of obvious visual clues is common, and extra
pounds or a lack thereof are often blamed on holiday/vaca-
tion eating, no exercise, too much exercise, a delicate stom-
ach, too many restaurant meals, too many beers, heredity,
bone structure, or dozens of other excuses.
Most eating disorders begin in adolescence, are chronic,
and affect women disproportionately .23 0 An estimated 90%
to 95% of anorexics and bulimics are women .231 About 3%
of all young women have one of the DSM-5 eating disorders:
anorexia nervosa, bulimia nervosa, and binge-eating disor-
der.228·232 The rate among high-school students is much
higher. 233
In American culture a woman's self-worth has historically
been tied to her physical appearance, especially her weight.
High-school girls often have a distorted perception of their
appearance; 36% of twelfth-graders believe they are over-
weight, while in reality only 6.3% are.
Today obesity, anorexia, and bulimia are more common in
developed nations with an abundance of food and a media
that equates thinness with beauty and desirability. The glo-
balization of pop culture has helped spread these disorders.
At the Hospital for Anorexia and Bulimia in Buenos Aires,
Argentina, hundreds of emaciated teenage girls are patients.
The United States has seen an increase in the diagnosis of
anorexia and bulimia; from the mid-1950s to the mid-1970s,
cases of anorexia grew by 300%.234 According to a recent
survey by the National Eating Disorders Association, approx-
imately 20% of college women have an eating disorder.23 6
Anorexia nervosa is most frequently diagnosed in young
women 14 to 18 years old. It afflicts an estimated 0.5% to 1%
of women in their late teens and early adulthood . Women
over 40 seldom develop anorexia. The illnesses can, however,
strike any age group, from children to the elderly. A high
incidence of anorexia in males is found in high school and
college wrestlers, who must maintain a certain weight to
compete in a category.
"It was our coach who tau9ht us how to throw up to maintain
our wei9ht in hi9h school on the wrestlin9team. We'd 90 to
smor9asbords,eat a bunch, throw up in the bathroom,eat
a9ain, throw up a9ain. Most ofthe team did it. Ofcourse
we weren'tsupposedto tell an~bod~,but about a ~earand
a half later word 90t out and he was fired."
College wrestler
Women gymnasts, runners, swimmers, dancers, cheerlead-
ers, and figure skaters are often at risk for eating disorders
especially if they are compelled by teachers, coaches, and
trainers to maintain a certain weight. A complex of disorders
afflicting women athletes, called the female athlete triad,
consists of:
• an eating disorder such as anorexia or bulimia; it also
includes elimination of certain food groups and abuse of
weight-control methods such as dieting, fasting, and the
use of diet aids and laxatives
• irregular menstruation (i.e., missing more than one
period)
• osteoporosis or irreversible loss of bone density, which
can result in pain and fractures 237
It is not clear whether eating disorders precede or follow
women's participation in sports. Any extreme method of
weight loss has physiological and psychological conse-
quences. Even moderate dieting increases the risk of eating
disorders in adolescent girls .237

AnorexiaNervosa
Anorexia was practiced as far back as the Middle Ages and
was known as the "holy anorexia "; monks and nuns piously
starved themselves to achieve an ideal of holiness and control
over the desires of the flesh. Over the past three centuries ,
there have been numerous descriptions of anorexia that are
quite similar to the modern-day definition of an addiction to
weight loss, fasting, and minimization of body size. 239 •240 In
the Victorian era around the end of the nineteenth century,
eating and all that was associated with it-defecation, break-
ing wind, and even food preparation-did not conform to the
image and the values of a proper young woman , so careful,
minimal eating was considered the appropriate way to remain
desirable to the opposite sex; these attitudes persist today 241
Definition
Although anorexiameans "without appetite ," the condition
has less to do with loss of appetite than with what one expen
calls "weight phobia." Some anorexics, the so-called anorexia
restrictors, continue to lose weight by limiting their food
People (mostly women and young girls) who suffer from anorexia
can drop their weight to as low as 75 lbs. (34 kilograms ), where the
risk of permanent heart damage , kidney failure, and death is always
present.
Cl DenisPutilov.Bypermissio
n of l 23rf.
Other Drugs,Other Addiction
s 7.51
intake through dieting, fasting, the use of amphetamines or
other diet pills, and excessive exercise. Binge-eating/purg-
ing types of anorexia promote weight loss by purging through
the use of diuretics , laxatives , enemas, or self-induced vomit-
ing. Anorexia is graded mild, moderate, severe, and extreme ,
based on the BMl, or body mass index ."
People afflicted with anorexia nervosa are afraid of putting
on pounds and eventually may lose 15% to 60% of their
weight. They do not maintain a normal body weight , and
they harbor a distorted perception of their body's shape and
size, often convinced, even when emaciated, that their body
or parts of it are overweight. Their emotional state is so tied
to their weight that they allow the scale to dictate how they
feel about themselves. Anorexics are often ignorant or in
denial of the seriousness of low body weight. Peer approval
may aggravate the condition by praising and encouraging
"the look ," which confers high status among adolescents in
the United States and other industrialized nations. 242 .m
France acknowledged the seriousness of this condition by
passing a law in 2008 banning Web sites that glorify anorexia
or extreme thinness as a viable lifestyle.
Causes
Some psychologists see anorexia as a compensatory behavior
for people who are overly concerned with following direc-
tions , pleasing others , and achieving perfection. Even though
a young female may be a model student, a good athlete , and
academically talented , she may lack the self-esteem and the
sense of self necessary to recognize her self-worth . A refusal
to eat gives her a measure of control in her life, and continu-
I
ous weight loss can be an index of her discipline , achieve-
ment, self-esteem, and status among her peers.
"I didn't havea senseof mqselfor mq bodq9rowin9up, but I
triedto be so perfect. But wheneverI do anqthin9,I feelI'm
9oin9to be criticizedforit, especiallqbq mq mother. I mean,
evenwhenshe's not around,I stillhearher.And she's not a bad
person.So the onlqthin9I couldcontrolwasmqeatin9. And
the moretheqtriedto 9et me to eat, the moreI couldsaq no.
I thoufihtthat if I couldcontrolmqeatin9,I couldcontrol the
rest of mq life."
19-year-old recov ering anorexic
Additional characteristics of anorexia include delusions
and compulsions . Anorexic delusions are persistent unshak-
able ideas that one is unattractive or overweight ; compul-
sions are rigid, self-imposed rituals, such as weighing food,
dividing it into small pieces, or eating in a prescribed order.
Family studies, including twin studies, indicate a higher
prevalence of anorexia in those with an immediat e relative
who is anorexic. 24'-' 45 A follow-up study of a twin registry put
the influence of heredity at more than 50%.2'° One theory
suggests that what initially may begin as a strict diet begins
to change brain chemistry after about three months, so
more of the body's natural opiates (endorphins) are produced
and the person becomes addicted to those brain chemicals .247
The act of eating precipitates withdrawal symptoms similar
 7.52 CHAPTER 7
to those of heroin withdrawal, thus encouraging further
abstinence. Other research looks at how the brain's reward
or survival circuitry can be activated by a strong external
stimulant at the same time the body is deprived of food, so
the self-starvation seems desirable. 248
Effects
Semi-starvation strains all of the body's systems, especially
the heart, liver, and brain. Dehydration from vomiting
depletes electrolytes, a dangerous condition that can lead to
arrhythmias and cardiac arrest. Mild anemia, swollen joints,
constipation, and lightheadedness can also occur. Females
can decrease their estrogen levels; males can deplete their
testosterone levels. Amenorrhea (absence or abnormal cessa-
tion of menstruation) often occurs in women with anorexia.
It can take several months of treatment before a normal men-
strual cycle is reestablished . Other disturbances include
stomach cramps, dry skin, and lanugo (a downy body hair
that develops on the trunk) . There is also a growing belief
that the early use of amphetamines and other strong stimu-
lants to control weight will disrupt normal weight-control
mechanisms.
Additional physical consequences include osteoporosis, ste-
rility, miscarriage, and birth defects. Rates of years oflife lost
among anorexic patients are estimated at 4% to 20% over
the life of the disease, with risks increasing as weight loss
approaches 60% of normal. The most frequent causes of
death are heart disease, especially congestive heart failure,
and suicide. Studies suggest that the brain shows continued
gray matter volume deficits even after the patient has received
I
sufficient nutrition for a period of time. 249
The extreme weight losscausedby
anorexiachangesbrain chemistryso much
that self-starvationseems desirable.
Bulimia Nervosa
Definition
Although bulimia is an ancient Greek term meaning "the
hunger of an ox," the term is used today to designate the
eating disorder characterized by eating large amounts of
food in one sitting (bingeing) followed by inappropriate
methods of ridding oneself of the food to prevent weight
gain . These methods include self-induced vomiting (used by
80% to 90% of those with this disorder), use of diuretics and
laxatives, fasting, and excessive exercise_43-250
"It waslikedepression. ~ouknow.I'djust keepeatingall da~
and so I got to the pointwhereI wasgainingweighttoo fast.
I spokewitha friendaboutit. and shesaid. 'Do likeI do-
throwit up.' I wentinto thismad tripofeatingever~thing I
couldshovedownm~throatand then if I felt badaboutit
or if I feltan~guiltat all, I couldthrowit backup and
all theguiltwouldgo awa~."
28-year -old recovering bulimic
People with bulimia are often ashamed of their behavior;
they consume food rapidly and purge secretly. Although a
slightly overweight condition may precede bulimia, those
suffering from the disorder are usually within a few pounds
of normal weight. People with bulimia may feel a loss of con-
trol during binges followed by guilt.
A binge is "an abnormally large amount of food, on the
order of a holiday meal, eaten in two hours or less and
definitely more than most people would eat over the same
time span." Continuous snacking during the day does not
constitute a binge. A diagnosis of bulimia requires that binge-
ing and purging occur at least twice a week for three months.
Although many binge eaters prefer sweet, high-calorie foods
like ice cream, soft drinks, and cookies, bulimia has more to
do with the amount rather than the type of food. During
binge episodes there may be a feeling of frenzy, of not being
in control, and a sense of being disconnected from the sur-
roundings . Between binges low-calorie foods and drinks are
often consumed to control weight.
Causes
Like anorexia, there are multiple causes of bulimia. Because
the disease afflicts different races and classes, it is clear that
cultural and environmental pressures to be slim are the most
influential. In a study conducted in 1995 soon after television
was widely introduced in the Pacific Island nation of Fiji,
only 3% of girls reported that they vomited to control their
weight. Three years later the number had grown to 15%. In
addition, the study found that 74% of the Fijian girls reported
feeling "too big or fat," while almost two-thirds reported diet-
ing in the past month. 228
The biochemical changes involved with bulimia can make
the disorder self-perpetuating. There is evidence that
metabolism slows down to adapt to the bulimic cycle, which
causes weight gain from the same intake of food. This
increased weight gain gives rationale to perpetuating the
binge-and-purge behavior. There is also evidence that purg-
ing through vomiting or laxatives produces higher levels of
natural opioids (endorphins), so people suffering from buli-
mia become addicted to the body's own natural drugs. 200
Effects
The effects and the health consequences of bulimia are less
severe than those caused by anorexia . Problems include dental
complications, a greater liability for alcohol and drug abuse,
dependency on laxatives for normal bowel movements, a high
rate of depression, and a greater risk of suicide.
People with bulimia vomit frequently, putting them at risk for
stomach acid burns to the esophagus and the throat, result-
ing in chronic sore throat and greater risk of cancer. Vomiting
produces an acid that eats away tooth enamel, produces a
high incidence of cavities, and gives front teeth a ragged,
chipped, and mottled appearance. Dental professionals are
often the first to spot bulimic activity. The back of the fin-
gers and hands can become scarred from abrading the skin
on the teeth while pushing the hand down the throat to
induce vomiting .
 OtherDrugs,OtherAddictions 7.53

Bulimia can cause heart problems, such as arrhythmias,
electrolyte imbalances, and irregular menstrual periods or
no periods at all. Additional problems are caused by the
abuse of ipecac syrup . This medication, usually taken to
induce vomiting in cases of accidental poisonings, is used
regularly by some bulimics and can cause heart problems,
tears in the esophagus and the stomach lining, vomiting of
blood , seizures, and death.
Binge-EatingDisorder
At the beginning of the twenty-first century, for the first time
in history, there are as many people overweight as under-
weight; about 1.1 billion of each condition is noted in a
worldwide population of 7 billion. In North America over-
weight peop le outnumber those who are underweight by a
ratio of 12 to l; in Europe, 9 to l; and in Latin America, 5 to
1. In Africa they are about equal, and in Southeast Asia there
are five times as many people who don't get enough food
compared with those who eat too much .251
"Eatinghas becomea recreational sportherein Americaand in
moreand morecountriesthroughoutthe world.Most people
eat so theqcan livetheirlives.I livemq lifeso I can eat. For
me everqactivitqcan be punctuatedbqeating.Anq rewardI
givemqselfusuallqinvolvesfood. All socialthingsI do revolve
aroundfood."
28-year-old 290 lb. compulsive overeater
Definition
Binge-eating disorder is marked by recurrent episodes of
• eating rapidly and swallowing without chewing
• eating when uncomfortably full
• eating large amounts when not physically hungry
• eating alone to avoid the embarrassment of eating too
much
• feeling disgusted and distressed when overeating 43
The symptoms listed above are similar to the 15 quest ions
that Overeaters Anonymous uses to help a person decide if
he or she is a serious addict or simply overweight (Table 7-7).
If people answer yes to three or more of these questions, it is
probable that they are well on their way to having a compul-
sive overeating prob lem.
Refinedcarbohydratessuch as sugarand
flour overactivatethe "go" switch,damage
the "stop"switch,and block communication
between those two parts of the brain.
"Eatingat 3 o'clockin the morning,sneakingfood whenmq
husbandwasasleepand mq kidswerein bed, hidingfoodso mq
kidswouldn'tknowI had it becauseI didn't wantto shareit
withthem, and it wouldbejunk. It wouldbe cakesand cookies
and sweetstuff,sugars.That wasprobablqthe heightof it and
feelingso lousqaboutmqselfbecauseof the weight."
Recovering binge eater

I
binge eating without the use of vomiting, laxatives, or other
compensatory activities to eliminate the food. A pattern of
frequent eating (not just snacking) over a period of several
ComJ>ulsive
Overeating
Self-Diagnostic
Test
hours is a symptom of this condition. 1. Doyoueatwhenyou'renothungry?
Mild: 1-3 binge-eating episodes per week. 2. Doyougoon eatingbingesfornoapparentreason?
Moderate: 4-7 episodes 3. Doyouhavefeelings
ofguiltandremorseafterovereating?
Severe: 8-13 episodes 4. Doyougivetoomuchtimeandthoughtto food?
Extreme: 14 or more episodes 5. Doyou lookforward
withpleasureandanticipation
to thetimewhenyou
caneatalone?

"Whqdo I alwaqsemptqthe plateno matterwhat I eat? After I 6. Doyouplanthesesecretbingesaheadoftime?

finisha normalmeal,I am hungrier - no, that's not true;I just 7. Doyoueatsensibly
withothersandmakeupforitwhenalone?
wantto eat more,bingemore.It'sas if the foodprimesmq ap- 8. Is yourweightaffecting
thewayyouliveyourlife?
petite,it doesn'tlessenit, so it can't be truehunger.I just want 9. Haveyoutriedto dietfora week(orlonger)onlyto fallshortofyour
the mildhighI get fromeating,particularlq mq comfort foods. goal?
Unfortunatelq, the fat comeswiththe high." 10. Doyouresentotherstellingyouto "usea littlewillpower''to stop
5 1-year-old 281 lb. male compu lsive overeater, always in recovery overeating?
11. Despite
evidence
to thecontrary,
haveyoucontinued
to assertthatyou
Eating certain foods (e.g ., refined carbohydrates, fats) and candietonyourownwhenever youwish?
eating excessive amounts of them activate the mesolimbic
12. Doyoucraveto eatat a definite
time,dayor night,otherthanmealtimes?
survival (reward) circuit, not only giving pleasure but also
blocking out unwanted emotions.116 Individuals with binge- 13. Doyoueatto escapefromworriesortroubles?
eating disorder eat in response to emotional states rather 14. Haveyoueverbeentreatedforobesityora food-related
condition?
than to true hunger signals. 15. Doesyoureatingbehavior
makeyouor othersunhappy?
Symptoms of binge-eating disorder include:
it isprobable
If peopleansweryesto threeor moreofthesequestions, thatthey
• frequent episodes of eating large quantities of food arewellontheirwayto havinga compulsiveovereating
problem.
• feeling a lack of control while overeating or bingeing
 7.54 CHAPTER 7
© Fitzsimmons.Reprinted by
permission of eagle cartoons.
People with binge-eating disorder believe they cannot con-
trol the amount of food they eat, the pace at which they eat
it, and the kind of food they eat. They stop eating only
when it becomes painfully uncomfortable . Most people
I
with this disorder are obese, but there are people of normal
weight who suffer from binge-eating disorder.
Causes
Regardless of the underlying reasons for mindless eating, it
is the inability to stop while bingeing or continuously "graz-
ing" between meals that suggests crucial neurochemical
changes to the "stop" switch that escalates compulsive
overeating to a binge-eating disorder . Dieting may trigger
binge-eating disorder in some cases, but one study found that
in nearly 50% of all cases people had the disorder before they
began to diet. Two different studies of adolescents found that
depression more than doubled the risk of obesity and
increased the risk of bulimia and anorexia. 252 •253 Weight gain
often increases stress, causes guilt , and leads to depression-
all factors that perpetuate the overeating cycle.
"I was molested,sexuall~abused, at 12,and I rememberfeeling
reall~uncomfortableabout m~ bod~ a~er that and usingfood
to just feel comfortableand ma~beas a la~erof protectionto
keeppeople awaf not wantingto lookgood becausethen I
might have to interactwith the oppositesex and ma~behave
some kind of altercation. I was just afraid of men a~er that."
36 -year -old female recovering compulsive overeater
Treatment and Support Groups
More than 66% of U.S. adults are obese or simply overweight ,
and efforts to turn this trend around can be seen in many
quarters. Every month a new diet book comes on the market
with a sure-fire plan to help the reader shed unwanted
pounds. Recent entries into this field are the 10-Day Detox
Diet; Wheat Belly: Lose the Wheat, Lose the Weight, and Find
YourPath Back to Health;and Eat to Live. The more traditional
approaches are the Mayo Clinic diet , the New Atkins diet,
Weightwatchers, Jenny Craig, Nutrisystem, ® and the
Mediterranean diet. In addition to the slew of diet books,
programs , and magazines , there are:
• more than a half dozen types of surgery to help mor-
bidly obese individuals lose weight (e.g., gastric bypass,
gastric banding, gastric sleeve, duodenal switch, bilio-
pancreatic diversion, and LAP-BAND®)
• dozens of medications to curb hunger (e.g., amphet-
amine and amphetamine congeners, which are effective
for a short period of time but can lead to abuse and even
weight gain if used chronically)
• self-help 12-step groups like Overeaters Anonymous, ®
Food Addicts Anonymous, ® and GreySheeters Anony-
mous ®
There are counselors and in- and outpatient facilities that
offer programs designed to change the lifestyle and the think-
ing of compulsive overeaters and those with anorexia , bulimia,
and binge-eating disorder. Although cognitive-behavioral
therapy, motivational interviewing, family therapy, and inter-
personal psychotherapy achieve varying degrees of success,
unless children learn good eating habits when they are
young, maintaining a normal healthy weight can become a
lifelong challenge. Once the "stop" switch becomes dam-
aged, the hedonic set point (the level of food intake needed
to satisfy the eating drive) rises above healthy levels .

SexualAddiction
In modem society the vast number of outlets for sexual activ-
ity coupled with people's willingness to engage in such pur-
suits has pushed the boundaries of acceptability well
beyond what was once considered respectable. Viagra,®
Cialis,® and other treatments for erectile dysfunction have
extended men's ability to have sex. Free sexually explicit
videos and pictures on tens of thousands of Web sites are
responsible for 30% of all data transmitted online consid -
ered X-rated. Condoms, lubricating gels, and erectile dys-
function medications are advertised on television in prime
time , while adult bookstores and paraphernalia shops and
Web sites do a booming business. This environment fosters
the attitude that anything we do is okay so long as it doesn't
hurt anybody else.
The porn/adult entertainment industry is estimated to gen-
erate more than $100 billion per year worldwide. The
United States, China, South Korea, and Japan spend about
90% of that total. 254 •255 •256 Although most people visit the
sites recreationally, 10% of cybersexua l surfers are addicted
and spend up to eight hours per day watching pornography
online . Ominously; one in seven adolescents reports being
propositioned over the Internet.
Using the Internet to view pornography , developing anony-
mous online sexual relationships, masturbating while chat-
ting or viewing pornography , engaging in phone sex , and
meeting online contacts in person-all are characteristics of
a sexual addiction . The inherent anonymity of the Internet
characterizes traits found in many sex addicts. The avail-
ability of sites presenting illegal, fetish-based, or culturally
aberrant content fosters the perception that the practice or
behavior is sanctioned by society.
Many of those with cybersexual addiction use chat rooms
and message boards to find sex partners. Sexual predators
target mostly children and women , which led the Federal
Bureau of Investigation and many police departments to cre-
ate Internet crime units that operat e stings to arrest online
predators . Austrian authorities busted a major international
© 2014 CNS Productions,Inc.
Other Drugs,Other Addictions 7.55
child pornography ring involving more than 2,360 suspects
from 77 countries , who paid to view videos of young children
being sexually abused .257
As their compulsion increases, cybersexual surfers become
more secretive , hiding their activities from their friends ,
families, and partners. The Internet eliminates the need for
expensive 900-number phone sex calls, embarrassing trips to
adult bookstores, potentially dangerous visits to prostitutes ,
and often all forms of normal sexual activity. One survey
found that 70% of all Internet pornography traffic occurs
during workday hours .254
Definition
The National Council on Sexual Addiction and Compulsivity
(now the Society for the Advancement of Sexual Health)
once defined sexual addiction as "engaging in persistent and
escalating patterns of sexual behavior, acted out despite
increasing negative consequences to self and others ."
Abnormal or compulsive sexual activity is defined in part
by the culture and the mores of the people involved .
Behavior that is considered immoral or wrong in a strong ly
religious country or community may be acceptable in other
populations. Adultery was once illegal in most U.S. states as
were certain sexual acts; those laws have either been stricken
from the books or are no longer enforced . In some countries
adultery remains a crime, and stoning a suspected adult erer
is considered an appropriate punishment. Sexual behavior
that is not practiced compulsively might still be against the
law, causing adverse consequences.
I
There is some controversy as to whether sexual compulsiv-
ity should be classified as an addiction. Some describe it as
an addiction similar to alcoholism or drug addiction .258
Others are satisfied with describing sexual compulsivity in
the same terms as an obsessive-compulsive disorder. Impu lse-
control disorder is another description , as is hypersexuality.
The DSM-5 does not list hypersexuality as a specific disease,
but the International Classification of Diseases defines it as
"excessive sexual drive," subdividing it into satyriasis (for
men) and nymphomania (for women) . In the DSM-5 specific
sexual habits and dysfunctions such as excess use of pornog-
raphy are included but not sexual compulsivity itself.
The most accurate description of sexual addiction comes
from the members of the 12-step recovery group Sexaholics
Anonymous (SA).
"Earl~on we cameto feeldisconnectedfromparents,
frompeers,fromourselves.We tuned out with fantas~and
masturbation . We plu99edin b~ drinkin9in the pictures,
the ima9es, and pursuin9the objectsof our fantasies .
We lustedand wantedto be lusteda~er.We becametrue
addicts: sex with self. promiscuit~,adulter~, dependenc~
relationships,and morefantas~.We 9ot it throu9hthe e~es.
we bou9htit, we sold it, we tradedit, we9aveit awa~.
We wereaddictedto the intri0ue,the tease, the forbidden.
The on/~wa~we knewto be freeof it was to do it."
Sexaholi cs Anonymous, 1989
 7.56 CHAPTER 7
The object of sexually addicted behavior can be the pursuit
of the pleasure and/or a desire to subdue pain or anxiety.
Most significant is a lack of control over the behavior, a
continuation of the behavior despite adverse consequences,
and a continuing obsession with engaging in, planning, or
simply thinking about the behavior. 259 ·260 ·261 It is interesting
that some brain lesions or damage to areas such as the medial
basal-frontal, diencephalic, or septal region can cause some
hypersexual or paraphilic behavior (e.g., fetishes). A para-
philia is an atypical or extreme sexual behavior for arousal
and sexual gratification.
Compulsive sexual behaviors are practiced by males and
females, young and old, gay and straight. Sexual addiction
can include excessive masturbation and viewing pornogra-
phy (the most frequent behaviors) along with multiple
affairs, phone sex, and regular visits to strip clubs. Illegal
sexual activity includes prostitution, sexual harassment,
sexual abuse, exhibitionism or flashing, child molestation
(pedophilia), rape, and incest; convictions result in fines,
public humiliation, and incarceration.
"Once I 9ot married.the firsttime. I wantedit all the time.
And I masturbatedquitea bit, qou know.I mean,we had sex
all the time, but that wasn'tenou9h.And it 9ot to the point
whereI masturbatedfour,five,six timesa daq and wanted
to 90 homeand havesexwith mq wife."
34-year -old recovering sex addict
Sexual disorders listed by the DSM-5 under the heading
"Paraphilias" include exhibitionism, fetishism, frotteurism
I
(clandestine rubbing against another person), sexual mas-
ochism, sexual sadism, transvestic fetishism, and voyeurism.
Collateral addictions include love addiction (the compul-
sion to fall in love and be in love) and relationship addiction
(either a compulsive relationship with one person or multiple
relationships) .
Some studies report the incidence of sexual addiction to be
3% to 6% of the population. 262 ·263 About 80% of sex addicts
are males, with the behaviors developing during the teen
years, peaking at ages 20 to 40, and then gradually declining.
Effectsand Side Effects
Whether it is for the high or as a way to cope with depres-
sion, anxiety, stress, solitude, or low self-worth, compul-
sive sexual behavior conditions the body to the release of
pleasure-giving neurotransmitters, especially dopamine,
enkephalins, endorphins, epinephrine, and norepineph-
rine.264 Tolerance develops to the behavior as it does with
anything that releases a surge of neurotransmitters. More
and more time must be spent engaging in the sexual activity
to gain any emotional benefit. Damage is done to careers,
relationships, self-image, and peace of mind, but the activity
continues despite all negative consequences, including
incarceration.
When a person has a sexual addiction, sex is the person's most
important all-consuming activity, and the pursuit of the addic-
tion has been described as trancelike. Part of the elevated
mood generated by the activity may involve risk or following
a routine or pattern that increases the excitement. Often there
is a culminating sexual event (e.g., rape, violent sex, flashing,
watching pornography, or molestation), usually involving
orgasm, over which the addict has virtually no control. As
it escalates it is often followed by remorse, guilt, fear of discov-
ery, and resolutions to stop the behavior. For many the sexual
behavior is pursued with a sense of desperation, and the addict
becomes demoralized and may suffer from low self-image,
self-loathing, and despair over the time and the money wasted
in pursuit of satisfaction or the inherent danger of injury
or disease. Sexaholics Anonymous, Sex and Love Addicts
Anonymous, and other affiliated groups see compulsive
sex as a progressive disease that can be treated.
"I thinkit wascompulsivesexualitqbecauseI usedto lovejust
a man bein9with me. I likedthe moneq,for one. I likedthe
moneqthat men would9iveme for sex. So I thinkthat anqtime
I wouldseesomeonethat I knewpersonallq,not as a prostitute,
I wouldalwaqshavethat temptationthat I wantedto havesex
with this personand I wouldalwaqsdo it. I wouldalwaqshave
sexwith men who werefriendsof mineor so-calledfriends."
38-year-old female recovering polydrug abuser and sex addict
About 80% of those with
hypersexuality
are men.
There is a high co-occurrence of drug addiction, behavioral
addiction, and mental health diagnoses among sex addicts.
Drugs are often used to increase sexual functioning, lower
inhibitions, or desensitize a person physically and psycho-
logically. Many drugs that influence sexual functioning can:
• release dopamine (stimulate the survival/reinforcement
pathway)
• release norepinephrine and epinephrine to stimulate
body functions and increase excitement (e.g., cocaine
and methamphetamine)
• block acetylcholine and interfere with erection and
orgasm (many downers)
• release serotonin, which can inhibit sexual activity as
does a selective serotonin reuptake inhibitor SSRI).
Because sexual activity is so basic to who we are, it is often
very difficult to treat some behaviors such as pedophilia
(sexual activity with children) and sexual violence. Many
treatment professionals believe that most individuals who
fall into this group are untreatable. Others believe that they
can be treated only with medications. In addition to chemical
castration, researchers look toward drugs that act to stimu-
late serotonergic activity as possible choices to treat many
forms of sexual addiction because drugs that block sero-
tonin seem to increase sexual activity. 259
-260There are many
reports of how SSRis such as fluoxetine (Prozac®) decrease
sexual craving; others use opioid antagonists (used to treat
alcoholism and opioid dependence) because it dampens
dopamine release in the survival/reinforcement pathway .261
 OtherDrugs,OtherAddictions 7.57

ElectronicAddictions 2012 more than 2.405 billion people worldwide (34 .3% of
total population) were connected .

Over the past 15 years, the dramatic expansion of electronic
media has broadened the opportunities for addictive behav-
iors. Television, the Internet, satellite radio, cell phones,
smartphones, electronic tablets , and electronic games-all
can involve the user for minutes or days at a time. They can
be vital to one's work and need to communicate , or they can
just be convenient diversions. For those reasons it is hard to
define electronic addiction; how much is too much?
"Havin9it on qourmindat all times,just likeanq verqaddictive
dru9. Wheneverqouevenwalkawaqfromit, qou'rejust thinkin9
of what qou're8oin9to do next on that video9ame, puttin9
all the hoursof qourlifeinto that feelin9that qourlifeis less
importantthan the videoaame."
22 -ye ar-old o nlin e game player
Internet abuse by young people is not confined to the United
States and Europe.
Electronic media , like any business , offers content and ser-
vices that users want. In addition to the news and informa-
tion sites, there are sites featuring games, erotic material,
and, more recently, gambling-all pleasurable activities for
many, but which also have the potential for compulsive use.
The ease and the anonymity of the Internet enable people
to form relationships and behave in ways they might other-
wise have avoided. As worldwide use of the Internet grew,
the number of compulsive users increased. China, India,
Korea, and Russia are a few of the countries in which high
levels of compulsive Internet use prompted the establish-
ment of treatment centers specifically for addicts.
The qualities of the Internet that make it a valuable tool are
the same ones that can lead to compulsive use . Besides ease
of use and anonymity, the Internet is inexpensive , always
available , validating (it doesn't criticize), rewarding , conve-
nient, and escapist, and the output is seemingly under the
control of the net surfer .266

'The Chinese9overnment... hasjoinedSouth Korea,Thailand,
and Vietnamin takin9measuresto trq to limitthe time teens
spendonline. It has passedre9ulationsbannin9qouthsfrom
Internetcafesand has implementedcontrolproaramsthat kick
teensoff networked9amesa~er fivehours."
Washington Post Foreign Service , 200 7
The Internet
Also called Internet compulsion disorder and Internet addic-
tion disorder , cyber-addiction is marked by compulsive
involvement in chat groups, game playing, trading stocks or
commodities, market watching, online gambling , sexual
relationships, and other online activities.
Symptoms of Internet addiction include:
• logging on for hours at home, work, or school (40 hours
per week is not unusual, compared with eight hours for

I
nonaddicts)
The predecessor to what is today known as the Internet is the
Advanced Research Projects Agency Network , a military net- • thinking about the Internet constantly
work launched in 1969 and subsequently made available to • feeling irritable and anxious when offline
defense researchers at universities and private companies. By • needing progressively more time online to get the same
the late 1980s, most universities and many companies were satisfaction
online. In 1989 a British-born computer scientist, Tim
• losing track of time while logged on (hours go by like
Berners-Lee, proposed the World Wide Web project with
minutes)
help from Robert Cailliau and others at CERN, now the
European Particle Physics Laboratory. When commercial • neglecting responsibilities
providers were allowed to sell online connections to indi- • allowing relationships with spouse , family, co-workers ,
viduals in 1991, the explosion of the Internet began. As of and friends to deteriorate

WorldInternet
Usage
andPopulation
asofJune30,2012
265

WORLD
REGION POPULATION INTERNET
USERS, INTERNET
USERS, PERCENT
OF
(2012ESTIMATES) 2000 2012 TOTAL
USERS
Asia 3,922,066,987 114,304,000 1,076,68
1,059 44.8%
Africa 1,073,380,925 4,514,400 167,335,676 7.0%
Europe 820,918,446 105,096,093 518,512,109 21.5%
LatinAmerica 593,688,638 18,068,919 254,915,745 10.6%
NorthAmerica 348,280,154 108,096,800 273,785,413 11.4%
MiddleEast 223,608,203 3,284,800 90,000,455 3.7%
Oceana
/Australia 35,903,569 7,620,480 24,287,919 1.0%
WorldTotal 7,017,846,922 360,985,492 2,405,518,376 100.0%
 7.58 CHAPTER7

YoungInternet users play online games

at an Internet caft in the city of \½ihan
in central China. Researchfound that
more than 24 million adolescentsare
addicted to the Web. The Chinese
government has tried a variety of
strategies to limit use, such as limiting
content, but the use continues to grow
all over Asia.
@ GregBaker.Bypennission
of Associated
Press

• posting more and more messages and downloading more Cyber-Relationship

Addiction
and more data
If connections made on the Internet are not initiated for
• eating in front of the monitor sexual activity but become compulsive, they could be called
• constantly checking e-mail, text messages, or social net- "cyber-relationships ." There are hundreds of dating Web
working sites 43 sites, chat rooms, and special interest forums where people
meet and develop friendships. Problems begin when the
Some people experience a stimulant-like rush when online ,
online relationship draws one or both participants away

I
whereas others experience tranquility from their quiet,
from his or her real-life relationships . Online friendships
isolated online experience. Repetitive compulsive use
can lead to "cyber-affairs," sometimes to the altar and some-
induces tolerance and changes in physical and mental states.
times to the devastation of a neglected partner or spouse .
Physical symptoms include blurred vision, lack of sleep, car-
Like all behavioral addictions, when activity increases, other
pal tunnel syndrome, and twitching mouse fingers.
parts of the user's life are squeezed out.
Relationship problems can also be tied to excessive use .
Internet use requires little direct human contact. Some young Internet Compulsions
people who find cyber-activity to be less threatening than Internet compulsions are fed by accessibility There are hun-
actual human interaction may be less likely to learn how to dreds of online gambling opportunities, stock trading sites,
deal with people in real life, forcing them to rely on elec- and auction houses , for example :
tronic communication. Like other addictions, only a small
• Sportsbook.com , Rushmore.com, FullTiltPoker.com ,
percentage of users will have serious problems.
and PlayersOnly.com
The most common forms of Internet addiction are cyber- • Ameritrade , Yahoo! Finance, MSN Investor , and
sexual addiction , cyber-relationship addiction, Internet DailyStocks.com
compulsions , information addiction, and computer games
• eBay,eBid, OnlineAuction , uBid, and craigslist for those
addiction .
who want to buy or sell anything
The small percentage of compulsive users who become

>
Forsome, compulsiveInternet use actsas
a relaxantbut for most, it actsas a stimulant,
even inducinghighswhen online.
CybersexualAddiction
Cybersexual addiction falls more under the heading of sex
addiction rather than Internet addiction. See "Sexual
Addiction " earlier in this chapter for a full description of cyber-
sexual addiction.
addicted can lose hundreds of dollars from the comfort of
their own home, day or night. While there isn't the excite-
ment of gambling at a casino, the element of control is
important: "I can do it when and where I want." Online
traders do not have to rely on brokers to buy and sell stocks.
The promise of large winnings or profits spurs continued
activity. The online stock trader who loses control of his
activity goes through the same stages as compulsive gam-
blers: winning , losing, desperation, and giving up (see
"Compulsive Gambling"). The convenience of the Intern et

I CI\N'T DO MY WORK THE PHY5ICI\L WORLD
BECI\U5E THE INTERNET NO LONGER HOLDS MY
15 TOO Fl\5CINI\ TING. INTEREST . I FIND JOY ;i
ONLY ON THE INTERNET .
Information Addiction
The ability to access countless Web sites for information on
every subject imaginable is attractive to many. The potential
downside of that accessibility is the lack of direct human
contact or depression and anxiety caused by all the "bad
news."
'The newspapershavegotten too expensiveor disappeared
altogether,and at anq ratearehoursafterthe fact. I have
the worldat mq fingertips.Unfortunatelq,I get nervous
whenI'm not connected.I evenhavemq computersignal
alertswhensomenewsagenciessignalan alert."
49 -year-old news junkie
Computer Games Addiction
'Thereweren'tanq videogame consolesreallqavailableuntil
I was10 or 12. Now, thinkof the kidsthat arepickingup this
controllerwhentheq'refiveqearsold. Thinkof the impactof
that and how that willdamage,in a sense,theirlifeonward,
if the parentsaresaqingthis is the newbabqsitter.Think of
whatphqsiologicallq that is goingto do to the childlateron.
This is how theq'regoingto socialize."
19-year-old computer game player
The sophistication of electronic games today draws players
into a variety of fantasy worlds. Simple handheld games of
the late 1970s such as Merlin "' have given way to Nintendo
DSi,® Sony PlayStation ® 4, Xbox® 360, and Wii, ® but even
these game consoles are receiving stiff competition from the
flood of games available online or programmed into com-
puter operating systems. Smartphones, tablets, and some
game consoles can access the Internet to play these games.
The early computer games like solitaire and Minesweepe r"'
are still popular, but hundreds of other games, particularly
the MMORPGs (massively multiplayer online role-playing
games), were introduced in the 1990s and the number of
Other Drugs,Other Addictions 7.59
CI\N I TI\KE I\ HIT
li ON YOUR i PHONE
BEFORE I GO BI\CK
TO MY CUBICLE?
© 2007 Scott Adams.
By permission of
Universal Uclick.
© 2013 Kentoh. By permissionof Pond5.
I
active players exploded. The most popular of these games is
Happy Farm, with 23 million daily users and 228 million
active users . World of Warcraft®has 8 million to 9 million
subscribers worldwide . Other popular games include Wrath
of the Lich King, with 9 million subscribers, mostly in Asia;
World War II; Final Fantasy XI; Farm Ville; RIFT;® Entropia
Universe;® RuneScape;® and Guild Wars. ®
These games can support hundreds of thousands of players
simultaneously. About 23 million daily active users play
Happy Farm (predominately in China and Taiwan).
Farm Ville, similar to Happy Farm, has 24 million users who
play on Facebook. In Korea the obsession with MMORPGs
has gotten so bad that the government banned their use for a
six-hour period at night, specifying 19 games (that account
for 90% of all players of games of this type). 269
"Havinga videogameat hand isgreatfun, but qou need
to understandthat it'ssomethingto do as a pastime,
somethingto just relaxwith;it's not somethingthat qou
shoulddo with qourlife. I remembertalkingto one of mq
'guildies'[WorldofWarcra~ ® plaqer],and he wastelling
me about how he just lost his housebecausehis wifedivorced
him, his kidsarenow out of hiscustodq,he lost hisjob, he lost
everqthing[becauseof plaqingWorldof Warcraft® obsessivelq].
He is now backto squareone, livinginsidean apartmentthat
his motheris paqingfor and he is 35."
19-year -old recreational computer game player
 7.60 CHAPTER 7
Game playing is more common among men, teenagers, and
children. About one-third of all games carry warnings con-
cerning sexual or violent content, a dramatic increase from a
few years ago. Most game players spend an average of 30 to
60 minutes playing, but game addicts can easily play for five
or six hours .
"Peoplehavecommittedsuicideoverthesegames- literall~com-
mitted suicide- becausetheircharacteris deletedor something
happens;and it's patheticactuall~.I find it reall~sad. It's just
likean~ other drug that's out there;it can ruin~ourlife."
19-year -old recreational computer game player
TelevisionAddiction
The average American watches about 2.8 hours of televi-
sion per day-the equivalent of about nine years of life .272
The British watch about two hours per day. For compulsive
TV watchers here and in a few other countries, six to eight
hours a day is not uncommon . In surveys, half the respon-
dents said they watch too much TV (similar to 80% of smok-
ers who want to quit yet keep smoking) . To fuel this craving,
most cable or satellite television providers supply upward of
200 channels 24 hours a day. More than 60% of American
homes have three or more sets; in many households the TV
is on more often than the lights. 271 -272
There are learning channels, insightful documentaries, top-
notch entertainment, and an abundance of how-to shows.
There are also hours of sporting events, political rants, reality
shows , and infomercials. Regardless of the quality of the pro-
I
gramming, the question remains: ls excessive TV watching
really an addiction?
"Well,I take in m~ drugthroughm~ e~esand ears, direct/~
to m~ centralnervouss~stem.M~ equivalentcrackpipe is the
remote.I continueto watchevenwhen I havethingsthat need
doingaroundthe house. I would ratherwatch an~sports
eventon TV than pla~with m~ three-~ear-oldson. I endless/~
plan what shows I'm goingto watch that da~, but I'[[watch
an~thingratherthan get up. I don't care if an~oneelsewatches
with me. If I'm troubledand don't want to deal with a problem,
I nip up the leg reston m~ reclinerand becomea cliche."
46-year-old "TV addict "
Some of the benchmarks of addiction also apply to television.
• Compulsive use. "There are days when I watch 8, 10, 12
hours a day. I can't seem to get up from the chair. 'Couch
potato' is an understatement."
• Using TV to change one 's mood . "TV is my sedative.
When I'm anxious or angry,I plop down and watch a show
I'm alreadyfamiliar with so I don't have to think too much."
• Craving. "I crave it differentlythan I crave a cigarette... not
as strong, but I can go to outrageous lengths to make sure
there is a TV in every room I spend time in."
• Loss of control. "Evenwhen I have a housefull of guests, I
sneak up to the bedroomto watch my favorite show."
• Continued use despite adverse consequences . "I just sit
therewatchingwhile the grassgrows,while my kidsfind their
© 2014 CNS Productions, lnc.
own way homefrom school, while my wife and Iforget how to
talk, while I remainslow to reactto any chaosin my life."
• Development of tolerance. Each year adolescents spend
1,500 hours watching TV (900 hours attending school)
and view 20,000 commercials. By the age of 18, they have
witnessed 200,000 acts of violence and 8,000 murders.
Eventually, the brain develops a tolerance to these images
and learns to ignore the emotional overload just as drug
addicts ignore most of their environment.
The averageAmerican
watches 2.8 hoursof
televisionper day.
Rutgers University psychologist Robert Kubey listed six
dependency symptoms of heavy TV viewing: using TV as a
sedative, indiscriminate viewing, feeling loss of control while
viewing, feeling angry with oneself for watching too much,
an inability to stop watching, and feeling miserable when
prevented from watching. 266 ,270
If indeed environment is one of the factors that determines
the abuse of drugs and addictive behaviors:
• the distorted view of people's lives and how they solve
problems (often violently) presented on many TV
shows makes it harder to make good decisions
• the portrayal and the promotion of dysfunctional
families and relationships as the norm rather than the
exception is confusing to adolescents and young adults
• sexual situations that involve risky or inappropriate
behavior can hasten initiation of sexual behavior 273
• the fear created by excessive reports of murders, wars,
and violence makes a viewer more likely to react inap-
propriately to a benign act that the viewer perceives as a
threat 274
And, like cigarettes, alcohol, and other drugs of abuse, the
younger a person begins to watch TV in excess, the more
extensive problems become later in life. Among 4,000 studies
examining the effect of TV on children, one from New
Zealand reported that kids five to 15 years of age who

watched the most TV were the least likely to graduate from
high school or college . The results took into account basic
intelligence and financial means. 275 Of course there 's the pos-
sibility that those who don 't do well in school are more likely
to watch TV and those who are more motivated in school are
less likely to watch .
SmartphoneAddiction
"It's hardfor me to not text duringworkhoursbecauseI feellike
I'm not connectedto m~ friends.I tend to text morethan talk
on the phoneon a dail~basisbecauseit's easierthan talking
faceto faceor evenhavingan extendedphoneconvers ation.
When I can't text, I feelants~and I thinkabout it a lot. Do I
thinkI'm addicted?No, but I can't go a da~without texting."
20-year-old female with texting compulsion
From 385,000 mobile phones in the United States in 1985, to
33.8 million in 1995, to an estimat ed 373 million by 2013,
the growth of mobile phones and smartphones has been
phenomenal. Worldwide the growth has been equally
astonishing: 2. 7 billion phones in 2006 to an estimated
5 .8 billion by 2013, with the biggest growth in Asia .276
More than 56% of Americans own a cell phone. 277
Smartphones, introduced in 2007, provide Internet access,
thousands of apps (applications) , and electronic games at
At a 12-step program for overcoming
cell phone addiction.
. Pennission by AmericanUniversalUdick All rightsreserved.
© 2006 John McPherson
Other Drugs, Other Addictions 7.61
the touch of a finger. Use accelerated as the cost per call or
text message dropped. Many people use their smartphone
and/or electronic notebook as their computer .
It's inconceivable for most teenagers to imagine life without
their phone, a constant and obedient tool of communication .
Two of every five U.S. youths use a cell phone and spend an
average of one hour per day talking and texting . For some
users , 90 or more calls and/or text messag es per day is not
unusual. Several studies in Japan, Korea, and the United
States found that more and more students measure their
self-esteem by the activity on their cell phones .278
The jury is still out as to whether the advantages in com-
munication are overshadowed by the loss of privacy and the
sometimes rude intrusions into everyday life. Witness a cell
phone tune ringing out in church or during a movie .
According to a survey conducted by the advertising agency
BBDO, 10% of cell phone owners have admitted to interrupt-
ing sex to answer a call. This could be classified as continued
use despite adverse consequences. A new word had to be
coined to cover this obsession with smanphones .
Nomophobia is a fear of being without your mobile phone,
and it affects 40% of the population .279
Most complaints about mobile phone use focus on texting
while driving . The chance of being involved in an accident
while texting increases by 23% each time a driver sends or
reads a message . Eleven percent of drivers age 18 to 20 who
were involved in an automobile accident and survived
admitted that they were texting when they crashed. 280
Texting while driving is considered six times more dangerous
I
than driving drunk (greater than 0.08 blood alcohol level). 281
Complaints about mobile phones involve inappropriate use
(bad manners) and the cost of extra data, minutes, and mes-
saging. The accessibility to work , family, and friends has
certain advantages, but because the mobile phone/Internet
revolution is still evolving, its impact on social and cultural
behaviors is yet to be defined. That said , there are enough
instances of dysfunctional cell phone use to put it on the
"needs more research " list.
Conclusions
It is important to remember that the disease is "addiction,"
not inhalant abuse, steroid misuse, or compulsive gambling
or eating , smartphone use , shopping, or sex. They are the
manifestations of the disease . On the other hand , if one
generalizes too much, it obscures the distinctive characteris-
tics of a specific addiction that need to be addressed in treat-
ment. For example , with eating disorders and sexual addic-
tion, returning to normal levels of behavior is the preferred
option , unlike gambling and alcohol or other drug abuse that
stresses abstinenc e. Fortunately , psychoth erapy, behavioral
therapies, self-help groups, and psychiatric medications tai-
lored to specific compulsive disorders offer hope for effective
treatment and recovery of any addiction.
Introduction • Hartmdva,;culllprob lems,lungdamage,livuto
icity. blood 1oxicitythotcandamag< thebrain,md
x-

neonata l problems,,uch ti growthr<tarda tion•nd

• The disease is c,lled add iction . not alcohol i,m or tremor,,ueoftenlound
oompu!, iveg,mbl ing
• Ulng -t<rm effeca often come from nerve damage,
• It isr:1refor,n,ddicttobeaddicted1ojustonedrug includinga<:kofcoordin.otion, inabilitytoconcrn -
oroneaddictivebehavior . Whena,;.,.,ing•clien t ,•11 tr.lt<,wnkn<>•,dOOrirnLation,•nd""ightlos,
drug< • ndbeha,ionmustbeevaluated
. \.ol.otilenitrit<sdil.ot<b loodve,sels.50thehart•nd
thebrainm:eivemoreblood.Theeffect:5<Lart in7to
Other Drugs \O,erond••ndb<tfo r upto60,eronds
• \.ol.otile nitriln c:aw.e • !«ling of fullnes, in th<
Inhalants h<ad,,rush,mildeuphoria,dizzin<»,andgiddin<>•
Exc<S<i,.,u,,c:anc:au«oxygrndepri>'at ion,fainting
• Inhabna•reusedfor t heirstupef;ing,intoxicating
orpas,ingou1,and1<mpor:1r,· n phpiotion
,ndocca,ion.ollyl"'ychedeliceffeca,!ncludingillu -
•iom . h.allucin.otiom,,nddelu,iomorju,;1,dre•my • Nitrit« a repopub r in th e g:t)'OOmmun itybec:au«
stupor they are thought 10 enhance ,au.al activity Mo,t
• Theycancau«lemporarystimubtion,moodeleva - : ;~:,•:::.:;h':~n~~:!ol.,ome other drug,, •nd
tion . •ndreducedinhibit ion,,but<>'<ntu.allyu«l<.ads
tocrntn l nervous ,y,tem (CNS) depr<>sion.dizzi - • Th<mostpopularm<>th<t icisnitrou,oxide("bugh -
nes,,slurnd ,peech, •numt<•dygait, drowsines, inggas "),wh ichc:aU><>giddines, . dOOrirntation.,illy
mddelirium . lmp;aim:ljudgmentmdfai n ting • re • t.o ~~e:, t;:~: ingintheaB . • ndocca<ionallyvisual
po,oib le
• Theyneu,edmo, tlybytheyoung,thepoor,m:rnt Sportsand Drugs
·m ignnatoc'fn . •ndnat'verultu~
• Sw-•thl<te,~ceAnns t rongandA lexRodriguez
• ~:~e:,lexpo,uretornvironmrnLalinha lmacan w<r<upo«dforu<ingperfonruonce -enhancingdrug<
(PEO.),ucha,;st<ro id,
• Themo,twide lyabusedinlu.bna,re
• Athl<t«U>< therapeutic drug<,ucha,;p;ain reliev -
• vobt ile,olvrna, a t.ocalled h)Urocuhon,, made er>,anti -infi , mm:tlori«, a nde,peci>llysteroid,•nd
lromoil (e .g.,ga.,ol ine,glue,,pr:1ypaint, tt roool huma n growthhormone(HGH);they , t.ou«recre-
<pn.y. b.cquerthinner,mdcorrectionOuid) >tionaVmood -• lt<ringdrug,(l<g • landilleg:,l)
vobt ilenitrit<>(e.g .. • myl,isopropyl.OObutyl.md • Th<Wo rl dAnti -DopingAgrnc)"(WADA),w,tchdog
cydohe,cyl) for t h< Olympics •nd other athletic organization,,
:i:.~ctics(e.g.,n itrou,;oxide,chlorofonn,•nd regul.orlyupdat<> il5listofbanned,uhsLancn
• Steroids were u<ed first in the 19~2 Olympics •nd
• The mo,t common ingredirna in volati le 50Jvrna havemn oinedanongo ingpro blem
includeto luene,trich loroethylene,N -hu:me,m<th - • Steroidscanbuildmu«bandincra«wright,but
:;;;.,bnutme,m<thylbutylk<tone,•ndchloroOuoro- theyc:an•l>oc:au«•ggres., ion,physio logic:al prob-
l<ms,,bu.,,and,ddiction
• Jnhabnacanbe<niffed,huffed,lngged . ,prayed . or • Perform:tnce-<enhancing<timubna( e .g .. eph<dn•nd
inlu. ledfrom,ba lloon . V,porized,lrohol,l iquidnic - m<th • mphewnine) •nd "'m e other drug, (e .g., HGH
otin< . •nd<>'<nnon-combustedm:triju•ruocan•l>obe •nd er,-thropoi<tin)>re a lmo,;ta,;widelyu«da,;ste -
inhaledin•pncticecalledvaping roidsin,omespora
• Inhabnac:andeliverdang erou,; , mounaolpre«ur< • U<ingpainkill,,,;,ucha,;opioid,1orelievep•inc•n
intothelung,andcmfr<ezetheti>oue cau«moredamagebec:a0><1h<athl<tek<<J>5•tr<>s-

•~:.~ti!:~::t.:
!':~::in:,.~:% ::,;,,b,oto~
ing1h<injur,·
• Anabolic androgenic ,teroidsne
to5t<ron<or')nthe,ized
derived from t<s-
. Theyincre:L5<bodyw<ight,
• Dangerous effeca include nerve damage, memory l<anmusclemas,,muscub.r<trength,•nd,to•le:soa
impairment,a<:kofcoordin:ttion.mdlackofoxygrn extrnt,<Lamina . P')-chologic•lly . theyincrea«•ggr<s-
c:au,ing>uS<TtO!""'OUIOfd'e <i,.,n,..andconfidence

• Athletes may take 20 to 200 times the recommended
dose of steroids.
• Steroids can cause "roid rage," mood swings, cystic
acne, cardiovascular irregularities, high blood pres-
sure, bloating, changes in facial appearance, as well
as swelling breasts in men and masculinization in
women.
• HGH increases muscle mass, skin thickness, and con-
nective tissues in muscles. It also can cause metabolic
and endocrine disorders, cardiovascular disease, goi-
ter, menstrual disorders, decreased sexual desire, and
a loss of up to 20 years of one's life.
• Stimulants, particularly amphetamines and meth-
amphetamines, are used as frequently as steroids to
enhance performance. Caffeine, tobacco, and ephedra
are also used as PEDs.
• Other drugs such as EPO (erythropoietin), beta block-
ers, and androstenedione as well as blood doping are
widely used, especially by cyclists.
• PEDs that are hard to detect are developed by chemists
and used secretly by athletes. The sports agencies are
increasing their investigations and drug testing to limit
abuse. They are also now saving urine samples for years
to test again as new PEDs become identifiable.
• Drugs such as marijuana and alcohol do not enhance
performance and are used only recreationally.
MiscellaneousDrugs
• Camel dung, embalming fluid, gasoline, kava, kratom
(mitragyna), aerosol products such as hairspray, sarpa
salpa, strychnine, and even toad secretions (bufoten-
ine) have been used to get high.
• In attempts to change mood and improve health,
herbal medicines and supplements, so-called smart
drugs and drinks, nootropics, amino acids, vitamins,
and nutrients have been abused.
Other Addictions
CompulsiveBehaviors
• People engage in compulsive behaviors to change
their mood, get a rush, or self-medicate, much as they
do with psychoactive drugs.
• Compulsive behaviors include compulsive gambling,
compulsive shopping and hoarding, eating disorders,
sexual addiction, electronic addictions (e.g., Internet
and cyber-gaming), compulsive TV viewing, and
excessive smartphone use.
Other Drugs,Other Addictions 7.63
Heredity,Environment,and
CompulsiveBehaviors
• Like substance abuse, compulsive behaviors can be
triggered by genetic predisposition, by environmental
stresses, and by the repetitive behavior itself.
• These three factors can change brain chemistry and
make someone more susceptible to a behavioral
addiction.
CompulsiveGambling
• Gambling, like drug addictions, also involves com-
pulsion, tolerance, withdrawal, abuse, denial, and
relapse.
• Gambling has grown dramatically over the past 30
years, particularly in the United States. Almost 9 mil-
lion Americans are problem or pathological gamblers.
• Gambling, on-site or Internet, includes poker, black-
jack, craps, roulette, pai gow, slot and poker machines,
state-run lotteries, keno games, horse racing, sports
betting, and stock speculation.
• A small percentage of gamblers are responsible for
most of the money spent. In some research 80% comes
from 5% of the gamblers.
• The different types of gamblers are recreational/social,
professional, antisocial, problem, and pathological.
About 2% of Americans have severe gambling disorder
(pathological gamblers) and another 2% to 4% have
moderate gambling disorder (problem gamblers).
• For the first time, "Gambling Disorder" (rated as
mild, moderate, or severe) is listed in the DSM-5 as an
addiction.
• Symptoms include increasing amounts gambled, agi-
tation when cutting back or stopping, many unsuc-
cessful efforts to stop, damage to the gambler's life,
and preoccupation with gambling.
• A big win can fuel the craving to gamble. The phases
are winning, losing (including chasing), desperation,
and giving up.
• Magical thinking and believing the gambler's fallacy
that random events can be predicted are common
traits of compulsive gamblers. The action is more
important than the money.
• The main differences in treating gamblers versus
other addictions are the gambler's egotism and sense
of entitlement.
• Gamblers Anonymous is the main source of treatment
for most gamblers.
7.64 CHAPTER 7
Compulsive Shopping and Buying
• In an era of easy credit and conspicuous consumption,
the debt load of the average American has exp loded;
many of those debtors are compulsive shoppers/
buyers.
• Maximum excitement for the compulsive buyer seems
to be the moment just before telling the clerk, "I'll
take it."
• The acceptance and the deferential treatment at the
store is part of what compu lsive buyers seek.
• Prob lems handling money is one of the characteristics
of almost any addict.
Hoarding
• Collecting, accumulating, and hoarding are offshoots
of compulsive shopping and are rooted in an individ-
ual's belief that his or her worth and self-esteem come
from objects and the ability to acquire them.
• Hoarding is gaining in awareness. Hoarders avoid get-
ting rid of anything because of the anxiety that remov-
ing it from their lives produces.
• "Hoarding Disorder" is included in the DSM-5.
Eating Disorders
Overview
• More than one-third of Americans are considered
obese and another one-third are overweight. Health
problems such as diabetes and heart disease are the
result of compulsive overeating.
• The three most common eating disorders are anorexia,
bulimia, and binge-eating disorder.
• Binge-eating disorder is further divided into mild,
moderate, severe, and extreme.
• One reason contributing to the current obesity in the
United States is the government's decision to bu lk up
Americans with a school lunch program after World
War II. The food companies loaded their products
with addicting refined carbohydrates like sugar and
flour as well as fats and salt to increase sales.
• Genetic, environmental, and neurochemical factors
determine one's level of compulsion to eat (or starve).
• Some eat to get a rush, for recreation, or to contro l
stress and anxiety.
• Obesity causes high blood pressure, heart disease,
type 2 diabetes, sleep apnea, and greater risk of cancer.
• Psychologically, higher rates of depression, a negative
body image, and issues of self-esteem are more com-
mon among those who are obese.
• Diet books, weight- loss organizations, diet pills, and
surgeries exist to try to he lp people control their eat-
ing habits and risk of obesity.
Anorexia Nervosa
• Anorexia invo lves starving oneself by limiting intake
through dieting, fasting, the use of amphetamines or
other diet pills, and excessive exercise, to feel in con-
tro l of one's life.
• Self-image is distorted, and those with anorexia do not
see themselves realistically.
• Weight loss usually exceeds healthy levels and can
cause damage to all systems, particularly the heart,
liver, and brain.
• Anorexia usua lly affects girls from the ages of 14 to 18
but can develop later on in life.
Bulimia Nervosa
• Bulimia invo lves uncontrolled overeating followed by
risky behaviors, such as vomiting, excessive exercise,
and taking laxatives to avoid weight gain.
• A binge is consuming an abnormally large amount of
food in less than two hours. A feeling of frenzy and
being out of control usually occurs during a binge.
• Those with bulimia are often ashamed of their behavior.
• Accompanying health problems include denta l com-
plications from stomach acid, a greater liability for
alcoho l and drug abuse, dependency on laxatives, a
high rate of depression, and a greater risk of suicide.
Heart problems that include arrhythmias and electro-
lyte imba lances are not uncommon.
Binge-Eating Disorder
• This disorder involves recurrent episodes of uncon-
tro lled eating, often involving large weight gains.
• The level of the disease can be measured by the num-
bers of binge episodes, which range from 1 to 3 epi-
sodes per week (mild) up to 14 or more binges per
week (extreme).
• Other symptoms include eating when full, eating
rapid ly and swallowing without chewing, and eating
alone especially when bingeing.
• Neurochemical changes to the "stop" switch make the
binge eater unable to stop until the plate is empty and
no more food is availab le.
 ON'o,,._ON'-.. 7.'5

SexualAddiction
• This dlsotd<:r ill ddinol n ·mp,;nc in perslslrn, • Ttii.i>markrobyop,ndi111<ndlaohou1Sonth,
Wacalatlngpo11<rn<ofscrwrJl>ehfflof , 1eltdo1u lnt<rn<t=hingforinformallonondd,,1,1 ,
::si::.
.lncnasi1111
n,pti.-., coru,qumca 10 1<lf Md CompvterGameAddiction
• Su111loddl<tionsincluden><ofpomog111phy.m»- • \'cryaddl<tiwonlincpmcs,P"nl<ut.,ly.MJ.1ORl'G>
1urt.tl0n, mulllJ>I• liai!iOns,onlino hook-ups. mul• (maooivdy multiplayc, onhnc rol<•pla)'l"l pm<>) ,

=:'.
!!pl< offal,., and mone Kriou,; rompuWons such •
•bu<t, uhib i1ioni.m, pedophtlia, T11p<,and
• S.xu1lrompul,lvityiso/1<nu.edto rope,,,nhper-
oonal prnbl,m, 1nd childhood 1nurnas or S1rtS1,
1111htrtlunlimplythepunuitolpleasure.
• u .. ofsu .r,laltdWebli~hal1111dotholnttmt1the
main 111tthmbmf0Tthegrowthofoullli oddlction
• T...,mrnt puups include Saaholics '4.IIOflJ""OIII ,
Su ondl<nTAddicrsAnony,n,na,WO<htfaflill
::!""rn:!':'bo:""~
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such a, Wodd ofW:ucn.f1! ,Jong with rontole pm<>
,ucha>So nyP!aySta1!on•~.NV<btromo:•popular
anda,;addictivea>anydruR
• Gameaddictscanea.ilyploy)(lhou1Sp<rwttk.
TelevisionAddiction
• The•v,ng,Amttican..,.1Chesollou1l .8hoursol
tekvisionperday.F<>rcompulsiv<""ICht,.,6to8
houni>notunrommon .
• • Ei<c..,.;.,,vi<wingiJoltcnlOthtaduslonolmany
IClivitiain1....,..lifi<(c.1- , r.mU11fricnds,md

"""'·
p~

ElectronicAddictions Smartphone Addiction

• Woddwidtinl013th,r,:.,-.r,:,.8bllllonccllphono
• TM<XJ>"nslonofthtl n1<rn<1andth<!nvrn1 lonor lnth,U nit<dSU.~thatnumbtr..,..373mUllon<< ll
phon<>(morethanthtU.S.popula!lon) .
mobil<phona,>a1<1li1<radio.elec1ron!ctablet1,<l<c•
tronl<: g,,mu. multip!aya &'""'· and hundred , or • Act!viti<>oncelimit<d10rompu!<rusc1r,oow"' .. ;i .
ab!eon,manphon <>ondnotebook.t
:~~;~~".\: hm rontribut<d IO th, obus< of
• '4<ff,ofth<US,populationhasnomophobio-th,fa:r
• Mor,tlun2.41rillionpropl<..,.tholntemct-'>out ofbeingMthouton,'omobilcphonc.
or,e.thi,do/thtworldpopu!ation
• &..o1 .... ,1"""}'JDiq,;lowap<n>< . andftuibillty Conclusions
pytronuolu,th,u,a .
• SymptomSolln,,,,,.,.addictionlndl>d<lon&hou1S • Althougbthemou,olmanycompulolonsu,:simi •
onlinc, loanc uack of~ thinklncabou, tht la,,ther,.,.dilJ,,.,,... ; obsti!ICIIC<ls~IDT
ln1<mt1ronsw11ly.n,gkcting~btlilicl , 1nd1
=ryfmm"°""addlclions , ....,..,.uornurn10
dounmott . nonnallnThollCliYityitnec<Mary'wl lhothn--o(c.,- ,
atingdi<order>,,hopping,or<ltctlOflicaddl<tiom)
CybersellUIIAcldiction
• This lnduda online pornogr.,phy and X·T11!<dchtt

Cyber•RelationshipAddiction
• Thlllnvolv<> <l\P&inil nr,lation,h lpso nll Mln1n
obseul~manoer . Pmblem,l>,ginwh,n thconlinc
rda1lomhlpdn.-son,"'bothpanlc:ii-,,tsowoyfrom
hlsorhnlCll ,hf,rdationships

lr>lemetCompulsions

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 NO EXIT © Andy Singer

;{Ei•G
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:: HAVE PICTURES OF \. FOOD LABELS WITH .)
CANCEROUS LUNGS PHOTOS OF MORBIDLY
AND CHEMO PATIENTS :, OBESE PEOPLE?

OR PICTURES OF OR PHOTOS OF DRUNK

TRAFFIC JAMS AND PEOPLE IN AWKWARD
POLLUTION ON CARS SITUATIONS ON
?'? ~,m;-~ ~~~i,;t LIQUOR BOTTLES
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© 2011 Andy Singer.Reprintedby permissionof Caglecartoons.
 DrugUse and
Prevention:
FromCradleto Grave
Th<thrtttypuofp=<ntion - •mpply,dem.or.d,rndharmmluct ion ---<lr<<nm -
ined •long with the v..riou, methods u«d to imp l<m<nt pr<v<ntion and the chal -
leng<> to this fidd . Thtlegaliu tionofrrwij,unainsom< "'-t<•i•clu n ging
• proplt1' , ttitude,toworddrug-abuS<Cprev,ntionandha.s~eitmor<d iffirultto
rommunie11<thera l cbng<noldrug alm« a r.daddiction
Th< ways drugs •ff«t • ll ,1na of 50Ci<ty,from pugranl mother>, youth, and ool-
lege >tudena to WOTk<rs,the mili tary. • nd th< eld<rly, i, aJ50 co, ., rro . , an the
df«aofdrugsonl0>'<>ndS<x . Drug1<,tingisadd~ a,; well • •howitha.s
beenint,gratedintothewOTkplaC"<Cmdtrnlrnrnl

l'r<>'rnting • bn., an daddiction,wheth<rit involv n drugsorb<h.oviora l rom pul-

oions,is a lw:ay,mondfectiv,th2ntryingtostopthe0owofdrugsortru tingabus,
:.:di:::: after it 112soa.,.m ro. M.on)" approach
<>
have
been tried . bu t succ
ess
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fo, h,ooai>ta« rx c.:uu rl,a,- tli,>ant<pro/,l<m.\M,,tl,, , ~·,0,1,,;,,roap,ri"""t

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•lthoughth00< th r<• tsnev,r>topp<dcrimin • lorganizationsandstrtttch<mi•ts,
whou,uallyfoundway•to=deth<l • w.Cm:libl e ncsearchonth,dangenoftobacco
ho,ronv!nc ed holfofAm<ricm , mok<r>toquit . Deathsfromdrunkdriv!nghov,gon<
downHMoth<r>A g:,instDru n kDriv!ng (MADD) rn d law,nforc<mrntpenonne l hov,
raised.,. .. ,. ,,,.. md !ncre.osedthep<ruo lties . A, th<u5< ol onegrou p ofdrug,isdim in-
ishedthrou ghron«ned <fforts , howev<r . anoth<rgroupo l dru g, g:,ins,trengthb,c,u se
 8.2 CHAPTER 8
addiction is a disease and any drug or behavior is at its root.
If the disease itself is not prevented or treated, demand
reduction will have limited success and supply reduction
is only temporary. The arguments for legalization, advo-
cated by many as the solution to a host of drug-related prob-
lems, have miles to go before credible evidence is found. The
positive or negative results of legalizing marijuana in 2014
for recreational purposes will not be known for years.
Conceptsof Prevention
Prevention Goals
Because drug use affects people throughout their lives, many
drug educators believe that prevention should be practiced
from cradle to grave. It is up to each society to determine
exactly what it is trying to prevent.
Drug users are at different levels of use, from experimenta-
tion, social use, and habituation to abuse and addiction; and
because there is such a diversity of cultural practices in the
United States, making decisions on prevention can be diffi-
cult. ls the goal to prevent any use of any psychoactive
drug; is it banning only illicit drugs; or is it simply trying
to limit the damage caused by use, abuse, and addiction?
In the United States and most other countries, a combination
of prevention goals has the best chance of success.
• Primary prevention is preventing the development of the
disease of addiction in nonusers by teaching skills that
will help an individual resist abusive drug use, make wise
decisions, solve problems, and resolve inner pain and con-
flict. Skills that instill resiliency and suggest alternatives
to drug use are also useful for those who are not currently
using, even though they might have used experimentally,
socially, or even habitually. Primary prevention can also be
for those who have stopped using and are in recovery.
I
• Secondary prevention is stopping inappropriate or
potentially destructive use in "non-dependent users ."
• Tertiary prevention is reversing abuse and addiction
in "dependent users" to restore people to health and to
suggest alternative ways of thinking and living.
Most programs focus prevention efforts on nonusers and
dependent users, but the most important group in terms of
SUPPLYREDUCTION DEMAND REDUCTION
Coast Guard interdiction AA meeting
© U.S.CoastGuard © AlcoholicsAnonymous
reducing drug abuse is non-dependent users. These are
either new users or regular users who have not yet suffered
the complications of drug abuse. When young people decide
to use a drug for the first time, they are usually emulating
someone who uses but doesn't suffer many consequences.
They usually don't begin using to emulate an addict or abuser
with obvious problems.
"Non-dependent usersfuel specificdru9 epidemicsin the
United States. from cocaine. to heroin. to methamphetamine.
to OxqContin.® While public responseshave focused on the
dru9 itself, policieshave failed to focus on the real sourceof
the epidemic:the pool of non-dependent userswho exist in
everqcommunitq across the countrq virtuallqunaffected bq
dru9 policq."
Hon. Andrea Barthwell, MD, former deputy director,
Office of Demand Reduction, ONDCP 1
Another impediment to effective prevention is the lack of
enough long-term programs available for those who are not
currently using and for those in recovery. To be effective, these
programs should include medical therapy (e.g., anticraving
drugs), desensitization to prevent relapse, dean-and-sober
social and recreational outlets (other than 12-step groups),
mental health follow-up services to continue treatment of any
underlying problems, extended family services, and cultural
disapproval of drug use to reinforce nonusing norms.
'To combat dru9 abuse, especiallqamon9 teens and qoun9
adults, we in the Obama administrationare partnerin9with
communitiesall across the nation to preventdru9 use from
everstartin9 in the first place, intervenedurin9 the first si9n of
trouble, and support those who have achievedrecoverq.That
is whq PresidentObama has called for a 13% increasein
preventionand a 4% increasein treatment fundin9."
Gil Kerlikowske, former director, Office of National Drug Control Policy 2 ,3
Supply,Demand, and Harm Reduction
There are three traditional approaches to reducing the levels
of psychoactive-drug use and abuse. The actual policies used
to implement these have often depended more on the pre-
vailing political climate than on long-term public health.
HARM REDUCTION
Needle exchangefor addicts
© 2012 Public Health, Seattle and KingCounty

Reduce the supply of illegal drugs. Interdiction of drug sup-
plies, legislation against use, and legal penalties for possession,
distribution, and use are the most common tactics employed.
Reduce the demand for all psychoactive drugs, legal and
illegal. Tactics include treating drug dependency and foster-
ing prevention through education, emotional development,
moral growth, and individual or community activities.
Reduce the harm that using drugs causes to users, their friends
and relatives, and society as a whole . This controversial
approach includes promoting temperance, providing medica-
tion replacement treatment (e.g., methadone or buprenorphine
maintenance), providing resources to lessen the consequences
of abuse (e.g., designated-driver and needle-exchange outreach
programs), and decriminalizing/legalizing drug use.
Historically, supply reduction and harm reduction (temper-
ance) had been the most widely used methods, but once
addiction was recognized as a disease, demand reduction
became a viable method of prevention . About 42% of the
projected $25.3 billion in federal funds requested for drug
control in 2014 is allocated to demand reduction. 2 ·3 The
other 58% is for supply reduction. These figures do not
include the costs of incarceration and parole, which would
almost double the budget.
"A common fault in drug policqhas been anticipatingor
promisingdramaticresultswithinan unrealisticallqbrief
period. Reducingand stopping drug use requiresfundamental
changesin the attitudes of millionsof Americans,and that
shi~ in attitude is moregradual than we would wish.The
National Drug Control Strategqpromotesa steadq pressure
against drug use and underscoreswhq drug control must
be lifted out of partisanconnict."
Barry R. McCaffrey, former director, Office of National Drug Control Policy
"We know that treatment works.But we also know that there
are too manq Americanswho, for a varietqof reasons,cannot
accessthe treatment theq need. Bq givi~f]peoplea choice and
the means to help connect them with effectivetreatment, we will
be able to more directlqhelp drug userswho have recognized
their problem."
John P.Walters, former director, Office of National Drug Control Policy
History
Temperancevs. Prohibition
"I am awarethat the efforts of scienceand humanitq, in applqing
their resourcesto the cure of a diseaseinduced bq a vice, will
meet with a cold receptionfrom manq people."
Benjamin Rush (Rush, 1784)
One of the Founding Fathers of our country, Dr. Benjamin
Rush (1746-1813), was among the first to attribute alcohol-
ism to the properties of alcohol that made a susceptible
drinker lose control rather than to the performance of an
immoral act that was a matter of choice. 4 From this position
Drug Use and Prevention: From Cradleto Grave 8.3
he promoted temperance as a way to counteract the excessive
drinking of rum and whiskey that was rampant in the early
1800s. Since that time attempts to regulate drugs, particu-
larly alcohol, have wavered between moderation of use
(temperance) and outright prohibition. The tenets of tem-
perance pronounced heavy drinking and especially drunken-
ness as destructive, sinful, and immoral, but moderate use
was believed to improve health and mood. Initial temperance
efforts consisted of convincing drinkers to switch from dis-
tilled spirits (hard liquor) to beer, wine, or fermented cider.5 •6
By the 1850s the goal of total abstinence had replaced that
of temperance. Seventy years later this led to the passage of
the Eighteenth Amendment to the Constitution, forbidding
the manufacture, sale, and transportation of alcohol.
The conflict between moderate use of alcohol and psycho-
active drugs and moral/legal abhorrence of any use of any
amount persists to this day. Historically in the United States,
the concept of complete prohibition, or zero tolerance,
seems to run on a 70-year cycle (1780, 1850, 1920, and
1990). Over the past couple of decades, every state raised the
drinking age to 21 and decreased the allowable blood alco-
hol concentration (BAC) from 0.10 to 0.08. Currently, sev-
eral states have zero-tolerance laws that suspend the driver 's
licenses of youths under 21 convicted of driving with a BAC
of just 0.01, the equivalent of about half a beer.
Did ProhibitionReallyFail?
"A~erone qear from the ratificationof this articlethe
manufacture,sale, or transportationof intoxicatingliquors
within, the importationthereof into, or the exportation
thereoffrom the United States and all territorqsubjectto the
jurisdictionthereoffor beveragepurposesis herebqprohibited."
Section 1 of the Eighteenth Amendment to the U.S. Constitution;
ratified January 16, 1919; repealed December 5, 1933
I
Over the decades the consensus about the Volstead Act,
more commonly known as Prohibition, enacted into law in
1919 by the Eighteenth Amendment (enforced in 1920 and
repealed in 1933), was that it was ineffective . An examina-
tion of medical records mentioning diseases caused by excess
alcohol consumption as well as criminal justice system
records shows that Prohibition did reduce health problems,
domestic violence, certain crimes, and consumption .'
• Admissions to mental hospitals for alcoholic psychosis in
Massachusetts fell from 14.6 per 100,000 in 1910 to 6.4 in
1922 and 7.7 in 1929. In New York the rate fell from 11.5
in 1910 to 3.0 in 1920, and it rose again to 6.5 in 1931.8
• Nationally, death rates from cirrhosis of the liver fell from
29.5 per 100,000 in 1911 to 7.1 in 1920; they stayed
below 7.5 throughout the 1920s. 9 •10
• Legal costs decreased-there were fewer drunks sent
to jail, less domestic violence, and less crime overall.
Arrests for public drunkenness and disorderly conduct
declined 50% between 1916 and 1922_10
• Per-capita alcohol consumption dropped by half and did
not return to pre-Prohibition levels until 20 to 30 years
after Prohibition was repealed.
 8.4 CHAPTER8

The goal of Prohibition in 1933 was greeted with

joy by the anti-Prohibition forces known as the
"wets" and with disgust by the prohibitionists and
supporters of Temperance.
Reprinted by permission of the WisconsinHistorical Society.

• Bootlegging increased the supply of alcohol in the late
192Os; and though medica l problems again increased,
they were well below pre-Prohibition levels.
It is a myth that Prohibition created organized crime.
Criminal organizations existed long before Prohibition,
although organizational techniques were refined during
that era, and they took advantage of the opportunity to step
into smuggling and the distribution of illicit drugs.
Prohibition reduced illness and crime as well as the public
concern for and treatment of alcoholics. Prohibitionists
the Amethyst Initiative argued that the current drinking age:
• is unrealistic and routinely violated by college-age youths
• encourages dangerous binge drinking
• leads students to make ethical compromises such as
using fake IDs , thus eroding respect for laws
• inhibits development of ideas to better prepare young
adu lts to make responsib le decisions about alcohol
Some colleges wanted to eliminate the burden of policing
their students and enforcing underage-drinking laws on
their campuses. 12J 3J 4 ,15 The Amethyst Initiative took the pre-

I
believed that once alcohol was banned, all alcohol-related
problems would be solved. 11 Even though Prohibition
banned the "manufacture, sale, and transportation of intoxi-
cating liquors," it did not crimina lize drinking. There was
continuing support for Prohibition from President Herbert
Hoover and most state governors in 1929; and had the Great
Depression not occurred in the 193Os, the Eighteenth
Amendment might have lasted years longer. The need for
increased tax revenue, the activities of the anti-Prohibition
forces known as the "wets," and the general public's desire
to drink again led to its repeal.
AmethystInitiative
In 2008 a petition movement known as the Amethyst Initiative
attracted endorsements from the presidents of more than 100
of the nation's leading independent liberal arts institutions.
This initiative called for an unimpeded dispassionate debate
on the drinking age in America. In effect, these academic lead-
ers were interested in lowering the drinking age from 21 to
18, the age of consent and the age Americans are granted
many other rights. Eighteen-year-olds are granted the right to
vote, purchase nicotine , serve in the military, sign contracts ,
sit on a jury , and agree to consensual sex, but they cannot
posses.s or consume alcoho l until the age of 21. Proponents of
vention communi ty by surprise. Numerous studies conducted
after the drinking age was raised to 21 in 1984 (the Nationa l
Minimum Drinking Age Act) have consistently demonstrated
the law's effectiveness in minimizing alcohol-caused prob-
lems. 16,17,1a
Recent studies by the National Highway Traffic
Safety Administration estimate that 4 ,441 drunken-driving
deaths were prevented over a period of five years. 19Another
study found an 11% reduction in the ratio of alcohol-positive
to alcohol-negative drivers under 21 who were involved in
fatal crashes in the United States. This study also found that
state expansions of the National Minimum Drinking Age Act
making it illegal to use false IDs to purchase alcoho l signifi-
cantly reduced the percentage of drinking drivers age 20 and
younger involved in a fatal crash. 20
Authors of the Amethyst Initiative focused on several ideas
for prevention that should be considered regard less of the
legal drinking age:
• mandatory alcohol education tied to driver licensing
• alcohol education that includes exposure to victims of
drunk drivers and to individuals in recovery
• lowering the alcohol content of alcoholic beverages that
are popular with college-age drinkers

Colle20president-.:,favor lower drinKing
Some colleges are making significant efforts to implement
prevention programs. The University of Virginia in
Charlottesville, for example, has deve loped a "social norm-
ing" prevention initiative for students that relies on peer
counseling, social events, and solid information about alco-
hol to challenge students ' misperceptions about drinking. 21
ScareTacticsand Drug Information Programs
Earnest attempts to lessen substance abuse did not begin
until the 1960s, when recreational drugs came out of the
ghettos and the barrios and began to be used by middle-class
kids. The percentage of Americans who had used any illicit
drug went from 2% in 1962 to 31% in 1979 (back to 23.9%
in 2012). 23 These jumps in use spawned many grassroots
prevention movements. 22
Beginning in the late 1960s, early prevention programs
assumed that young peop le lacked know ledge about the
dangerous effects of psychoactive drugs. Knowledge-based
programs were established to teach students about phar-
macological effects, causes of addiction, health effects of
drug use, and legal penalties. Providing young peop le with
factual information with a heavy reliance on scare tactics was
considered enough to reduce drug use, but the scare tactics
often distorted the credib le information; and because some
statements about the dangers of drug use were so blatantly
false, many young people dismissed all the information.
the earl~1970s,the9overnment
'"In askeda 9roupof treatment
professionals, includ.in9mqself,to review2.97d.ru.9education
filmsthat wereavailable.
We foundthat wecouldbare/~
recommend.evenone or two of the plms becausemost of
them had. had.information, relied.on/~ on scare tactics, or
werejustpoor/~made."
Darryl Inaba, Pharrn.D. , Addictions Recovery Center , Medfo rd , Oregon
Drug Use and Prevention: From Cradle to Grave 8.5
age ...
0 2013 Dave Granlund. Reprinted by permission.
Although providing credible information about drugs pro-
duced measurable increases in knowledge, changes in atti-
tude, and abstention in some young people, there is little
evidence that drug information alone causes changes in
behavior . In fact, some studies indicate that providing infor-
mation about drugs in a poorly made film may actually instill
curiosity and lead to drug experimentation and perhaps to
abuse, whereas a well-made video might lead to experimen-
tation but might also limit abuse. 24
"B~ the timeI 9ot to colle9ein 2012,I had
I
tried.alcohol, marijuana, and. OxqContin® and.
Vicodin.® We feltwe knewit all b~the tentharade
or evensooner. B~colle9eI feltjaded. . I knew it all.
To counter that, I received.on/~ one d.ru.9education
lessonin m~ p~h-9rad.e class and.two or three hours
in m~ ninth-9rade healthclass. The~ talkeda lot
aboutall the differentt~pesof dru9s and dru9use.
Some in the class actuallq made me quite aware that
I was missin9 out on a whole lot d.ru.9
s." of
21- year-old college stu dent in recovery
Most adolescents believe that they are invulnerab le, have a
limited view of the future, and are indifferent to long-term
health consequences, making information-only approaches
to drug education ineffective. School-centered knowledge-
based programs also miss those students who skip school
frequently and who are at most risk for the health and crime
problems associated with drug abuse. Although good pre-
vention efforts do decrease drug problems at a fraction of
the cost of supply reduction efforts , these programs often
suffer because the skill set of teachers and trainers is lacking,
the material is not appropriate to the developmenta l level of
the targeted students, or the duration is too brief.
Skill-Buildingand ResiliencyPrograms
Once thedi..>S<ronceptol • lrohol i<m mddrugadd ic-
t
::
tiontookho ld, prnentiondforuexpandedto•d<IRH :::

:r.F~~;E~'°;,:~~~~::::!::~~~
::2~:;:,~~~~i;~d~,::d,~
tion•nd •bu«. The mor, ri,k lactor,in• )'OUngp<T"'n's ::,

nri~~~;!%
*
GonffolCoinpntncylluildinf Th<><progr.unsaimtoinc~
lh<«lf-comJ><trncy•nd!i<ll-confidrnceinindividu•loby :::
providingt.-.inlllj!in!i<IF=tttm,>OCiallyacc<puble:::
Nh.oviors, decision-making. o,clf-asontion , problem- :,::
solving,andvocational,kiU..Prognm,<mployingthes, ,:=

~~=.~~:,:::~~~;t~~.;~
t,,,
th1en<»oflhi<kindofp=<n tion ef!on . AllPokK;,ls
Ma.liing/!,alrhyCh ok <>(2006)andAkoltoiLlt<racyC,._,llrn~
;_

~~~;~;:~;:;;;;~,,·
""""''"'-·
..;~rogn,~;.~
~--------
u,c~~.,,.~~~.-..,..- ..,,.. ~ cunca. u ,cxm ~ C"l""I: Cal~ ""'t"iii,~otlla-,1,i,,i1,,..,,,,,,. <Ml"'""'
prug,.,.
AdministntN>I> (SAMHSA) National R<gi-,ry of Evidtntt- """"1 -og,,~Udm, I• (J) tu<>t"!tloi..ui""<Jttl ,",!<•odp,1,.,kal
Based Prognms md Pract;cr. (NREPP) Web site. " ,_,u,,i,"' ""'1t1y; Wd"n.&-"'.! '"'"''ion I• ""'1rty-r-ol""t
,1.....,..,,,,(l.<.,••"olli>lk<>ptt""'°">);(J)dn~"l' "t•plan0>1'tlp
Copni (tHi11anu) Skin, Sp,c ific coping,kil1', like par=ting ,q,,wlr~ ,,.,~,..,,ion (I.<., d,u,-,,,lol•t,. ·lw,"l"I! •"I""' mit,I<
claSS<s, anger maruogemrnl , md learning breathing tech - M,ffwl-.-,),ood(i)n ·ofw.ui•tP"i•""""''"..ladmi,..,ttl•t
niq_u,s,he lppeopl< lace<tre.,fuloituat iom. These,kill, ><lf-ttb,fo,um<n<"'"P!'"""""'
help an individu.ol dndop the «lf-rdW>ce . confidence
and "nnerresourceontcr<,uytore,tdrugu« andt o
n.tion•llydn.lwithdifficult,itu.otion,oothotdrugu"'is le.ad, to drug md alcohol abu« . The N,two,~ Thtrapy
al<s••ttractiv<option.Anothert<chniqueu.,,,p,ychologi - J>rcx,-amisaneumpl<olth i,pre,.,ntionapproach .'"
cal inoculation, which involv<> le.oming-appropri>t< md
healthy replies to frequen tlyfac:ci ,itu.otions like peuor
Changing the Environment
adv,rti,ing pr<Mur<>. Coping Ull, • cognitive beho,ion.l Preventionprognm,nowlookb,yondindhidua1'toth e
~~7,::'
~ i, •• example of• progr.,m targ<t<d toochool -age ,oclalrndemironmentalinfiuence,oldrugw.e.,uch••
r.mily.peergroupv.,lu,,;rndpncticn.•ndtheinfiuenceof
med i.a.Otp.nizingrommunity -basedprogram,;is • W>}·to
RoinfOfflftf-factonandRHllioncyTh<s ebuil donan emurecultural,ensitiv!tymdprovidelocalcontrolo,u
individu.ol• natunl strengths. The factoB that increas e J>T<''<ntionefforts like billbomkand other m~< media
rc,ilirncyareoptimi,m . <mpathy , in,ight,int<ll<ctuolrom- >Ome communityprogram,;locu,;onsoci<talandorg:miu -
p<t<nc<,det<rminotion,dim:60norpurpo"'inliF, , and tioruolchrng e,,uch asalt<ringp roctic<>in,choo l, ,WOTk-
p•nirularlyself-,>t«m. " Mostproplealradyposses,th<S< plx<> . civicrndculturlllgroup, , •nd,oci<tyatlarge.Theo,
ropingresoun:e,,md reinfon:ingthemmak<>themmOT< rommunity-based,,~t<ms-orient<dprogmnshoveefftt-
av..ila ble." Th,J'mSp,cUJ!Programlo rfourthgrader, ism tivdym.ar,hol,drntir<eneighboThood,totaktr<e•ponsibil -
aampl e oflhisp=rntion•pproach. "' ityforprnenting,ubstanc<•buli<C
Addr... •ncl-Ril k fKlon Early=ivdoppo,i tional Typicalcommunityco•lition•ctivitie,include
behovior,pov~ty , lockolparenta l ,upervision.dy,/u nctional
• asse•singth<n«dsofth e commonityandth<pattem,
drug-abuoingpeen,andotherriskfactors&>SOCU.t<dwith
ofdrug•bu,e
future,ubotanttus,e disorders(Sl!Do)can he <X2minedand
JH<>cr'scd whilt practicing stnt<gieo to minimiu their • roordinotiRJ! exi,ting ,ervic,c, 10 •void co,tly rulun -
dndopmcnL "" Thebtcrrdibl< Y<<1T>l'rogrllrnforparent,of dancy a ndtofillinlhe,er.fo,g,p,
pn,choolchildrenisanexampleoflhi>p=ention approach ."' • ch2nginglaw,andpublkpolicytorulucethe aVllilabil-
i1yofal cohol a ndtob=o
~rtS-,.....Oftolopfflont Providingn.,yacc,"to•ymp•·
thet" """'""'""'h ast< le1' <rn,u.-.nc,' ;,n "on; • incre a,ingfundinglorlamily.>ehool, mdrommunity
livingaloneOThomeworkhotlin <>fo rstud enl5<truggli ng p=rntion.,r.icn
wi1hthep,,..ureolochoolruluce,1h,<1.,..th.o1oom<1im<> • rommunity-widtt,..ining•ndplanning "'-''
 Drug Use and Prevention: From Cradleto Grave 8.7

Project Success, described at www.NREPPsamhsa.gov, is an Parenting Program-is an examp le of an evidence-based

example of this prevention approach .26 family approach to preventing behavioral problems. 26
Unfortunately, much of the focus is on the potential addict
PublicHealth Model rather than on how the family's environment and family
relationships affect susceptibility to addiction. Occasion-
The more complex prevention efforts became, the more
ally, when the family is too dysfunctiona l, placing the youth
important it was to understand the relationships among all
in foster care or with another family member is preferab le to
elements in society The resu lt was the public health approach
continued exposure to drug and alcohol use, not to mention
to prevent ion model, which holds that addiction is a disease:
the chance of physical, emotiona l, or sexua l abuse.
• in a genet ically predisposed host (the actual user)
• who lives in a contributory environment (the actual
location and the social network of the host) in which PreventionMethods
• an agent (the drug or drugs) introduces the disease.
Whatever method or combination of methods is deemed
In the public health model, prevention is designed to con- most effective, it is necessary to examine supp ly, demand,
trol addiction by affecting the relationships among these and harm reduction in more detai l.
three factors . For example, programs designed to limit the
pervasiveness of an agent like tobacco in the environment SupplyReduction
seek to regu late cigarette advertis ing . Efforts to raise the
drinking age or to have drug-free zones around schoo ls are "Supplier of chemicalsused b4 illegaldrug labsgets 6 4ears."
designed to limit the host's access to the agent. The most Los Angeles Times,June 10, 1986
visible programs are nationa l ant ismoking, drunk-driving,
and HIV risk-reduction campaigns, wh ich seek to limit the
"Illegaldrug seizuresat the borderjump 16%."
influence of the environment on the host.
Los Angeles Times, November 27, 2001
Research on the relationship of alcoho l outlet density to
heavy use by college students has demonstrated a clear
"Drugczar: We're winning.'Methamphetamineproduction
link. 32 Other stud ies have also linked the price and the qua l-
is down."
ity of the alcoho l available to problematic alcoho l use. This
Portland Oregonian,July 21, 2006
has prompted many communities to enact limits on the
number of alcohol outlets available or to increase taxes to
discourage alcohol abuse. "From mid-2008 through 2009, methamphetamine
availabilit4increasedin the United States."
Other prevention activities aimed at the environment/host
National Drug Threat Assessment, 2010 (SAMHSA, 2010)
relationship are designed to reinforce the emotional
strengths and the protective elements already existing in
people's lives or to improve the economic and emotional "Anti-druggains in Colombiadon't reducenow to U.S."

I
environment of those most at risk. New York Times, April 27, 2007

FamilyApproach "UN reportsAfghan opium decline."

BBC News, August 26, 2008
"When I ask the kids at 'juviehall' about finishingtheir
sentencesand going home, a majorit4of them don't want
to go home because,for them, that's wherethe problemis. "Eventhough productionis down, Afghanistanproduces
Over half of them have one or more parentswho are either over 90% of the world'sopium."
incarceratedor 011 probation,often for drug crimes.A majorit4 Wor ld Drug Report (UNODC, 2011)
of their parents use. For those juvenileswho are in here for
possessionor occasio11all4 dealing,the4 have 110 place to go." 'Tougherbordercan't stop Mexican marijuanacartels."
Juvenile Detention Center officer, Medford, OR
New York Times, February 1, 2009

For a number of years, treatment and prevention specialists

have embraced a family-focused approach, wh ich makes
sense because susceptibility to addiction often stems from
family dynamics. Family support, skills training, and
therapy, along with parenting programs, greatly contribute
to reducing the risk factors that lead to drug abuse
and addiction .33 Strengthening a family system and interac-
tion among members have been documented to reduce
ado lescent problem behaviors. Strong families and effective
parenting are critical to these efforts. 34 Triple P-Positive
"DEAlaunchesfirst RxDrug 'Take-Back'Da4."
Associa ted Press, September 24, 2010
"Recordseizureof illicitdrug ketamine"
VancouverSun, January 26, 2011
"Illegaldrug pricesfallingas purit4, pote11c4rise, researchfinds."
Los Angeles Times, Octobe r 2, 2013
11><UnltedS..1,stw1ptntbUllonsofdollushclpi"l1the
Colombian,AFKh,an.Mtxlcon,1nd01htr1ovmirn,nt,6ght
lh,productioIJ1ndth<unu&gllngo!coc,ln,,h,roln,m, th -

___
amph,tamln<,andmarijuano, y« th• now ofdrupinto tho
1.0p,,.,i.,,, x u~tt.,,,,.l,,ylll<DEA,1o,..,,. .. ""'"1,~M<>n<""
Un!t«I State>tw no, diminish«!. The Notional Oru1 Threat
...ic.....i.,,, .... Mrifi<,ia.pM« rM5i""1""C••<r(U9 .. !III....
A.. ,,.. mrn t 20 10rtponbythtU.S.O.panmcntofJuollc< l6,00011>< . o/ ... n.,.....,2 6,000!k.ef,«oJr1<,JJ.,illloo«,..,y
,1a,n . "Ovm1ll, th ,1 voll1blll1yornucnd rupl nt heU n lted
~'::~
i~I~:~~~::• ,he ha,""""'
"affiL1, ,.,.,.J
.. ""·
".."""""""
only dru1 wMS< supply
p111~....i1,20011>< . o/01t!Aamp,\<ldOlinoW<rr""Ud,Aody<1d,"ll

Supply ml u<tlonKci..10dttrc,1Hdru,1buKby,.. d u,cln1

th, aVllilablUtyofdrup 1hroust, r,gulatlon, r,s\rlcllon,

--n:
intndiction,andlawonF01um,n1 . Supplyn:ducllonl1th, • idmtifyin1, di.rupting, aiid d;.man tl ln&crnnlnol pnp
rc>p<>nsibll!tyof: andotpn iudc rim<
• •ta1<andlo<alpollcodtpanm<n11 • ,upponing and pa.. ing I•~ .. h!lc main •
• th< Dq,arun,nl ol Jus,lco, which lnclud<S !he Fod..,.J llining&ir=1<neingpoli<i<>
&m1uoflnvc<llptlon, 1ho Bun:auoff'nsons,th, • fuoding add itional community polltt offi<nro
lmmlpatlon ond Notunlludon Suvtoe, and Ibo<[)nia
• dwuptlng money-lauDduing actlvllla and KlzlnJ
EnFoittmrntAdmln!Mration (OEA)
-uo£ d rug<kakn t<>limit th< prnfi11 fromlllopl •
• 11><T-.yo,p,,nm,n1.whlchlncludcsth<Burauor

=n=-=ri~
dru&activities
Akohol.T"'-tto,1ndAram,s;th<ln1<mal~11<
• ..,pponingloc,r,[and"°"P"lic,inbW,-lnttnshydrug •
S<rvia:mdth<CmtOmSSnvta,

. ~~=:!t:::=~::.i:i:
• 11><0q,,,nmnnofO.f.t111<
nax,nlinatinglntolh..,...
• bramtgupdom<>tic1nd/on:ign....,,usof..,pplyby
mpportingnadi<2tion1ndth<antidrugd£oruo("""n •
Thisrompla,._.,,tkofqtnd<slscoordln,tedbyth< tricslik.eAfgbanistan,Colombia_Mul<o,andPaklsw,
0£ri<,,o£ Natio,..J DN&Conaol Polley (OSOCP) • mactingtra001ndotbainl<mllionalqrttm<n11to
workronjointlytmmdwpplymluctlonpls "
Somcofth< supplyml11<donKtM 1lalncludc :
• lntadi n ln11drua...,ug&lo:rsln,h<1ir .on1hc ... ,1ndon L.gislationandl~l~lties
th,high,..y
·,4-.,·,pu1,1;c""'"'t........,.""'"'th,U,,;r,dStor,,
• !i>crnsln;iila..-rnFotttmtntKIMtl<sotbord<rcn,ulnp
• intmll<tin&•ndlinthln& thesupplyofprc,curoorclle m~ ~~~:1"..:!t.!."t':'lf,~t
..d. , .....,.1t 1r
col,U><d!nthtmanuf0<turtof!ltlcl!drup(o
rin<. 1 p,ttut"OOroFmtthompht11mln<)
.i., <ph«l- ....................
.~,_- ...........
. ,,....._,, .,.,1

2,400,000
UnitedStates
PrisonPopulation
2,000,000
1,600,000
1,200,000
800,000
400,000-l-------
o 1:::::::::=:====================
1990 1992 1994 1996 1998 2000 2002 2004
Year
"Penaltiesa9ainstpossessionof a dru.9should not be more
dama9in9to an individualthan the useof the dru9itself;
and wherethe~are, the~shouldbechan9ed."
Presidentjimmy Caner, regarding marijuana, 1974
"/ head up the executivebranch;we'resupposedto be
carr~in9out laws. And so what we're9oin9 to need to
have is a conversationabout 'How do ~au reconcilea
federallaw that still sa~s marijuanais a federaloffense
and statelawsthat sa~that it's le9a/?"'
President Barack Obama , interview with Barbara Walters, December 14, 2013
As more and more states legalize marijuana for medical and
even recreational use, a reexamination of existing drug laws
is under way. Much of the increase in prison and jail popula-
tions is related to drug use and/or distribution, giving the
United States the distinction of having the highest incarcera-
tion rate in the world.
Laws to control the use of opium, marijuana, and other
drugs did not exist in the United States prior to the nine-
teenth century. It was not until 1860 that the first anti-
morphine law was passed and not until 1906 that the Pure
Food and Drug Act, requiring accurate labeling, was
approved by Congress. In 1914 the Harrison Narcotics Act
was approved; this was the first attempt by the federal gov-
ernment to control drug use. Since then laws such as the
Comprehensive Drug Abuse Prevention and Control Act
of 1970, the Sentencing Reform Act of 1984, and the
Anti-Drug Abuse Acts of 1986 and 1988 established federa l
guidelines for mandatory minimum sentences, including a
minimum five-year sentence for possession of 5 grams (gm)
of cocaine base (crack).
Many believe that these latter acts were discriminatory
against African Americans and other minority groups
because possession of only 5 gm of crack (popular in poor
communities) resulted in the same minimum sentence as
possession of 500 gm of powder cocaine (which is more
Drug Use and Prevention: From Cradle to Grave 8.9
Stateprisonpopulatio
n
Localjail populatio
n
Nearly one in five inmates in state
and local prisons and jails are
Federal
prisonpopulatio
n incarcerated for violating a specific
2006 2008 2010 2012
is close
drug
USOOJ,
2009
to In
law. 50federal
%. prisons that figure
expensive and more widely used in affiuent White
communities)-a ratio of 100 to 1. On August 3, 2010,
President Obama signed into law the Fair Sentencing
Clarification Act of 2010, reducing the huge disparity in
sentencing, removing the mandatory minimum sentence for
simple possession, and giving judges the prerogative to con-
sider the disparity between these two forms of illicit cocaine
when sentencing a defendant. This legislation still implies
that crack cocaine causes more prob lems than snortable/
injectab le powder cocaine .36 ,37 ,38
Other legislation includes the federal Controlled Substance
Analogue Act of 1986 (which controls designer psycho-
stimulants), the Omnibus Drug Act of 1988 (which prose-
cutes money laundering and the smuggling of drugs and
I
precursor chemicals), various asset forfeiture laws, chemical
precursor laws, and the Illicit Drug Anti-Proliferation Act,
enacted in 2003 to protect youth from club drugs such as
ecstasy.39
To curtail drug availability, stiffer penalties, including long
prison terms and asset forfeiture, are imposed on suppliers
(those who manufacture, smuggle, and distribute). In most
states it is illegal to possess syringes, although such laws
raise the likelihood that injection drug users (IDUs) will
share needles and increase exposure to blood-borne viruses
like HIV and hepatitis C.
Women have been prosecuted for using dangerous sub-
stances during pregnancy. 40 Such prosecution can be coun-
terproductive, however, because pregnant drug abusers are
less likely to present themselves for prenatal treatment of
drug abuse or prenatal care if they fear jail or loss of cus-
tody of their newborn. Lack of prenatal care has greater
long-term adverse effects on a baby than the use of cocaine. 41
Pilot programs in New York City and in Michigan tied wel-
fare payments to drug testing as a way of routing clients into
treatment. 42 In England one charity paid addicts £60
(approximately $100) to use contraceptive implants or coils
to prevent conceiving a potentially drug-affected baby.43
 acid) . Most,tat<shavepol ici,.i nplxe that=trictthe '-lleof
producacontainingephedrineandp,eudoephedrine.Thi,
has led to •dmrutic drop in mom-200 -pop meth l>hs. which
hav,bemsupplmtedbygreat<rqua ntities,muggledfrom
MaicoandC.nodo•ndcbnd<>tine••uperb.bs"finonc:edmd
rrumnedbyM<Xicandrug -tr:offickingorganiutiora
More and more ,111<, allow medical m.arij=• US< or i..,.,
reducedthepeno lti«forpo,....ion.AsoflOH . 20,tate,
Mniy,tot<>IBmc•·thrtt,lrik« • r.d)'OU'I<oot"l>wruioiring and the Di<tricto/Columbi•had legalized medical mari -
• life!i<ntme<aftuthr,econvictions.Thisl•w"""originolly jw rn.atodifferentext<nt< . mdmor,•r,consideringlegi,1> -
int<r.ded to keep "'Jl<'ll offender, who committed violent cionto• llowmedi calmorijn•ruo. This~ led toconfu,ion••
crim<>and!i<riousfeloni<>offthe,tttrt . A,•=ult,the towhichl>w , toenforce. l', ingmedicalmoriju•ruoonlhe
prisonpopulo6on(local.•t>t<,andfeder.1l)m<>r<thmtri- job i, •n i<oue. Some employ,,. •llow it; others do not
pledbe tweenl980andl01lto•pproximotelyl.Jmillion becou«oljob .. fetyar.dth,,ero-to luancepoliciesof1he
Nearly ~l%oft heirnrweoin fede.-.1 pruo,lSwm,o.mt<nced feder•lgovem men 1." ln 1heN<1herl>nd,thecootol•pr, -
fordrugoffenM<inlOll . <lownlrom60%inl998. " Todoy ,c 'pt'on' ·rr riju•ruo ·, cov<r<d by 'nsurance · prior to
juot.!0%ofinmot<>in local,,tat<,•ndfedenlr.dliti«•rein l00lpotienl5h.ltobuytheirownaloneofthecoontry\
lor,pecificdrug -relat<dcrim<>;howevu,ifcrim<>committ<d SOO"ooff«shop, ."
tofttd a habit,crim<>committ<dundertheinflumc,oldrug, RegardJ,..o/howindividu.al,at<,viewmedicalrruriju.ana
and•lcohol,•ndKtsof,io lencetrigg<red by,uhsW>Ce abu «
J>O<""'ionandu«ofthe,ubstllnce<tillviol • «•f«l<Tilll•w.
aRCincluded ,theinca rcea tion r.tt<isb.etw«n60%•nd80%
Mor,thanbalFohllinmat<>reponeddrug=whil<rom- OutcomesofSupptyRl!duction
mittingtheoffense thatpu lthem inpri>on. Thepucentllge Th<,ucc<>0of,upplyreduc tion app roach«1othedrug
lorteenag er>iseven high<r."-'" problemi , debo.tllble.Thueisnodoubtthalth<<>timated
Thehugei ncra><in thenumberol,taterndfeden l pri>on - l0%tol~%oldrug,keptoffthemork<1,qu.at<•to a ,ignifi -
enresultingfromwha1~bemdescribed••·dr,conlan " cant•mountolilleg•l drugsneverreach ingthe<1rttts ."· ,.
and"racist"policino,,erburdemtheeconomic,iabilityof Thenumberolprop l,impri>oned lordrugcrime,d ecre=
ourimtitution.al,)'<t<m.Mootoftheb.w , ,liketheNewYorl< u«mddimibucion,md•nunknownnumberolprople a re
<tlll< laws moct<d in 1973 by then -governo r Ne!= di«u.adedlromberominginvoh-edwithdrug,due to the
Rockefellu . <>tllbli<hed rrumdatory minimum ><ntmdng threatofimpri<onment. "
basedonpo<5<55ionol,pedfic a moun,.olillicitdrug,md Advoca1<,of, u pplyreductionbeliev,tha1otrictpolicieo
didnotdiffuenti • t<betwerntho«whowrn,inpo«e..ion andstrongperuolti<,deloyth<impul«tou« . g<tprople
into t reatm<nt,•ndk<epthemthere.Detractorsargu,th.at
::.:.:~i::~.:.~o:~';'."w:;;7' ~':n';:!i~ o~:~ illicit-drugsei,ure,willncverkttppacewithdrugsm ug-
><nlmcn •nd eliminated mandatory minimums. The glingordiversion.•ndth,,oph iotica1ion0Fstre<1ch,m-
du n g« make it poo,ible for addicts to be div,ned into i<tswillront inn<tocrttt<alimitl<s,,upplyof abu,oble
ch<micaldependencytreat m entntherthanincar~nted subotlln<umasquerading .,herbalincense,ba th,al,. _ or
Sal<>tominonor'-ll<>n<>r5<:hool<may ... m a p<rpetnlor pl>nt loodsto•voidl<gal= ctions
uptotwie< theuou.al!i<ntmce. Supply reduction legi,b.tion DuringlOlO•numberof,ynth<ticform,oft<tnhydrocan-
,omelime,extendstolawsog•instproduc"madefromhemp .,.binol (THC) , th< psyc!to=ive ch<mical in marijuarut,
and to advertising or ,al« of drug paraph<moli.o, ,uch., ,..,re oold H herbal mttnse-·not for human comump-
roachclip,•ndw:o tupipe,found in "h<ad,hop, ." cion" in heod ,hop, md con,.,n imc, <10res throughou11he
Gm-nnmen,.•OOIBm,b.wsthatregul>t<the,al<o/legalpne - country. Suklunder a ,·:1ri<1yoftnderume,lik, Kl a nd
><riptiondrug,•ndthe av:oib.bilityol•lcohol•ndnicotin< Spice(Gold,Silver , orDi.omond),,omeofthech<mical<!n
DylOH most ,ute,ludgoi ned th<• uthorityandwere th<>eproduc""""'dozens,evenhundr,d,oftim«more
implementing comp uter prognm• to monitor Schedul< II pot<nlp<rgr=tlunTHCitsell . A numberofmedic • lprob -
lll,andlVcontrolledpreocriptiondrup(mostlyopioid lem,w,r,•icdtot'ciru«,prompt'ng a do.zrn,tal<>toout -
m edicatioru;andsedative -hypnotic.)toh<lpprevm~ l>wtheir,a l« bytheer.do llOIO . lnJulylOlltheSynth<tic
DrugAbu«P=entionAct,.,.,,ignedintolaw.lthanned
• "doc tor,ho pping "---4bu«f'.S!i<eingoev<ralphy,ic i.onsto
,ynth<ticcompound,commonlyfoundin ,;nth<tic mari -
g<tmultiplepr«eriptiomol•bu«dpr,,criptiondrug,
under S.Chedule I of the Controlled
• "<CTipt doc, "- unethical pr<>erib<B ofdh,enib le pre -
5<:riptiondrug,
Soon afte r the •ynthe tic mariju.an.a •ppured , synth<tic otim-
• pr<><riptiondrug•busu,;•nddi,,enionpatt<rm ,.
ulants lik< MDPV. pFBT, and mephedrone (+-m<thylm<th-
Oth<r,tnt<j!intorgetprecu™>rchemicalsu«dtommu- cathinon<)begon,howingupunduruom<>lik<V•nilb.Sky
&cturednrgs illegally(e .g.,ephedrin<.<ther,md,ulfuric andh'Ory(Suft,W•ve,C=tl;th<ywere,oldubathsa lts
 !Jn.lU...id-.ion:r...,,Crodloo,C,- 1.11

-
Fo,,-.,""""c,..,,r,o,jail
;o,,-,r,,.,..,...,.ft&n-
,.,. ... ,,i- ... ,.,.,

_,.,.,
......
___ .,................
_,.., ... u-11111, ....

,....ru,.,-..r-,y..,,..
·-·-_,_
....... _,_,,,1,i-,,i.
............w.
,,.,.,_,,..r-n,
.,
""'"-
0Tplan1£oodbutpromottd1 11yntl>nlccocaineormetlum - Demand Reduction
ph<:tamint that ...,uld ..cop< dtt<alon by• urine tut_ In ln rtten t y<2ndemandm:luctionha,berome1mottvlabk
July lOll Pr..!dtnt Obamo om,ndod th< Fod«ol Drug
option to mfucc dru,g , bu ... p•nkularly bec:auu suppl~
Polk-yoFthtUnlt•d s....,1obon both .. 11,natlon.o lly m:luction i, only marginally ,uccc>1ful. Th< lOl~ Drua
Thi1ahllhyto,ynthnl .. T!tCandstlmulantonalopcl,arly Contro l Budgetlord,mandredu<tionii,16'1;hlghtrthanln
domomtnt .. on,wdlttct!onlnn 1 ff1<:klngofobu.. blt,ub-
1013whil<th<supp l)·reductionbudgetii,3.8"1 tSI. ThOH
•tanc.,th.,1wlllmak, ltvlttua llylmpo,slbl<fo• o •upp ly punuin,i;d~udue1ionbelievtthat1h,h,.hh ,IOd1 l,
mfoctkmtffon10 ,uccttdgol n3/orv.ud andcrimtproblem,;.....ctatcdwlthdru 1• h"""<ouklb<
Scm,corgu,th&1ln=1otdlowmforc•m•nt,councoo1>,•nd p1 d y k~d 1t 1lr.1<1.\ono ftbe CORol•upplyn,duo-
!mplcmontatlon oflnl<fflttlonaldrug•polidng"l!,T'ttmena 1ion,fforu.ifonyofthetollowingthue<ondl1lon 11rtmn:
mokt1lru1nu1n:molyCORlyopp<-hd<Uvorin&•N:la- • imividw,il,newrdcveloponlntna.1lnus!n1psy,:MIIC •
tiVtcly minor impac, on th < 1upply. Oap;u: • five-fold liwdrugs(primuy puvcn tion)
!ncru« in f«ltm upmd!tura for Hpply r<duellon offon• • =n•vcrprogrnstoobu..OTaddlctlon(lecondary
!lnc,c l 986.coe1lnei1 1bo<112, '!j,c hnp<•!Odaylhan1 prnention )
dead.ago ."
• ~01oddicr.getuatrnml1nd1110p!htltcontinU<d
0neofthtbrightn1>p0Ulntswrnrom:n>mtl0da)-iotht US<(l<rtiuyprn-ention )
chu&<oun.AdT111 <ounio1colbbontlonofthe<ourt.tht
pra,ttUtion,publlcd<f<ndor1,Pf"l-tlonolfia,._,..,.,....,,,
The language 0£ drug -obu.. pmn,lion ,ti.,,._
oflm, but
1h< principles =nai.n the ,ame . f1>ruampk , """" tduca •
p,uvidn-1,mdthtlh<rtfl\dtpenmrnttocoordi""'""""'- ·
tonrdertoprumr]llttOldary,andtenll,ypr,v,mlonas
mmtoodladl11a1<pro:...,i11&ofconvicl<ddnigofftndrn- univ<nal ,K lttliv<,...clindia.kdp~tloll . Uni.......i
The<ouruavoiddog:l1t1<h<jllltloe tyltOlllwilh\bo• prnmlioni,,aimalatthe<ntln:papubtion ,K lttDV<b
ooncb ofUTDu ro, minor dn,goffmso br ,t;...ni111 lint - oimrd1tOllbgmv.p,tlwhottrioklacun,...cllndla11<d
time olfrnd<n to 1n:aun,n1- 1hcr<bf lhlhlna • 1upply b1imtdatindividuob..-hoancap<fkn<i11&symptomsof
Kductlaa ttcbniqut 10 a demand m!IICl!on otnus,-." lly
oubsw>ttobu..1ndpn,cticingprobl,:mbdu."1on.
Junel01lthtrt .. crtl,7J.4dn,1courulnoponOon . rtpre ·
..,ntingoll,OU .S.1ta1<1.Dru1a,unsmoll<~..,,... l'ri""")\~and<crtlaryarethtu:rmsUSNtnthb
beca.... 1ncar<..,.,lona,oub<t"''KnS10,000ond5'!0,000 l<Xtbook with apla,u.tion, of thrir conntC!lon to 1Utfwr111t
p«yurp,rprb<,f><r,.. . S1,,00for1wdl•ntnd"'1C0Un .,1,rnw,andiRdiaittd. "'
progrun .>U0rtt,,1mm1outcornestudlasuqutthotman -
dattd 1n:1tment of drua 1bus< by L,.w mfom:mmt -,1,. tn PlilTlilryFffvention
bettn-oum,,nathonthoscoc:hkv<dtlt:<>u&h..,luntary Prim>.rypKVtcDlionlrlntoontidpat<1ndpttvtntln\1ill
"""lm<nt .".,.,. Althoughd"'ICOUrutia,.·,(ncrtlOedln:lt • druguK.lti>torgetcdatyoun&-1•..,hoh.ovcllttlt orno
mentdcmand,thtrt 1ft llmll<d provlsto111foroddit!OTW exp<ri<na withalrohol ,tobacco,or othetdrup ondart
ffl05!atrisk . Prognm,ared<>lgncdto:
 • promot<nonu!i<Corab,;f c,c dencyprobl<m,{aboutl7tim,ol< .. tik<ly) ... ><V,ralfac -
• hdpyoungp<opledev,lopskillstordu!i<Cdrugs lorsmayocroun1forthi,. Anodolescrnt

• ~.'.:;C:,h< ag< of first us <, panicuLuly of alcohol md • ha•l=bodyv. .. t<ribt1hanan • d11l1

• ha•immatur<<ruym<m<taboli>m,y,t<m>
• •ncour,g< h<Uthy nondrug • lt<rnati>.,, 10 achieving • m,mi f«a th< condition (d<J><Ildmc<) ,hottly afte r
• lt<ml51•t<solronsciou,n<<S(< .g.,athl<tics,achi<Ving b<g!nningu><if g, n<tic• llyvu lnerab leto•ddiction
p,=molgo•ls,•nd • pJ>T<ciatingnotur<) • ismor,vuln<nbletoenvironmrntalotr,c550r,rnddrug
One ofth, most imponmt<l<m<nl5ofprimaryprev<ntioni, "',.ii.ability
education-providingcmlib le. <2>y-to-11nder,1.md in fonna - • ~:;:!:: ,time to develop life ,kills•nd h<• lthycoping
tiononth,hmnfulcons,qurncnofp,yc ~t i>'<,11b,;un ce
U!i<C.Contnrytopopul.orb<li<f,t«ruig<r<:rn,oft<n•wor<
lmporu.nt,.,..,.rchonthe:odolucentbrainha,di,.rov<=l
ofth,,ideeffectsoFdrug>andinmostinsunce,ov<KSti-
thotthebnindev,lop••lowlyfrombacktofrontandi,not
:r:::..~:.!~;J:;!~~:."t~: :-:::::;~,~:'!~~
df,ru.P,rhap,primarypr<v<ntion,fforts,houlddownpl•y
m.atur,untilag,H . ltuk<,ar,othul0to13yun(•lma,t
untilth < • g<o f-4il)lo rth,fron talandprrlrontalcott<xnto
becom,fin, -tunedandfullym.atur, . ll<ca11><1hi>pottol1 h<
theb<nefitsol • kohol•nddrug~plainingthatth<
brain includ es vital componrnaofth< rontrolcircult or
b<ndi:tfdru~ukint:'_";uchl':',r<W:lrdingthan":h"' ·,10 p",wi tch (, .g .. th,,.,n1nlmedlalprrlront>lcort<x , W.-
ciculu, r,ctrofla11>,andlater:1lhab<nul • ) t ha1c<>ordinate,
withyouthha,.,hdp<dapos,monymi>conceptioru;•bout
<><<cutiv,functioning•ndimput.<contro1' . • n•dolu«nt
theb<nditsobuinedfromri>kyb<ha,-iOTSlik<•koholor
is 1, .. •bl< to con t rol rompulsiv< drug us, ifi t ocrun;
drug cons umption.
b<for,th<S< • r<H • «fullyfunctloml
Primary J>K''<ntion •00 invo lvn p,=mol ,kill -building
a,rci.,.,,designedtoprevrntoratl,..,td<i.oy<,q,<rim<nl.0 - Fina lly,.i ud iescon finnth al youngp«>pl< • r,l, .. willingto
accept guidane< or int<rv,ntion from adults tlun from
tionwith a bUYbl<drug,.Exuc~•tt<mpttoinotillrui ..
theirp<m ,,oyo uthprogr :un,;,hou ld b<targ <ted•round
tancebyt<aching,kill,forcoping . lundlingpttrpne .. une
p«rint<r:1ctionar.dg11id.an«tooth<ryouthbea11><tr:odi -
decislon-miling,ronOictruolutlon,•ndoth<rtool, to h<lp
tioruol•dul t prognm,donotworkwithyo11ngp<opl< ." •
youngpropl<•vo idu,;ingp,yc~ti,.,,ub,; Lonc:a ."
Building><lf-«t<<mby,uminingth<rool5of,U>C<ptibility Thegoal,ofuniv,rulprev,ntion.,-,th, .. 111< .. forpri -
to:oddictionmdh<lpingchildrenhandleth<conlu,ion 1Il2I'fP'<V<ntion-toprev,ntordd•yth<•bu><o£sub-
angu ,rndpainofgrowingupin•tox icenvi ronm<n l>r< st>ncn-but • dd,,.. on rntir, popul.otion or community
also !mporu.ntcompon<n<> . ln a broad><n><.primarypr,- not jU>l)'OUth>in th<popula tion. Ev,ryon< is providedwith
v,ntlonalooindudnooci<tolotr.,1<gi<>•11chul<glsl>1lon inform.ationandthe,kill,nec,...r,·toprev<ntdrug•bu><
policyformulotion , • ndschoolrurriculumd,oignm<mtto r<g:mll=olth<ircu rr<nt11><. risk,orag<•tatu,.Bothuni -
pr,,,.,ntordd•yfir<tu,.e vusalmdprimoryprev<n lion<ffortstng<tintuvrnt ion,
1ow,rdnon 11><f'.'Sofdrug,or•kohol
Thoughthe imporu.nceofprimarypr,,,.,nt ionisu nivu,ally
ace<pted . thern-iews<v.th1 .atingth<<ffecti,.,n, .. olvariou,
progr.tm>>r<mixed . Controv<ny a t.ouisaoverth<b<>t Secondaryl'f<!Yi!ntio n
w•ytooccompli,hthi>imporu.ntl<>1'lofprevrntion
Sttond.aryprev,ntion!ittkotoholtdrugn><one<ith2>
Th,Officeo fNotio n.alDrugCon trolPolicyd<>igned• ><tof begun (u.u.ally among non-d<p<nd<nt 110<~) by Laking
principle• upon which prevention programming can be actionwhen,ymptom>>r<firstr,cognized . T hegoalofthi,
based( Tabl,8 -1) 1,,..,1ofprevrntionlstoJ>T<,.,nt<xp<rimenu l,>0<i•ll=rte •
atioruol. or labitu•l 11>< . •long with limited •bu><. from
~:ire;;m;:::~d;?d:~i:o;;,°~;:;.::~:::~ t!~~::; becoming pro longed abu>< a r.d addict ion . Program, " "'
d<Signedtoeducat<>bout,p,cifich<.:dthdf«<> . l,g.alcon><-
poinatoprimarypneventionHth<mos t imporuntlev,lof quence ,,and,ffect,old rugabU><on•family,•nd,omealso
dem.andr,duction. Unfonun otdy .primaryprev<nt ioni>th<
prm-idecouns<ling
1,,..,J thotr<criv<0th<l<ntam011n t ofFed,.-.l,,t>t< , •nd
localfunding. ><rond:,ryprev<ntion•ddsint<n-<n tlon•tr•t<ginto<du-
cation•nd ,lriUbuilding. Dn«drug11><isr<cogniud .•
Early.,oru;<tdrugu..,i,th<s ingl<b<"pr,dicto r oFfutur< numb<rofdiff<r<ntint<rv<n tiont<ch niqn ,s • r<<mployedto
drugproblemsinanindividwtl. " lndividualswho,xp,ri -
<ngag<th<u><rineducatio nalrnd couns<lingproc<M<>th ot
m<ntwithnico tin<,•koho l.ormari ju.ara.b<for< th<•g<of
::1:::,g e ab,;tinence•ndpr0>-id,,kill,1oavoidlunh<ru><
ll ar<four tofi,., tim<>mor, likdyto<xp<riencemojor
addictio nprob lems1hanthos,whow • itu n til they • r<l8or
19. Jndividu.al,whodelaythefirotu!i<Cofth <0<>11b,;t2ncu Drug div,~ion progr.tms (u,;uolly drug C011rts) rout<
until a Ft<rth< •geoFHrar,lydev,lopch<micald<p<n- fir>t-tim< drug offend<rSto ,d uc•tion md r<habiliution
 !l<ugUseondl're.e«Jon:Fl'omCrde»c, .....

Ewlence.a-d Prind
plesfofSubstance.AbusePrevemon
A Addr=_....rolnlP,-.:lo<!m lor..-,obus,i, 1dofined~
(~i-..,.'lt-re,der.rn
l . o.tr,e, J:Ol)l»1lon
2. -"'>«>INels<illll.
pr-""',.;--.a:,m1orN:~""
l FO<ll!oo
ollNels.JOlll'IGl=al-r,lh<>s,<>;<»«lr,hi,;,Ollandlcw~

1. 5"~~""'""'1.de,,ndnoon,.

~- ~fit,l>l<and"'-lrelulll""--""
).i'm<.<,r,;l;,nderiiorr.:,pr- 11lln1ilie>
....~-..-
· ~,ooolb<ndr\l,nd""'f~
9. fmur<N-=or,,wror<>111:bt.:~b,q-

ll . -•~-andfito.,,,,,,,,N:Cf'°"'lo!,r"-O<l.lrUt.u

11. --- - ---,d- r, oro,r•and.-oWDPfl'l t """'-n

12. _ ., _ __ N: nmAct nsl.rndirc horne.Ktool!.andOOt1

1J"'4'<

[ Mlnlltprorrom,tft«wtlr,
ll . Eno.xt~and""""IJ',ip!OIJ..,,,ndpr,lioei.
l<. ~.,,ti/f,ndvckn=t,--~
II . 11'
"'1110rind- p,'Oi!
am,Ol'/tfjyilo!pl,andot\O<"""ftbtnii"""""'-

prognm, instad of jail. Th is ha, proven to b<: uot:fol and ,tswlwo<risl<afdneloping,ubstmceabu,.ord<p<nd<T>C<:

v,rycost -dfectiv,otthislev,lofprn<n tion is,bov,,v,ng,: . Th<S<efforu mayarg,:t,p,cific,g, . grnd<r,
or &mily historyri>hor ,p,cific !iOC~nomic groups
S.condarr prevention i, ,omewhat handica pp<d by two

: ! :":n?t";
1
:.!~~~
that p r<,.,nalh,u
:,; d~c:;~0~;~1':d Bd;:. ;
,. rfromack no wl<dgingt hatthrn: is a -~!:~"11=~~Q~t.~t:
·;ro:t
i1t:
ij<>"'""'""'9""-&t l o!.w'l'l,,,JosooJ~ - -
problem . On av<T>g<it ak<stwoy <n< fOTpar<nl<tom:og -
ni,edrugu5< rn d , bu,einth <iTchildr<n . <>p,ci• llytod.y u
_,.,....,,,__
ch, ng« in ooci<:ty , nd th< domi n , nce of ,Tn2Itphon<0,
rompnt<B, and OOCWmedia TrWl< &mily communi cation
TertiaryP,.,.,..,ntion
mon:ch , llenging.
T,niarypn:vention!ittl<sto,topfonherd , m.og,:from
At.oromplia.ting,crondaryprevmtionisth<l,igphas, - lwl itu.otion , ,bu ... and,ddktionandton:otor<dntJ!•bU>-
th<tim<b<:tw«nlir,tu,.of a drugandth<d,v,:lopmentof <rstoh<, lth . ltrombin ,s drug -abus, 1r<otm<ntwith , tr:1t<•
phy,icalmd<motion.alproblems. Th< lagpt,.... lo rtobacco gi<><mploy<dinprimorymd=on darypn:ven cion . ,uchH
isparticularlylong b<can><it moyl2k<d<ad<s•fter ,o mron< intervrntlonrnddrugdiver>ionprogr>m<. T<rti,rypn:vrn -
b,gi n,m,okingfOT=en:hallhprobl<mstod e\..:lop tion « ele; 10,nd compu l,h ., drugu5<wilh,uch n:l.ops,
B<cau5<mo,tdntJ!U5 <r'Sd<>crib<1h<irinitWu 5<ofdrug,., preven tionm , t<gi<>"
rnjo y,,.bleandproblem -fr<<( olh<rtlmitobacco . whichl2k< , • , "nt<n-<nt" n to p.g < • p<15< 'n • tI<C
a tm<nt
.,, .,ra l we,k,; of U5<to be du i ra bl<), denial and• «n>< of progr,m locu «<l on d<tmcification, ,botin<nc <. ,nd
p<™>l'II.I inrnln<r> bilityto , d,.,r,.,:ro~urnc <5.al ong
with th< l.ogpha « ,mak<th<ml<>slik,lyto lully acc<plth.o t • cu<<xtinctionther,pylh al d<., nsitic ,s di<nt>top< o-
odmonition , ,bout harmfu l , ffeca , pplytoth<m pl e,pbc<>,andthing, th.ottrigg<ru «
Cbs,ic=nd • rypn:ventionprogr.,m,focu,thrir , fforuon • &milyth<n.py (<>p,cially impo ru. nt foryoung<ru5<r> ),
pw...:nting drug • bu"' from denloping in non -deprnd<nt grouppsycholherap y,orruidrnt ialtn: at m<ntinth<r> -
drug=;«:l<ctiv,preventiontargrt,groupsorindividu - pru cicrommuni ti<>
 • •pttificnl>l""P""''n t ionandlifemar12g<mrnt•kill, ;::;:;7._ 1notjuotnttd)tuatmrnt, but only Li million
tom>nLan•I ti nee ' ,ubstonc<>orcom1' ·,
b<ho,i0B(ana•mpl<of1hi>i>th<procrsoingolnego -
lnl008th,MentolHa l1hParltymd AddictionEquityAct
J,.,., Jf-irrag<with a coun.,lor)
wo.s signed into low with the expec tation that it wou ld
. poychophannarologicalotr.U<gi<>lik<m<thadon<main - increas,tr, atm <ntforaddiction. But..,ofmid -lOH,littl ,
1<nance, bupr<norphin< r<plocemrnt, •nd medication, if any change ho., resulted in tr<alm<nl acc<S< . prob.ably
th.ot canr<lievewithdrawal,ymplom,orn,ducec ravlng b<couS<ofth<00<l<x<mptionprovi>ionol1h ,Low.
• promotionofahn.lthylif<,tyl<
• dndopmrnt oF ,uppon and aft,rc ar< ,yot<ms, oftrn Hann Reduction
12-,t<pprogr.tm>
Hannruluctioni>apunntionm•l<Jffthataddr=<>lh<
Aswithtutlotypr<vrntion,indicatcdprev,ntionJ>Tognm> difficultyofg<ttingandk<epingpropl,inm:ov,rybyfocus-
torg<tdq,,ndrntdrugusersandtheniookmor<broodlyot ing on t,chniqn<> to minimize the p,=n.ol •nd ,oci•l
groul""orindividual,who<Xhibitarly,ign,of,ubstonc< probl,m, associ.ot<d with drug us, nth<T th.on making
aim>< or other problem b<hovion. Dr . Andr<a S.nhw,11 . fo, - abstin<nc,cth<prifflllI")'go•l
mer d,puty dir<etor o l demand r<duction fo, th< ONDCP.
One,x:,mpl,ol• hannruluct iontactici,providingcl<m
, tot<,that,urvry,documrnl••nbst>nce -abuS<ord<prn ·
,yring<>toaddiru.Am:rntstudyinChicagofoundthot
drnce •w>r<n<M gap of 76%. Thi , man< th.at 76% of tho,.,
n«dleexchangel , dto a long -t<nnruluctioninth , ri>ky
•=)'N who m<t Diag,w,ri<: and s,a,L5ri<:a.lManual of
pnctic,ofn«dle,harlng. '" In a nolderstudy . apmd_jointly
MrntalDisanl,n(DSM-,)dlognooticcrlt<rl a fo.- a bUO<Cor
dep,ruknceoFdrug,•t>ttthatth,ydonoth=anydrug ~:~:\o/·:;,;~~~::~~t:~ ~~:1da:,1rit:,:t~ •~ioa::
probl<m , (pr<viouslyr<f<rr<dtoa, a n· • ddictindrnial ")
n«dle-,,cdung, dfom can «due, th< •p«ad of AIDS
lndi catcdp«vrnt ionth<rrlor<includ<>scT<<ningproc,ss<>
withoutincrnsingill,gol-druguo,c _H
toh<lpidentifyth=whoexhibit<arly,ign<ol,ub<unc ,
alm><eor behavioral problem> . Thi, i, k<ytoth< currrnt Th<controvenycontinu«o,uth,,fficacyofn«dl<
>BIRT (Scrttning . Brid ln t,rvrntion , •nd R<fun l to exchange . By lOll mor< than 36 .9million,yring<>we,n,
· ,ent) "n "f t've,'nmany,uwc •· P""idcdto!DU,throughl2\n,cd l,~hangeprogmn,!n
theVnit<dSt1te, ."•" lnAustr:ol i.o,withapopulotionone -

=~
-y,,.,tnt<ntoo<U,,,,,,,J;,,rl,,b«taoJ,,.,,t,/f«tc«

~F;::~~;:i:~;~~:3f;:'~"t ~~~~e:;;
1<n1hth.o1o l th,Vnitcd SU.1<,,l1J,yring,,

:;'o~ ::.:' ~o i=<t;o,~dnruJu~~

• r< <xchongcd

7ad,,/,,,:,nt,~ o,.,,Jtr,at""ntfo,ad"'liprol,k'"""" Tu'"""""""''"'for:=don.,,,dJ,.,.,~b.o....,,t',

o>cc«< it. Th ,wit~ =t> ,oci<t~ °""dml, of!,ill- of tl,,,,,..r,1orl,,l,,t,r=l/"'P"!ationaodtoba0in
"'-lanin~«bi.tjf,an,mba,ra,,,,.,nttoo,<r
wci<!ijtl.at""'"'""'''<>poodtotlu.di,,.,,wtthtl,,!,,.,j
o{'tr,atm<ntfr<"lo oil,,, ~1.,,..,.•
Duryl l......_11w ,. .D.• """""""'..._,,,.c.,,.,
,-, ...,_ot.
;=.1~d:i~~::·
~tiivca~:r
... .D.......'"""""",""-'"'"""""'F
j<,i,,,,.,_....,..- ~•Uia»e<
Anoth<ru:•mp leol!armruluctioninvohuoubotituting•
Ext<n<i,.,=an:hho.sb<rnronducl<don1h<dT,ctivrn<"
l<goldrugaddiction fo,an ill,golon,as in m<tludon<
oftr, atm<ntfo,akoholi>mrnddrug•ddiction , andthefind -
Jrulln1<n•nceprogn.1n< . Thes<progr.tm>hov,h< , n,hown
ing,•r<con<ist<ntlypo<itiv< . Tnatmrnt (t<niarypr<V<n-
toimpro,.,th<h<•ltholtheuS<randdecr<as<crim , inth<
tion)r< , ulnin • bstinrnc,o,decrttS<ddrugu0<in i 0%to
rommunity.lnl0ll . .306,3llp>ti<ntsW<Cr<<nrollcdinl,609
50% of case,, a great uduction in crime (H%), and a sav -
ings of Si to$lOfo,,vaySI >p<nt hyacommunity ... m<thadon , Jrullnt<IUne<progmru , r<pres<ning aboutl2%
10JO%ol • llhuoin add iru inth ,U nit<dSt11<,(d<p<nding
De.pit<th=r<sults,fondingfortrnlmrntprogr=,con -
onth,,urv,y )."'- " A>1udybyth, UnivenityolPrnn<ylvanlo
•i<trn~y f.oll,<honofm«ingth< n«ed>olthos,.,,king
loundtha1rompneh<ru;iv,m<thodon<tr<alm<ntcomh incd
tr<atm<nl. M0<1publiclyfund<d1ratmrntprogram<typi -
within1rn,iverouru.dingruluctdillicit-drugu.,l,y79%
callyho,.,hundrul,ofpropl<onth<irwoitingl ist,withm
Oients w<r< al>o five rim<> kso likely to g<t AIDS."
ava:,g,w•itingp<riodofonetothr<<month>b<fon,th,y
Addi1ion.ally,criminolacthitywasruluccdby 57%whik
con :ac<n> trnlm<nt . Only 20% to 30% 0Fth00<eon a wa it-
lull -tim<<mploym<nlincra<robyH %."
ing list follow through and <nt<T tuatmrnt, po>0ibly
b<cause th,yinit i.ollyamefo,he lpatth<iTmootrnln<nble Mmyharmreductiont>ctic,lora lcoholandtoboccoa>< a r<
and tu atabl< moment , and when that moment po,;o.<>,o too wid«pr<od . Enmpl«includ,d,oigru,tcd-drlverprogran,, ,
do« th, hop< that J>T<dpiul<d the action to sc,k help l<gi,Lotingbu,to,nv,foodtomitigot<th,,ff,ctof alco-
Approxim.ot<ly 13% ofthoS< who do no t com< back commit hol,r<gulotin g th,purd,...,ofakoholandtob>cro . and
suicide. Nation.ally, lO million American< :,r, «tiffllltcd limiting•dv«ti,ing.
 !l<ugUse ondl're.e«Jon:Fl'om Crde »c, .....

Challengesto Prevention
legal Drugsin Society
In l\l96S...gnm broke theliquor!ndustry's><lf-impc,><d
montor!umont<l<Vis ionadv, rti,inglhoth.!b«nin <ff« t
ford,cade,,andby20071iquorcommerciaisw<r<common
Thehypocri,y,urroundinghllrd -liquorad,.,rtisingde<>not
gounnotic<dg!vrnthefocttha11h<r<ehll<nev<rb«n a ban
agoimt•dv<rtisingbeeronTV:Th,p,rva<i,.,n ,,.,olbttr
odvertising•ndindignontrnitud«tow•rd•d,utising liquor
p<rp<tuat<5themyththlltdrinkingbeeris,aferthandr!nk -
inghlln:lliquor.Th,fact,,howtha1mor<ca>«ofcirrho>is
? oltheliver•reduetobeudrinkingthantohardliquor .
Th<,ocialandh<althproblemscausedby a kohol•bu«c
tobacroabu.., . and,toal<ss<rext<nt,pre<erlptiondrug
~'ttdlt-o:d1o•g<J"<'t'"""""tfjttfati•,.J,, <l•t<llt°"i.l<n<toj •huKar<fargreat<rth•nthOS<Ccausedbyill,gol<lrug
lfll'.hq,,ul«~onolo><O<tlt1/«1I'""
•huK.lnrec,nty,andrug-abusepr<Wntion•ndtf< atm<nt
c,:,0 12eoo.....ra0-~~.., .... u,.rty dfomhll,.,incr<eamlth<<mph:i.si<on>lcohol•ndtobocco
• bu.semdmoslr«<ntlyonbehavionl•ddictioru;such><
Thes<l<gol-drugprn1'ntion t.octicsrrc<i, ·e!iOm<cr!tici,m g:,mbling ,eoti ngdi!iOnl<n ,md« xu•l•ddiction
bec.usetheym.oybemiY.pplied . For<nmpl< . 501Il<on<g<ts L<galdrug,suchastobacco•ndalrohol•rewidely..,,Ul-
<V<ndrunkubeauseth<r<eis•de,igruot<ddr!,.,,,wh<I<C a> •bl<andrel<ntl<sslymarktt<dll>ingw,ll,cr:oft<dcampaigns
mothuusu•ugm<ntsmethodonewithalcoholoranother thlltportnyth<lun, sophistication,•ndcamarad<ri,»sod -
drugtotrytog<tincreosedsedatingdf eru, thu,;promoting "'<dwith the><product<.Establi,hingbnndr<ecognition•nd
h.,. ,i<rdrugu><. lnadditiontoneedl<<xchang<, hllm loy:,ltya1m<arlyag<isth<go•l;J<><Uffi<l " •ndth,
:~~i:ra:ticuand proposals tha t h..,., proven contro- Budw<i~lropareca«ic,xampl<sofcartoonlik<chara<: -
tusthlltwendesign<dto<ff«tivd ytarg< tyoungpot<ntial
• =ponsibl<-useeducation -t his•ccq,ts!iOm<levdol ,mok<r, a nddrink<n . Eachy<>r•lcoholcompani«<pend
aperim<nt.o l or!iOCialu.semdoutlinnw•y•olusing mof< than S~ billion and tobacco rompani<> mor<e than
lhotminimizedangrn; $8.Sbilliononadv<rtisingmdpromotingth<irproducts
• decrimim.li:E>tionorl<goli:zationof•ll•buseddrugs through giv<>w•}'>, coupon, . pnmium> . and promotional

. permittingoddictstotot.ollyd<>ignmdm.onag<lh<iT
"ntervent"onmdtru'1Il<nlprocesses
•nttFedaaldrugpolicy(nou«ofill<g> l drug,).Clu.ng<>in
lows•ndpo liciesoddr<>oingrum nruluction•reslow1oma1<
rialiubeaUS<many<lectedoffici•ls • void•ppearing!i0flon
crime•nddrug,.Advoca~ofth<"WaronDrug,; "l.,. ,thot
myrnemptatdecr!minaliutionorl<g>liutionwouldintro-
duc,th<landol•mbiguityabou1drug,thatprev.ti led!nlh<
1970.•ndcrttt<confusion•boutwh<th<rdrugUS<i>unde
,inbleo,hannful.ThisOMumptionis,upport<dbyther<>ults
olth<lOllN ationa!SurveyonDrugl' ><andH<.o lth,which
,how<dlho1abu>eoi.,ubstance,in=oc=•ll1"'1"'lo
tions when th < pucq,tion of drugs u being harmful
dec=ses .'' fum>ruluctionisup londindepthinClu.pt<r9
"/h0Jo,,.rol,ofliu,..,j,otol,l..,tol,.,,,,tliostod1,rdn.gr
al"""_Dro,~;,al,.,~o,,~olmkpot"""'•""tliot
b.tl...,,com,tol,,li,,,,,d,at/c.,n'ttal;,o '"l,.,,,J •• lt,'uie
cl,,nuco/ ioto "'lj o..l ,~II"""'"' i• rm,wl"lj
___ "'4_.....,
Tiiat;, , ti!Jwliotl,oclto..,Jb,1;,,,,;._·
~~,::~n::".:~:
:~~'7'
.:~i::::i~c~:~
lionper) = •. •ndtobacco<al«exc:ttd SIOObillion .11"
P=rntiongroupscanl,arn•lotfromth<waythetobacro,
•lrohol, andenergy.<fr!nk rompanie,succeosfully tari;<t
•g•••ndculture-sp<ci!icpopulo tions.Theyc•nrq,licat<
thos e commercial <ucc,,.., (o r a1 l, ast level the pla)ing
- field) by crealiv,ly cu,;tomizing th< prevention me,uge
When M.. sachu«tts <pent money producing md •iring
mti -, moking m=ag<> in prim< tim e, cig:,r<tt< u,.e dropped
dramatically.
- PhillipMorris<p,ndsmillion<inprintmdbroadcastodvu -
tisingforitsW<bsit<,whichprovidesinfonnation•boutth<
danger,of,moking . Cynic<belie,.1'thatthi,is•tactic to
· ploc•t<anti<mokinggroupsintothinkingth<r< i,l<><ofa
ne<dto produc,po,.uful•nti<mokingm<><ag< <beause th,
to baccoind umyi ,"add...., ingth<probl <m"ATV,po tpro-
duc<dinl\l97by1h<,ta1<ofC:.lifomialho1featured•nico-
tin< addict smoking through• ho le in hu throat had •
powerful impact on Orq;on •nd C:.lifomia ,mok<r,--;an
impactthet<>MCco industrywouldrathernotsurepe at<d
M•nuW:tureroofover-th<-cou nt<r(OTC)andpreocr!ption
drugsspendbillionsonadvert i,ingand1111.rk<ting.Th<se
efforts promote the roncq,t that th<tt is • chemical
1'•"1;)' .l<id...i,; °' '°' U5!""'60S
from2008-.l0!2 "'1 l2.l !,,llion. Jlw
"""""'" "'"""'""'""'"""'"'"""1
from,efr .ll'<olt<on.lro,,·ool;,."1;)'
.M.tO~ E., ~.l "" lt"'l " "" "'l"' !Ld.
"' °" """bJ an oddir1,,,1,1J 1lJ0,1 ot
"'"lf 20! 7.

wlutionfor•nyailm<ntordi!iromfon,panirul•rlypain mus t b<taught , or>tl <>.Stb<remind<dof.th<pot<nti • l <lEi-

and cr<>.t< • ,oci<t:d dicho tomy b<tw«n occ<ptabl < md ger,;of,moking • nddrinking. Th< r<lotivelyhighnumb<rof
unxcq,t>b l,drug,.Thi, vaiu, incon,i>trncyb~cyni - l« mwho,mok, todoy i> du,inpanto•n•bs<n ce ofth<
ci,manddisb<li <fo l prevrntionm...age,in:ulo l<se<nl5md kindofstrmuou , prevrntion,fforuconduct<dinth<bt<
young adult,_ II p=tion m<>,ag<Sare not coMist<nt md l 960> •nd 1970.t hat includMpublicoavice•ds , limi ta-

=
acrur>t<,lh<yar<ror<lydfo:ti, ., tiomontobo.ccobro:ul cast•dv<rti>ing, • ndhigh<rcigar<tt<
tax<S. T ·ng10baocolow<ncomum ptioff >tax· ncnc"-'< ·n
Conclusions
"'°"i,hlamco'1t:,,,.,Jthat~•mpiri<: ol ,.,,ord, t'ai.1,
~7!:: ~u 7c:;,d~;; ~:~ n ~t ::,.:;;;:::i;:;
Mo<li,ro/ AIIGat<>.·oyDrux, : Porabl<>fo rO.r Tim,.<pid<m i-
to.locum,nt,
iy>iji
co•!f'>'im'•lo.i:i
•t<mtooloo""'fro,,,,our ologi>t md author Dr. John Newme,u ,ugg,,15 that the
US.lruii"""""/'<"'mm,fforn,/.,,our,ffommoolwit lJnit<dSut<srould!i0lv<illdrugprobl em,byl<gaii<ing.
ut<1,.,,.,n1
_'Attht""""'"l"-"•""'"'litlwkd,tl,,,t our taxing. • nd diocour aging no, ifpr<vention m<Magn to
,ct,""'"""~ · ••d.,;"8tl,,.,t,olotb.tt<rthan""I disrour>g<OO<W<r<ad<qn•t<lyfund<d ...
"'"'Ii ti,,,. ot oll. Som,M'j"""' ""..,~ l,a., b.tt<r tool.ol
oordisf<>"'/ · Thethirdr<aiityi,th,factth.t a llprev,ntionc • mp • igns
bttom<progr, .. iv,lymor<edifficult . Pr<,., ntiontechnique,
.......c."""'"""'
·"·o............,.. ..,..,..or aremor, , ucc,.,fulwhrntheyr<och pro pl<who a r< ru dyto
li<tm - thos, a lr<adypm:!i>po,<dtohe<d wa m ing,. Aft<r
Ontofth,re•litie,ofprnentioni,;th.otth<r<i,noquick · 't'.t , ucc,..,,. tb<rom,shnder toprn<l ra l< '<p<r ·nto
lix.Modnnrn<mp15 tom:luce,mokingb<g:,nwilhth,fir>t anypanicubrg<n<r:ationtochang<•ttitud ,sand b,haviors
h<>.lthwarninpi>su<din th<mid -19'50<. bu t ithHtaktn
Finaily,JtO•ingl < •pproachh.asb<rn,howntoworkconsis-
mor<thmhaifa«nturyforantismokingdforutob«om< t<ntly, proba blyb< caa>< th<r<>r< "' manyvni •bl<, !hot
ubiq_uitou,. Knowl<dgecom<>first,th<n atti tud,schang< rontribut<to,ubstance •bU><and add iction . Mor<impor -
andfiruollyp ractic<>. Th<S<chang<>C2I1tak< a grn aa tionor
tan tly, the comtantbombardm ent ocro55 ailm<dia,indud -
mor<>nd canb<profound; · no,moking " inpublicbuild -
ing «>ci,,l n<tworks , giorifyingdrugu,,d=mitiz<>)-OUng
ing,,re,taur:onl5.andoffic<> wa> unimoginobl <• f<wd<eade, propl< to r<p<titiv< pr,v<n tion m<M>g<> uni<>• they a r<
ago. Today.acrordingtoth , Am<ricanN ommok<n ' Right,
imogin •ti v,mdf=hlypr<><n t<d
Foundation, 79 .~% of th< U.S. popu lotion liv<S wh<r< b. n,
on,mokingin"workpl oce,, rnd/orre,taur:on" . •nd/orbar,; Funding
h•v<b<<n <nact<dby a , tat<, rommonw <>.lth . orl ocai bw. "
F'Kv<ntioniovastlyunderfundedwhrnrom parrdwi th th<
Some loc•lgowmm <n"•"trying toat<ndthos,prohibi - ro,ttosoci<tyof a lcoholanddrug• bus,rn dth,billion,
tiono to outdoor location,;. Mrny compmi <> offer ,moking - manu!.cturu,;,p,ndontoo>cromdairoh ol adv<rtising . ln
ce, .. tion prognm, to their <mploy= c md ii they cm \ qui t a soci<tyth. tv:alue, fre, rnt<rpri>,,p=tion,f!orudonot
lheyarefirrd maOr lorg, , umso f mon cy- butth<ydo ,,n~ Lorg, , umsof
Th<o«ondrulityofpuv<ntioni,th.otthtjobi,IKV<r mon<,'. Th< basic m...ag < ofpr,vrn tion i> ,impl<: don)
rompl<t <. Each yar • r,ew group of childncn <nt<r <l<m<n- ,mokr . don\drlnkto<x<:<M . and...-oiddrug,( a ndrom -
tary <ehool, middl< <ehool, high ,;chool. • ndcoll<g<,who pul,iv< b<hlivi<>B) th.t h.ov< long -trrm health • nd soci • l
 !l<ugUseondl're.e«Jon :Fl'omCrde » c, ..... & 17

ronKqutnceo . e,p,ci•llyifyouu<egrn<ticallyandrnvi- While the ral<S are f.oirly comJ>1,rable•mong Whit< . Black,
romnrn1111yvulnerabletooddiction.hionol a v,ryucit - mdHiopanic Americans,thedi,propottionot<lyhighurat<,
ingme..age,andi1d0<>notpr0>uk<th< kindol"r.tlly o/Block•ndHiopanicAm<rican,inpri,onsfordrug -nlat<d
'round " f<TVOTCTnledbymE1y•c:tsol>OCialin j u•tice.Th, off,nse,,ugg<>t5<itherthatth,.,<thnicgroup,trndtofall
publiciounint<r<>t<din pa rticipatinginprevention activi - preymoterudilytoth<n<gati,·e • •pec:tsoladdiction • ndlor
ti<>. infonruotionforum,; a reoftrnpo<rrly a ll<nd<d.and d<>.ling,orthotth<y • re Lorg<t5olgreat<rlawrnfor<:<m<nt
,moking-c,....tionda,=diYpp< ., fOT~kofinl<r<>L dfom.B~kAm<ri can,withdrugprob lem,bave • higher
'J,J,., a person· ,· ncf · OT. ,uff ' ng~ued · om!·, r>.l<of ' ncan:<rat'on a ndrec ·v,trnlrnrntlhroughth e c ·m -
prev<ntionoctiviti<>ar<nothighonhioOTherto-dolist inalju,tic<•)'•t<m,wh<r<a,\lfhit<> • remorelik<lytog<t
probation a ndrec<ivetrutm<ntlromm<dicalrnd,ocia l .., .
lti , crucialth>tpreventionprognm,areavailoblethrougb-
..-ic:<progr.tm>. About33%oltho,einpri,onfordrugcrime,
outap<T!i0n~life~au.,, achagegroupho,it5ownn«d•
•reB~k,•lthoughth<yrepn,rnt j us1\2'1',ofthepopula -
Prevrntionprogr=,,houldbe
tion;just26%oftho,einprOOnfordrugcrim<>areWhit<,
• culturlllly,pedfic •lthough they repre,rnt mor< thE1 7~% of the populotion .,.
• ag••pecific
• imagin>tiv<
• non -judgmenulornotpruch)"
• acru r.tt<andhon<>t
• grn,rou,!ylund<dand,uppon<d

Alcoholics and oddict5 are !ndividua~m< live in th<

inn<rcity . ,omeinthe,uburbs,andsomeindowntown
Patternsof Use prnthouse, . Theyinclude,omeolth<mo,t,kill<d,talrnt<d,
intdligrnt, a nd,ensitive!ndividuabinoursoci<tyPh)'si -
BecauKdrugu., • ffect5<V<r)'Oneinourculturedim:t lyOT ciansare..,likdytoh<addict<d..,thegen<ra l populotion,
!ndin,ct ly,fromcrodletogr.,ve,examiningthtpatt<msof olt<ndueto,lr<S5 a ndacc.,,oibilitytodrug,.Th<y a remore
UKinsoci<tyby<thnicityandrulture,,ociald, .. ,.ge, lik<lyto • bu,epr<>eriptiondrug,r.ttherthanillid1,ub-
•ndgendermak<,itpo,,ibletodeoignpreventionpro- ,,.nc<>. "' ln1<lligencedoe,notprot<ctoomeoru:from
gnm•tbath aveabetterchanceohucce" • ddiction. MembusofM,ns.o,ahigh -lQ50Ci<ty,aOOhave
• reiati-,-.lyhighrat<oladdictiona,dogUtedhigh -,;chool
UsebyRaceandC lass stud<nt5 . Membusofth< Americancl<ti!)' • loobaveahigher -
Addict5 a reoft<nponrayedinthemedia a, <itherinner-city than -av,ng< rat< ol a lcoholism; <V<n nun, have had •
dweller, who • re weak, bad, stupid, crazy, immora l. and prob lem with prescription ,edativ< abuse . Whrn ,omron<
pooror..,thedisenfranchiKdwhohovenothingbutdrug, u=p,ychoactiv,,ub,wice,,th,yanl i,bletoaddictiv<di,-
inth<irliv<> . Th<rulityho,lill l<todowith,uchponnyal, ...,,.gardle .. ofth<irrac< . claM. orth<regionofth<ooun -
WhrndruguKisstudiedon•tegioilllba,io . thef.oct5show ~~whichth,ylive . Addictioni••n<qual-opponunity
thatper-capiLaus,inrunland,mollurbanareui,,qwilto
•ndinwt11tinst2ne<,moreth•ntha t oflargeurNnareH
The2012NotionalSur.~·onDrugU,eandH._.lthlioted
"M~40-pli,,-'l'a"of<>/'<riM<,trmlilliioddict,
Rhode bwid . Or<gon, AJ..,ka . MonLan>. Colorado , and an.lolcohol.:,lia,con,;,t,nt !lj.,,Jco,.di,,~
Vermonta,th<,Lat<swithth e high<>tillicit-drug-usepopu -
>houoi
""that tl.;,cotrutrophic .,,,dk,,l d;,o,J,,
iationag< 12andolderon a percapiul,..,io. 11 Andwhil<
5on"l"ol-oppo,w,,illj<Uolro'j'r ·
one -thirdolth<home l..,are<>tim ,u<dtobave a drugor
•koholprobl<m,theyrep=tonly 5%ofth<oddict<d U.S
Da,
..,,I....._......_D
..""""-...,,,.,,c.o,,, ,_ot
popuiation ovenll . Whrn ethnicity,.... used., • ma,ure,
th< diff<t<11<:ninover.tll druguK (licitandillicll) were Use byAge
minim>l,althoughth<uKo f ,ome,pecificdrug,iohighuin
OvuthepastiOy<an,oneoltbemostimporuntchang<S
C<Tta'n<thn'c . rultural,econom'c,md,oc' lcommuc·tics ...
indrugabusehnbernthegraduallow<ringofthe•geol
ln2012cumentillicit-drugus,byth=llandokkrranged fu-..tuse( T•bl,8-2) . Thioioofpartiruiarconc <rnbtcause
oneofthemostrel iableindi catorsoffutureoddictionprob-
::mA:,i:::i:i::o~~ -::: ~~~~m;.;;:-•~:~2::; lem, i, ,.rly-onset drug us,c . An annual ,ur.~- by th<
•lmostdoub ledsinceth,1008,urvey,w<r<oonduct<d . Th< L!ni>-.r,ityofMichiganfoundthotfrom 1991 to201Jthe
f>l<>ofillicit-drugu,e in2012were8.J%fOTHiopanic,, r<e<nt(pa,1J0da)'•)u,eofmorijuaruoby<ighth - rndt<nth -
9.2% for Whit<>, ll.J% fOTBl•cks . md H .8% for per,on, gr,du,ho,almost doubled (<ighth1!rod,,.fromJ .2%to
<pott ' ngtwoormore<thn 'c'f<> ." 7.0%. t<nth -gr,d.,.from8 .7%to\8.(J'l',,andtwelfth-j!rad<n
 from 13.lfli toll .Tl.) . All th rtt•gegroup<havedemo n-
Awra,eAge(lnyurs)olinitiationol sln. ' 'nc rases"nrecen tn :; mause!nthepastS yur,

,., ='r-~t~~
-·- ••
-··+
:::~e:;:,~;,~ actllllly dem ...ing ,inc-e a peak that

Another measure of incre:,sed use (a nd possi bly morte-

11' 1/I 16.1 16.'I strident law rnfOTC<m ent ) is that the pe=ntage of male
=~~t"''.ing~_it _iveformydrugucep t alcoho l is60%

Although the numbu of Americans l2 and older who us«!

illicitdrug,inthepBlmonth(l3.Bmillioninapopulation
ofl60million)may,umsmall,theli<CuKrshaveanexag-
gentedeffectonalllndsoF>Ociety<>p eciallyinregardto
econom"c !OM, ac 'den<>. as,aul<>, su'cides, c 'me, and
domesticOTothu,-iolrn ce

Pregnancyand Birth
Overview

-~~==~,i'=t~X'~:};::~
P''/1"'""'~-
tl,,r,or,propl, ,.,1,o,1;,/"'1,1i,,.,,!aiiw,-ro,l,;,ld

1t";,:~of':":,;:/:ik"
~:,:;;t~1;::,.,::;
Th,h,oltl,of lx,il,t1,,..,t1,,,,nJtl,,d,ilJ,l, ould l,,1I,,
prim,,"!foc"'of~a1- u, p"9""""~-",.,llto,,«t,"""•
~ntali~nwtioo o""'til<litO
suJ'li<:itntprmatalcar,.,,J

II IOlS(l,4....,)
:cr:,;;~z7,;.,:~hd~o~:'i~~t-
~
"""'1ll,,._,...., • .D.,.... _ ., ,,,,,,.,,c,..,,_ Molloo!,OO
...,,.
iii«~

-
Tobocropr[dJ(!>

Mond"'["4....,)
Drugabus,duringpregru,ncyoccuBinwomenof allethn ic
and socioeco nomic backgrounds . ),\o,t psychoactfre sub-
s'1nc-..ca n beharmful101hede>'< lopin gletus . Acrordingto
theNationallnstituteonDrugAbuse (N IDA),forpregru,n t

-
womenagel 5 tol 5. 1!!%ofinfantswueuposedtoako-
....,,.ili«<tt(
holat"'metimeduingth,ninemonth,ofgestation . lhe
lobocropr[dJ(!> highestuposureduringthefiBttrimesta.lnaddition . i .5%
wue uposed to cocaine. 17.i% to marijuana . and more t han
ll% lotobo.cco. ''°' Frtalalrohol,yndromt(FAS) is the
llond"'~milm)

-
:;~~7':~:::i:":nb;::\t:: =:e~e lnding cause oF
....,,.ili«<tt(
Tobocropr[dJ(!>
~!:~::~:.:i~~~= :l~~:~:;
i,::::~r::it
all pregnant women admitting to <0me illicit-drug us,
10.0% to alcoho luse . i .'4%to bingedinking.0.1! % tohe avy
useofalcohol , andl 5.J% tosmokingcigarett<>.Examining
the ag<>of the pngranl respondents showro that women 18
tol5yarsweremorelikelytha npregnanttern, 15 to\7
y<n<and women M 10 +'I to have used illicit drug, or
smoke<l inthepBtmonth (Fi gure ~) .''" ·...
Th<National>Ur,,~·onDrugl',eandHa lthreli,.oncon -
fidrntialsell-di>cla,urelor !<>data. whichhasthepolrnlial
to skew th e results because pregnant women may not be
forthcoming in ..,, -...ling their us, of drugs. and mEl)'
women in the early stage of pngnancy. when ,ubotmc<S
 -~
!l<ugUse ondl're.e«Jon:Fl'om Crde »c, ..... 1 . 19

Aftud,li,,ery iti, thme tirn<> mor< oootiy to car< for•n

Akohol,Tobiw;<;o.andDrugUse "'J"'5<din!.ntthon fOT>nunu po,«!in!.n LAdditiomlrosts
b"fPrt8n.ancyStatus-200'l forpro bl,moincurndby,ubs tmc< -apo,«l in Wlts includ <

Hospitaliz.ationforpr<Iruttun: $13 5,000

drug-<xpo,«linf.ont
Halthcar<Ceo>t,,fir,tyaroflif,. $6-t,102
binhw<ight<l.500gm
Halthcar,oo,t,,fir>1yaroflif,. $l3,l06
binhw<ightl,'IOO-l;499gm
Halthcar,oo,t,,fir>1yaroflif,. S9,J03
normo l binhw<igh t

~•o,iu<MI 1. ,otfi,,.an,1.,.on,1,n""""'- •.r.,,,•'-'f""-'h ..,,.

,,.i.,,.,;.i, _4n,g..,_p,,,1k.io,lyo{•lroMl_ l,.,w:l,hiplarll.an
du.t1o i rot,1"Alrn"""" Tot«<q,< k,,t rorl,l,i<<il""'" ' '"""'"'r.
• .i11<h<1«n"'"'""ly,lip\<ly i•r'-'rl,iol1t1..,.,tt "

ru,,.,th,mostdanagingdf,ctonth<f<tu,.maynoty<tb<
•w.r<th.otthcy•r<pr<gnm L So.althoughth<daLodrn,on - Histori c•lly. th<<ff<ctsoldrug,md a koho lonpr<g rumt
,tr,t<an•lmninglyhighincid<nctof,ubstmc<"-'<bypr<g • womrn a nd 1h<iTf<tu«,rutv,b<rnpoo rly~rch «l•nd
rumtwom<n.th<numb<noouldactu•llyb<muchhigh<r.
Dngoing>tudi<>conduct<din'40,Lot<>byDr.lraJCrut<Iloff, :~:im!v;~ ;ti:r::1
:!':1~g~=~
•p«l ialrici>nandth<pr<>id<n t ofth,Childr<n'>R<s<•rch tmy . mostlll>.tm<1 · ' ·•·,·,.,..,r,.-<d>tm<n .... ., D,mag
Trutngl<,d,monm•«muchhigh<rrat«of illici1-drug . •lco- toth<f<tu,du,todrinkingrut,b<rnr<eogni,«l,ine<
hol.andtoh=ou«bypr<gnantwom<na,;documrnt<dby m<irnttim<>,but••p,dficdin ical,yndrom,,FA5,,....not
id<ntifi«luntill973. "" Byth,1980oi nt<r<stm dr<«.0rch
:;;.:~~"'d';.~;c ~ti:,;;i«y w< mu,t a.ggr<Miv,ly onp,rina,al,ff«tsoldrug,incr<Ca«d,a,;didfondingbyth<
N>tiorutl lnstitut<onDrugAbu,<,th<Natiorutlln,titut<sof
Akoholu«duringpr,gnoncy H<alth, a ndoth<rgov<mm<nt•grnci<•
• H1h<numb<ron,au«ofm,ntalr<U.n:btion
Whmadd,dtoth<norm.ol,ttt..,,andth<m<dicalrompli -
• H1h<oingl<most imporutnt f.octorin lutur<subs tmc <- cacionoofprrgrumcy. • busing drug, md • lrohol puts •
• bus, problrnu in 1h<in fants<xp<>Sro woman., ,-·,n highu ruk of m<dic•l md obst<tri cal com -
• =ultsinchildr<Cnwithm >v<r:>g<1Qol85to95 plicatiom . S-om, ronditions •ggra.,.. t«l by drugu., indnd<
• H»oociat<dwith80%ol • llout-ol -hom<plac<rr1<nts., •n< m i>, S<xi.Wly t=smitt«l di"' •- (STO.) . di>i><t<•
high blood pr«,ur<, n<nrological dairutg,, wn k<n<d
Dr. DrnnHEmbryofth,PAX!Slnotitut<cakulat,sthattth<
immun<•yst<m,andpoornutrition.Th<ri•koFinF<ction
polrnti>lrostof•,rnbst2nct-a:po,cdchildcouldb< ,uch H h<patiti• C, mdocnditH, and HIV/AIDS, •I""
<Xistsforpr<gnantwo<rutnwho:rn,inj<ctiondnlJ!u"'rs· '"
P« -binhandinf.oncy
E.ariychildhoodyur,;
Elrn,rn wyochooly,ar,
;t~:t;/:~7'4,"~l!,":~;"~.!~~
alotof"""'f•=· lcom,octdl,,p,,~wC. r,,liodn""" '""'
S«ondarymdt«ny,ar, STI:l,. Yoo1:.noov
. Id"" d"ri"li all'"~ P"9"""";,,·"'""I
cliilJr,nar,o/ftt:tdTl,,ofl,,,ff,ct,-,tillj,i,ip;c,,ll.jo/f,ct
Adult~an !h,.,.'f""l:.noov. lt","""'™"tilha,,,to!;,,..,;tl,·
,..,..,_......,.,_,.__,.,.
Eightypae,ntoFchildunwithHIVinthelJnit<dStat<•
w,r,bomtomoth<rswho wer,inj<ctiondrugabuon,;or
.,xualpartn<rsofinjectiondrui;abuS<Crs.Thelifrexpec -
,.mcy of m infant born with HIV i, l,so than two )'UH . If
u idoth)midine(AZT)mdoth<rpr<>erib<ddrug,n<us«l

~; ~: :•:::~::~~ :";S,::;t:~~ :;: r;1::"';;·t:!

i=cautiom . paniculorlythedrug,,n<notu.ken . th<I<Cisa
15%toi5%infectionrat< .1" ·'"""' 1nund<rdevdop<droun -
trie,with l<Mace<55toAZ T andothadrug, . thatm<jump,
lo 35% to -Kl% ."'' A pr<g,unt addictS liFntyl< is <mOtk
and ,h, usually 112>had no pumtal car, or medical int<o-
ven tion prior to delivay.
Awo11UJ>S•g<,r<gndl<S00Fdrugu.., . rouldalsoputher
infan t atgrttt<rri,kofromplicotion,b<c• n .,apr<g,unt
adol<SC<nth2snoty<tdenlop<dphy,; ically. <motionally .
orb<rulvior..:tly. •~1... 10..101

Ft!tal andN eo natalCompliaition, 11,,.itwlupi•t~i,prou« td.,.W pla<<n< ol!>amt,,.~k ~

""'"'""'""""f• l~ tt.!.l lp, y, ,._.,.,dn,pbn<><~dt~
Wh<n>pr<gnontwomonu,up,ychoactivedrug,,iti,dif- pwuat-.-,1t.,,-rt,,anJoff",<Mftt"'""'""'ga,1,,1y"""''"'""" ""
~::~::;:=:~i:,~~:!: ' o~<::;:~~l;::y~~:;
drug,,heisuoing.Poornutrition.blood -borne infectiom
>Ir<.. from domestic violence, •nd STD, from high -ri,k
b<ha..-iorscanc•u«mE1yolth<frtaloidedfect5 at tributed
, u.gecI<Cat«>riskofabnormalbl«dingmd,pontan<ou•
lothedrugit><lf.Although•nffidentr=an:hh.osb<endon<
1o idrntify1h , dir<ct<ff«tsof, .. rion>drug,,th<o,.,rall
a!x,nion . Th< third trim<>l<T(fin•I U ,..,,1<,
ofpngn.oncy )
inc lude, maturationolth< f,tu ,a ndpnporation for birth
,p idemiologyi,oomewhath•rdertodefin<
Powerluldrug,,uch .. huo inorroc,inecancauS<pnm.o -
Once•p,ychoactindrugcroo«•themultip l<celllayusof tur< birth md phy,;ical add iction in tht newborn . Drug,
theplacrntalbarrier(Figur,8-J),th,f<tu•isexpo,<dto hov,,uch a riagnifi<d,ffectonth < f<tuothroughoutpr<g ·
th, .. 111tch<micalsthatamoth<Tuli<C, . Th<plK<nta l bar- 11,mcythat a bstin<ncefrom•llunnec,.,.rydrugexpo,ur,i,
rierismor,porouothonth<blood -br.tinbarrier,although v!taltodelivering•h<althynewborn
theblood -br.tinbarriuisnotfullydevdop<d inth<f<tu,
until.,,.,,.lmonth,ormor< a lterbirth . AFt<rthtbal>yis ·1"",dri,,k,"lll,,w,,nJ.,,J4~1,r,o{'.,;,,,Jm1ji,J,,ni
born, many drug, pa,. into a mother> br< .. t milk, further
apo,ing a nursingin!anttodanguouoch<mi cals ~~'.:"~'=:
~:;.~~~t/;;'~~S::"l
alool,;ol,,,l,,a,t,o,dl,,,4lni;,,·>lj</""""',,Jl_,,,Jup
Bean>< ofth, !<tus~ md ,u!=qurntlyth< in f.ant ~ meu.bolic
,h,l,,,dpro;,ctil,..,.,,;6"8;'1,,,k/,,ttl"illa '"l""F t fo, oboot
imm.oturity. <>.ch,urgeofdf,rucau,;,d~-•nydrug,1hat
amontO_Sl,,l.,Jto,t.:i~illtl,,l.o.p.:talwliJ,/...,,,,k,,,,J_
themotherin jec t5,ing,,ts.,norts . or,moke,;mo)'b<pro-
F""'"9'tlirutof,,,,h,hoJtol.,,,,p,«Otl,,,api·
long<dinth<l<tn>
Th<p,riodofmaximumFttalvuln,rabili tyi,thefirst U
w,eks. During this first trimester . devdopmrnt rnd differ= - Th< immaturit)' of th< f<tu,, metabolic ,y,;t<m •l>o can.,,
Wltion of cells into fetal limbs and O'&'-"' occur . posing th< drug, to mnainin the f<tu,fo ra long,rp,riod rnd in higher
gr<>t<St polrnt lal rak to O'&'-n d,-,elopm<nt . B<c>nS< th< roncenu-.tion, than in the mothu . Th, problem,; c,u«d by
crnu-. l a ndp<riph ea lnervou,,y,;1emsd<>'<lopthroughout !etal druge,q,oour,ext<ndb,yondpr,grancy.m.onybobie,
the pr<gnancy. th< f<tu• i• vulner.tbl< to nrnroiogical <Um- n< born with rompromi,.,d immune ,y,;t<m>. Definite
>g< whtnev,r tht moth<T u,u drugs . Th< ,econd trim«t<r symptoms oFn,oruital withdrawal, intoxication . and devel -
(w«l<, IJ through H) involv« lurth<rmotur.ttion a nd oon- opmrntal o r learning dtlay,; have b<rn attribu ted to •
tinu<dvulnerabilityofth<ol)!m,.Drugexpo,ur,Olthi, nri<tyofdrug,,indudingaloohol. 101
; g ~~5-i Jll[f[ffllllfl~l i [~a'
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ln•dditiontoFASrndo 1h<ralmormoli1i<>,lh<r>t<ol•ud• pr,ma tur< binh (cith<r by wright or by g<>Utioruol ag<)
d en infantdeath,yndrome(SIDS)i,gr,atlyincre•sedif <>p<da lly when the mother i, • habitual u.,,- _ El<>,.t<d
a womandrinkscitherwhil<pr<g,untorwh<nnursing mat<molandp lacen <albloodpr=ur<cm , inrar<~
Astudyinvohingthelr.di,mHa lthS<r.ie<fourulth.otpr< · caus,thepb.cenutooep 1n1<pr<maturelylromth<W:1llof
vention,fforuinth,lormola,i,itingnun,whoh<ljlm theut<ru, (abruptiopb.c:<nta<), r<5ultingin,ponunrou,
moth<nwith•drinkingproblemdecrttscdtheincidrnceof abortionorpmnotur<ddhuy '"
SIDSby80%
Acut<ly el<VOt<dbloodp=•ur<cancaU><f<U.lstrok< . F<UJ
TheN • tiona l C,nt<ronSubsunceAbusearu!ChildW, lfare bloodv,..,l,inth e brain a r,, ., rylragileand cana,;ilyb<
alongwithth e Cent<ronAdd ictiomandSubsunceAbu.,at
Columbia Unive,,;ity n,i., conc,rn,; • bout risks to children
~g<dr~ ~""'."ur< to coc;ne an_d p>.rtic:~rJY •::;~<1
·
whos,parent> a ~ alcoholar.dotherdrug,.Thci
d<momtr:11<, that p•r<nts who ar< ur.d<r the in fluence
r work
~i;'!~:?;~u~',';;: =~~:'~~~':'!,
pnmotur< l•bor
<Xhibitpoorjudgmrnt,irritabil ity. p•r.onoio,andinronoi ..
Althoughthueisno,p,cifics<tofphy,l calabnonruolitie,
t<nt p>.rrntingandprovid<-<quat<sup,r,i,ion . Th<ir
connected 10 coc,n< or am/· m'n< UK du 'ng pr<g •
childr<n<xp<ri<nce a chM:itichom,lifeandth<pot<nti • lfo r
n,rncy. upo><dbabie,c , n,howsignsof a rr<St<dgrowth
violence . • re 2.7 time, more lik<lyto b< abUS<d and i.2
time,morelik<lytob<n,g lect<d, lackh,althc • re, • r.d • r<
,m a iler h<acb . genitourinary tr:lct abnormalit ie,, .,,-er,
intestin al dis<a><e(ga, troochi,i , , th< protrusion ol!nt<• •
apos,dtodrug,anddrugpar.,pherna lio. Maltr<atm<nti ,
tine, outside th< infant', body), ,ome dub foot or limb
theleadingcu1><ol1 rauma •nl.ot<ddathforchildrrnund<r
a bnonruolitie,, m d • bnormalsl,q,arulbre a thingp>.t •
lh<•geolfiv,yan,66%ofwhichocrurs a1 th<hand>of
t<m , _1. ... , • \.t<thamp' am 'n <• or coc•n <-<,q,o><d
par,ntsundertheinfiu

Cocaine and Ampheta mines

, nceof•koholorotherdrug,. 11'

::r
;i::~
:: :;;:i<r~n7«':;;~,higher rate, o l HIV, h<potiti, B

Thedoucompil<dbythe2012Na1ion.a!Surv,yo n Drug UK lnfantsapos<d to cocaine dur!ngpr<gnancy oFtrngo

and Haith ,how !hot a1 l<1<137.7 million Am<ricm, •g< 12 throughawithdrawol,yndromecharacteriudbyutr<m<
andoldertr i<dooc•in,duringthcirlif,
us<dcocain< dur!ngth<putyar,
tim es . 4 .67m illion
•r.d 1.65 million used
within th< pu t month ." Mor< men than women u,,d
:!:::::1i:: u:: ::.::?'.,'::~h•~~~:
intoxi cat<d, orboth,th<y
·.,:1
a rehighly irrit1ble,difficultto
rocaine . but••ignificm t numb<rolwom,nolchildb<oring ronso le.arultr <mulou,, a oor.ditionknown a,; irriublebaby
ag<uS<dcocair.<inth<pastyar,,omewhil<pregru,nt. In ,yndrom e.lnfantshov<probl<m,interactingwiththcir<nvi •
thel980> .w henoocain<u«wuatitshigh<stl<Yd,,it"'2S ronment , • r< · tolerant toF/,t or touch,~ nu, ' ,or.
ntimo~ ~"' abo~t i .~~F•l~.S. inf,mts:<r< dinationproblems, a r.dhaved ifficultywith,uckingmd

th.otlroml 5% to25%olbabie,l,omin,p,cificinn<r -clty

1
;: ~:::
1
. ~,:t{;~~;::%~1i:~•::,~:::::1:
~
hospiul,w<r<cocain< • ffect<d.'"·""' Th, IW.\10l 006U .S taminot<d by cocaine. Significant level, of m<th • mph<t •
Trtttm<ntEJ>HOO, O..<a S<t( T EDS),how<dth.otH5,970 amine (1810 68milligramsp,r kilogr • m lmgll<g] of the
pr<gnanl women w<r< adm itt ed for ,ubsune< •abu., tral • mother',v,.,ightp,rday ) r<main inbr< .. 1milk , ,oi/th<
m<nt . In 199-1, 8% of th<>< admiMiom w<r< lor m<tham • mother is using whrn hu baby i, bo rn, her breast milk must
ph<t•m in < .bu.,; in 2006 the pucentog< h2d ri,.,n to H % ." ::=1::/ ,~'._,;,4houn•ftuhul.ostuS<b<fore,h<b<g!n,
ThelOllNationolSur.·eyonDrugU!i< a ndH ,.. lthdocu •
m<nts a ,light ri"' in meth.omph<Wnin< a ~ afte r • lmost a
lnfantswhow<r<<xpo><dtoroc •in<w<r<studieda13.12
decadeofabuKl<>'<lingoffmd,lightlydecrtt>ing. "'
;:~:!.. i:;.::~~~h 0 ~·,::::i
~: =i~..:'':i:•;::b.n~;:;
higher,tote,ofarou,althonur.<xposcdchildr<n ."'·"' A
Sludyofl 50 cocain <•<Xpos<din!ant> a lsofoundth.otlow<r
l<wlsoF•lertn<,oandattrntiv<n<Hw<r<dir<ctlyrebt<d
toth< • moun t ofoocain<th< mother used durlnj;pr<g •
n•ncy ."' Mm)·ofth<><infants,how<d,omepo tt=of
nrurob<ho,iora l di,organiution.irr!tab ility. aru!poorlan •
guagedevelopmen1.Th<S<infants•lsoh2d a ,lightlyhigh<r

=~~';'~S~~ri;~~,!~:d::::l~~ ~fr:",~::;:o:;
drug,. '°'
Th< ,fmub.nts coc,n< and m<tham p hewn·n, 'ncr,as,
h<attni t< andcoru t rictbloodvess,l, . cau,ingdramatic R<eentstudi,s,ugg<>tth.otnrli<rpr< dktionsoFS<ver<ly

;~-= -•i~';;'ns~ri~:i !1"~= ::!:~h

blood . nutr i<nt>. aruloxygentotheplacen
::u::•~:11:~
";;'!,
u andthef<tu,
impalredoocaintb•bie,rulveb<enaaggeni
douharmthef<tu,
U5<T
, <>p,ciallywhenthemotheris
, butmostch ildrenpr<naullyexpos,dtorocain
t<d.'-- Coca in<
a ha vy
e uhib it
Thiscan,ometim<>r<5u ltinm.,rd<dfruldevelopm<nt • nd normolb<haviorbyth<•geolthrtt ."' ADD a ndlowlrustra •
 !l<ugUse ondl're.e«Jon:Fl'omCrde »c,..,. l .ll

diarrh<a . lns,vm:cas,,failun:tothri,1: . 5<llure, , or<klth

;;:~~~~.!.::::;,~~i:~:e:ht::~•~;.:1,::ir:"~ may occur. Th<S< withdr•wal dfo:a may b, mild or~"
:u:ce.. 1ogoodneoruo1>lmdp<d i•lricc •re . lti>unck u • r.dmayla., tf orday,ormonths. '"
whethucocain< -.rfect<dchildrmwillcatchuptonon<x -
Becau.«theonsrtol,ymptomovari<,,clos,oh«rvationof
po,.<dchildrenwithootthatqo•lityofc•r<
theopiold -e,q,c,sm neoruot<H nec<..,ry.Mo,t cas,, ofn eo-
Stodi<> on the dfo:aol m<thamph<wnin< abus, during ruotal n• rcoticwi thd rawalca nb<trat<dwithgoodnur>ing
pregnn,cy•re j ootb<ginning, bot th< drug •adv=df eca can:,loos, ,waddl ingin••id e-l}ingpo,i tion . quie t •nd
on • devdopingf«os • re•ppon:nLAotodyol406chi ldren dim lylit,urrouruhngo . goodnutrition. a r.dnonnalmatu -
born 10 153 m<th -• bosing women foond • phy,icaVm<n wl ru,1/infant bo r.ding behavior,_ Only in s,vere =<> H m«lic• -
<motion.ald isabilityr>t<ofJJ%,which i,,ubs12ntialwh<n tion rrquirrd for th< infant; whrn n<e«<a ry • milder op ioid
romporulwithchildrenbomtowom<nwhohadnot•~ ,ucha,;pon:goric,houldb<u,ed .1" 0pioldwithdr.owal in
duringpregnn,cyThelong -tum impactonth<developm<nt neoruite,canb<fatalan d ,houldb<appropri• t<ly trttt<d
ol•m<tlu.mph<t>min<-<xpo,.<dchild includesdiubiliti<>, b<forethebabyi,ulnsedfromthehoopit>l .'"
rag,di>ord<TS,growthmdde,;elopmrnLaldeLl.y, . •nd a
Opioidslw,ebttnfou n d inbn:Htmil k in,uffici<ntcon -
higherincidenc,ol a1t<ntion-d<fici1di>ordenmdSIDS. "'
= tr.otion to ,xpooe newbomo. Heroin •ndcod ein< or<
Therei>hop,lorporena.<duc,tor,,mdothu,;im'O lv,d in metaboliz«ltomorph ineinthebody,andth<typi cal mor -
thecm:md1h , <ducatio nofthe«children . M•ny0Fth< phineconc:,nt ratio ninth<bn:a,tmilko f •naboo ingmotha
•hnormaln<Urobdw ,ionl,ffecadissipat<ovat h< fu-st i> l .9to 10.5 nmogmno p<r milliliter (nglml). Though ,1:ry
thrttyttrooFlif, r>re, overdo,.e d<ath from morphine in br,.,,
milk ha•
occurred when th< mother I""'"'" the rue gen«
Opioid, (CYPl6"lA•llele and CYPl D6' ) . Th<«gen<>c>n«ultra -
r,pid me tabo lism of rod<i1><intomorphin< . wh ich =ulain
Withincr<a«dus,rndabu«ofJ>T=riptionop ioids.m<th -
high lev,1'ofmorphi n<(70to90nglrnl)inbrtt>1m ilk."'
O<!one. mdbuprenorphin<.an H«S< m<ntmu<t look~'Ond
heroinwhen•p~ntwoman,drugt<sttum,uppo,itiv< A babycanbe bomaddic 1ed tornopiat<ilthemo1herH
for opioid> . In 2012, 1% to .!% of U.S. v.'Om<nof chi ldbu r- being trea1<dwithm<thadoneor bu prenorphine . MethM:lon<
ing •g< •bu>ci heroin or illicit op Ll.tes ."·1'' Th<r< •n: • lso a i>•pprov«lbytheAm,ric•nAcademyofP«liatricsnth<
Ing< numbu of pregnan t opioid addica who ar< being
treat<dwithm<th>doneor buprer.orphin,throughou1
pr,gn ,mc i<, . Phy,ie1 l d<p<ndenceonopioidsi>th<r<•ultol
1h<iT :,~;:,e: .:::e':.~~•:.~:-;:~
:,c::;: 1i:1!
when methadone i, u,ed to rep lac:, otha opio id,, <>'<n
cont"nuou , us,,soth,, tt ,aonth, 'tu,>ttmgrututhan thoughthe infan t oft<nmusth<detmcili<d•ft<rbinh . With
thoo,frombingedrugo,uchHc oc.aine . Womenaddict<dto methadonethemotha i> •b letom.aintainher,ta bility•nd
heroin.hydrocodon, (Virodin °).m cycodon<(OxyContin ~), •voidtheha.:.:mls>«ocLl.t<dwithdruginj<ctionmdother
mdoth<Topioilihav<•grttt<rri>kofmiocaniag< , otill- complic>t ion,ofheroinu s,andi> morelike lytoportidpa.t<
bin h. • ndabruptioplac<ntat • longwi th rontract ing~n: "npo,t nat>l trtttrnent ." ' \" · '1<d O<Soccur · bra,t
infection,(HJV , h<p>.titi•El•ndC.•ndSTO.)fromlVu« milk>t•n •v,ngeoll.!!%olt hemother 's do«.withp<ak
•ndd eliverin11a low-binh -w<W, t baby ."'·' " level,otfoortofivehonr>•f tudo<ing . buttheAmeric•n
Academy of Pediatrico recommen ds !t, cont inued us, in
l'n:gn•nth<roinu..,ro<><p<ritn«d•ilyp<riodsoFwith-
bn.o,tf<edingmothu,
dr.nvaltha t •lt<rnat<withtheru.shthatfollow,achdrug
,_nort~r inj<ction: T~ i>: oo" _d:,m.a:;•nd,:;=~.n:ctn• - Buprmorphin< lr<atmrnt p=ted othu prob l<m5. In on<
study91 % ofth,in f.anl5wentthroughwithdraw• l,and 57%
maternallfetal complie1tion5. Elahi<, born to heroin-
addict<dmothers a n:oft<nprem.atun: . •maller .• ndweaker ;::'_ir:'1n:::C i':f ~~;:i~::.~ ,e;e~i: ~:!i1
~0~~
tlunnonnal. '"·" ' Preruot>l,xpo<un:toheroinha,•i>obeen • ppa rent ruson. '"'
.,,ocia t«l with a bnornu.l neurobeh •viora l devdopmrnL
Thesei n fant,have•bnorm.a!, l«ppouumar.dar<atg rnl<T Mariju ana
riskolSIDS . A600%incrnsei n SIDSdeathswnfourul in M•rijum.a i, u,ed by 5% to 17% oF women during th eir
> otudyoll6.i09drug-expoocdinfanainNewYor k City.'" pn:gruncy (dep, ndingonthernrvey ).Studi eo!ndi e1t<that
th eus,m.ayh< higher whenurinet<Saar,!llffltod<tu -
lf•mother isaddic t«ltoopioid, ,sois th< letu, _D,pending
min< <,rpo<un: rath u th.an anonymou, or confident i•I
onthemother'sdailyd,os,ofohort<r -act ingopioids,uch H
ockr.ow l<dgmrnt,ofu«.One5tudyt<•t<dp~n t ho,piLal
h<roin . h<Topiold~i n W\thas•60%to80%clunce
O<!mi55 ion••ndfound le>1:1'olu«tihigha,;lO'l,."'
oFexh ibitingnronat>l•botinrnce , yr.drome(NAS)oropioid
withdraWlll+llto7lhoun a Ft<-rbinh. " 'V,,"ithlonger -acting R<e<tllre s,a rchha,loundhighlev,1'ofanando.mlde inth<
opioids ,,ucha,methadone,itC2I112keonetotwow«cks ut<ru,ofm"c:,•nd•ngg<>t,thatt'Hnrurotransm"t· . m ·m-
Symplomsinclod e hypencti,ity. irritability, inc<S5a!ll high - ickedbym.arij1UI1.1.. h<lp,n:guLl.te1hee .:uly,tage,ofpreg -
pitch«lcrying,hyperac:th 1: rdlex<>. "'""ting,1r<mor> . irreg - ruoncymdperh>p,con<rol>thepa ino l childbinh. Thi>,tu dy
uLl.:rsl«p patt<m, . ir.cr<a«drespiration,uncootdinat<dand foundthathighlev,l,of a nandamide!nhibi t theprogr= io n
i1><ffectual,ucking•nd,wallowing.sn«czing,vomiting,and oltheferti lizedeggfrombwtocy5t,tageto<mbryo .'"·"~"'
Th<><discov<ries,h<dmor<lightontheprocessofg<>'-' · • C.ttpYDThrneise>idenc:, offealri,k, but benefit,
tion ,andt hey,uggestth.o ttheu«o lmarijuaruomig ht mayocc.,ionall)·outwrighth<rah(, .g.,DiLm tin ,•
dWUptthebinhproc<s> h<nrndillq,ina , and1<tracyclin<)
Mostmarijuoruiexposur<inn<wbom,gouundctectedor • C.IOp'/XPro,,enfetalrisksdearlyoutW<ighanyh<ndit
is Tn2Sk<dby tht u« oF otha humful drugs. Som< studies AccuW1e• is•n ex:omple
r<pon rrducci feta l weight gain . ,honer gesation,, md Luta tionrl>kguid d in esforpostpart umpracrip tiondrug
somecongenialanomoli<> . long -t<rmdev<lopm<ntstudies u«h.ovealsob<rndevelop<d .1•'
such., the Otawa Pmual Pm>p,cti,., Study showed that
childmiexpoocitotn1.rijuon•inut<rohadpoottr•hon - OveNhe-<:OUitt<randpre,cribalmedicationsareth<most
t<rmmemoryandv,rbal r,asoningatag,3 ." ~',. B<twe<n common drug, oocd by pregnant women. Nearly two-t hird,
theagesof5to6and9tollyan,occordingtothe0ttawa of•llp«gnE1twomrnaktatlaston<drugduringprq -
study . mariju:ma.,xpoocichildmi>COT«lsom<Whatlow<r nmcy, usually pr<Ill.t>l vitamin, or simple analgesics ,uch .,
onwrb•landm<moryp<rf<>rm2I1C<t<sts•nd<Xhihit<d upirin.lnon<otudyhalfolth<n<Wbom,uhjectshadnon -
impul,iv,/1,yp<ractiv< behavior. conduct problems , and st<roidal>nti-inlwrnru,torydrug,(NSAIDs),uch.,ibupro-
distractibility . Th<y> l50scor<d lowuon tasks • 550ciated fen,naproxrn,o, .. pirinin thrirm<ronium(th<ba hy'sfirst
withexecutiv, function - theindhidual's•bilitytop lm int<stina ldischorge) . Theu«olNSAIDsduringpregru,ncy
ahead,mti cipate,>nd,uppre .. b<h.ovionth.o t•T<Cinrom pat • incr=th<risko fpulm onaryhyp ert<nsionin newboms
iblewith a rurr<ntg oal."'·" ' '" ·'"' and mother, often neglect to in form their obot<triciam of
thriru.« .1" Medicationstotreatmat,nu l discom!on,anxi<ty,
Mon)·ofth<probl<m>t iedtomari jn•nau«h.ov,todowith pain . orinfectionmusth<pn,cribalcardullyb<cau.« a wri -
thedeliv,ry,yst<m . lf morijn•ruois,moked,oxygentoth< <tyolpr=:riptiondrug,areharmfoltoth<f<tu,_Sro,_tive -
moth<r a ndthef<tu, i,limited;itirri L>l<>>lvroliandbron - hypnotics • r,c•mongth<moststudiedolthesedrug,
chimdcon=babioto"'< igh•boutJ .iounc-.. l<>rnn av<r-
, 0 th.onnonexpc,o<dnronal<> .1" "'" Benzodiaupin,.atdooog,.nornu.lly .. fefor t h<moth<r
accumubt<inth<fetalbloodatmor,-dangm,u,l,vel,
ll<a11><thrnearewithdrowo l ,ymptom,.r,,,-c<ninghavy
orlong -t<rmu«ofmorijuanamdbeau«thef<tusisalso ln•dditiontohigh fea ldrugroncentntion,,excr<tioni,
exposed,itislogic• l to .. ,umeth.otnronotowouldexhibit aJ50>low<r. Thedrugsm dth eirmetaboli1<5rema ininl <tal
withdrowal,ymptom>. Anecdo talr,poru relote thatth<S< and newborn ')'St<Tll5 day, or w«ks iong<r th.on in th<
Tn2rijuana.,xposedbabi,ohave•bnonnolr<spon«•to moth<r . Highco ncrntra1ionsofthedrug ladtofr taldep r<>•
lightandvi,ualstimuli,incrnsedtr<mulou,ne ... ",tar,. sion, • bnomulheanpattem,,mdsom<time,dealh
ti<>." •n d a high,pitched cry uoociatedwith drugwith - lnthePhJ>ician',D<,0RLJ<rrne<undu•lpruoiam,th,wam -
drawal " ' Un like infa ntsundergoingnarroticwi thdrowa l ing,rad : ·o. causeof<>1p<rirncewithoth<rm<mb<rsolth<
mai;unoNl> '<>•r<notexc \.,1y ·, ·ta1,1 b<nzodillepinecla .. ,X2rw< • is..,umedtob<c•pableof
Moder:1te lenl>ofTHC hoveb<rnd<tectedi nth < breast cau,inganincrnsedri,kofrong<nital•bnorn1"liti<>wh<n
milkofpot-,mokingmothu, . Ther< i,..,m ,concunth.ot administer,dto•preg,untwomandnrinJ!thefirottrimn-
THC may lower oxytocin J,- .,1,_ which can d,cn,.., the t<r.Becau«meofthe«drug,isrorely a mott<rolurgency.
amoun t olb<ustmil k «cret<d . Th,Am<ricmAcademyof !: td= . ! ~ring th< first trim<>ter should • lmost • lwa, ., i,,
P<diatric,hosdetermin<dth.o toon tinueduseofmarijuanoi,
rontnindicated in bra>tl«ding moth<n. Thl> •nd other 5<udi<>ho,.,indicat<d•higherriskofddtlip•nd/ordeft
,ugg<>tions a r<co,.,r<dinthepub licatio nGuid,l ine,for pal • tewh<ndillqwnisus<dinth e firstsixmonthsofpr,g -
Bm1StJ«ding.,,,J1h<Dra,r -D<pm,lrntWoman .1" nancy. An<Wborn•ddictedtoh<nrodiu<pin<•moy<>1hibit
. , .. ri<tyofneon•L>loomplication , .lnfant>moyb,0oppy.
l'fesuiption andOTCDrugs hovepoor mu scletone,b<l<th.orgic,•ndlu,.,,ockingdiffi .
TheFoodmdDrugA dmin istr:1tiond evelop<d•chartthal , 'ti . A ' thdm.,.'yndrome, •m'lar to norrot' w'th-
categoriz<> a ndr.U<>p=riptiondrug,intemi,;o/dang<r dr-.wal. tn1.y at.o ... ult •n d persist fo, w«ks. Diu,pam
to•d<>,elopingfrru, andit>octivemeabolit<> • r<excret<dintobrea<tmilkmd
cancau,el<thorgy,m<n 1.>
l«dation/dq,r<S5 ion, a ndw<ight
• eoo...,., A Controlled studi<> in human, 1,a,.,
dem -
los,innuninginfants . Theu.,ofdiu<pamandoth<rben-
oru;trated no f,'21 rah . (Reguiar doses of viwnin, •re
rodiaupinubylactating wom<ni,pankularlyill-•dvi"'d
foondh<r<butnotlargedo..,ofviamins .)
Barloitur-.tuare • lsotobeavoidedduringpr<gnn>cy.
• eoo...,., I Animal studies indicate no feta l rl>ks. but
thrneare nohumElstud ia;or,•dver,e dfects ho,., Withdrawal ')mptom>. including hypuacth-ity, disturbed
b<rndemon,tral<din•nimal,hutnotinwell-rontrolled sl«p,tr<mors,andh)1"'"'0exia .occurininfan tsbomto
humanstudi<>(Tyleno!, • Motrin, • Pepcid ~) mothers whoing<>t barbiturate,in the Wt trim<>t<ro fpr ,g -
•Col•" C Ther< a r< no •dequote studies (>ni mol or
human)orthere • reodver,efrtaleffectsin a nimalstud -
nancy. Prolong<d withdr:1wal c•n b< trat<d through 1.>p<1"
ing theinfantwithp h<nobarbia lover a p,riodoftwowuks
-

i<>butno avoil• hl<humandata . M•nymedication,pr,g - Anticonntl,.nts,uch u ph<nytoin (Dilantin • ) inct<C

a« •
rantwomrn11><f.ollintothiscat,gory(mostdrugs) pr<gnontwoman'schancesofdeliv<ring a childwithcon -
 !l<ugUse ondl're.e«Jon:Fl'om Crde »c, .....

genitaldeferu,ucha,;cleftlip,cleltpa l.ol<,>nd heanm.olfo, .

m.otion. Consequently,phy,ician,mus 1 c,refullywrighthe
dangenofseizure,vs.thechancesofcongenitaldelects
inthenronat< . Pregruoncy • l>o•ltu,;the • bsorpcionol
thedrug,50 t here is a chanceofmor e-l=iuent>eizures .'"
:;;,,.,,..,:~~:.: ,,u ch "' l<tracycl'ne can earn• va 'et,/

M,ny OTC mtdication, ronain .,imuWlll . incl uding caF-

fein e or ephtdrine , and u se of th<se ,ubstance, by preg-
n2Ilt women ohould be carefully mon itored by their
ph~iciam

In theovaallpopubtion, the pen: en12ge ofwomrn who

smoked in the past month m>< from 3% in th e 1920. to
28 .2% inl\l9 7a nddropped tol0 .9% in20ll . Aboutl0.7%
oFpregnantwomtn,mokedciga.retteoduringthebs t three n,, .. ... ..... J;ff,..,.,,1 ,M<oj«<ondlla"'1"""0t:""'"••rl>
months oFthrirpre~cin;th io rellects a oignific•nt """".!" ""e"""""'I loloaJanJ(M,x/,,. ,a""'tacotl "f""'l lwtp.
.. ....,,....IA•lll•p/lowof• fatot,...iaa,'-iUO<Jod U
declineoince2000 ."· 1" 1n•nearlierotudy,th e pen:rn12geo l
pregnantwomrnw howereus ingt obaccoat thetimeth ey
g:,,,.binh wa,;8 .82%. The highestrate,of,mokingwrn:
, mong African Americans (20. ll %) a nd Whites (H .2%). "'
Somewomrnruru.ilm,okingduringpregrancybutretorn
toprepregrancykve lspo,1-deli very Babies born 10 heavy smokers 50me cim<> exhibit • weak
,uckinj! reflex and m.oy have a dep=d immune system at
Smokingduringpregruoncyioparticubr!ydangerou ,h=ause
to bacco ,moke conaim more thE1 2,000 different rom - birth,m catingthepotrntialforpneumoni a •ndbronchiti , ,
sl«pproblems. a ndlower levelsof alertnes, . Long-lrning
pounds, includ ing nic otine •nd carbon monoxide. Both have
elfectsofsmokinge,q,o>urebefon:binhcan includeloW<r
been,howntocrosstheplm:ntalbarrier•ndreducethe
JQandrognitiveability alongwithlowerv, rhal, reading,
fealoupplyofoxygen.Smoki ngio•con tinuoll§act ivity-
andm.oth,kilio. '"T here io •slightlinkbetw«n>mo king
on e, two,orthr«p•ck>oda~theimpactonthef<tu•
dur!ngpregruoncyandtheincidenceof at t<ntion-deficit/
hypenctivitydi<OTder. '"
Th<ri,kofpret<nnddiveryincrnse,ifth<mothersmokn
Smoke le55tobacco a l>oc•n have•nimpacton a f<tu,.A
OT iF, h< io expooed to=ndh2nd smoke .' " Recentotudies
indicatethatwomtnsmokerswlthoheavyhab itare about
twlc,c :,,; likelyto m i!iCIIrjor have,pon tanrou.s abortiomas
:~~!~ :"1th'!:r::~:::'7~:;
0

a two-tothreefoldincre
0
.~i~i:;;:"!:
... dfflkofde liv<ringaJow.birth -
nommokus . Nicotinedamag esthe pl acrn ,aand ha,;ad v<™
wrightbaby.~u , l state si nlndi aha vebannedthe,a le•nd
dTectsonthedevdopingfetU> . Scillbirthrates•re•l>ohigher
th e m,mufactur< of g,,<k.i, a mmbi nacion of m, okde,s
amongmothu,;who,moke ."'
to baca, and betel nu t, which ha> become very popular.
Tobacro use decn = new bombinhweights ;babiesbomto One -third of tobacco comump tion in Ind ia io ,moke l<M. m
mothenwho,mokeh eav!lywrigh , ontheOV<r.1ge . lOOgm
(7o a.) leH, E'<l,icen timeten•horter . andh,,vea,TrWler
headcircumferencecomJ>U<dwithbabie,o l nommoking Anearlystudyofpre~twomenfoundcaffein e in 7S%
andnon -drug -• bu• ingmothu,; .1" Smokingh»thepot<ntial ofinf:mll>tb inh. Theot imu latoryelfectsofcaffeineWt
~o can><Beminor ru:-in _and.nm': de:ts tha t ";" y.be hard:o longerinthefetu sbeca usepregnantwo menha, ,. decreasm
ability to m ru.bo lize m ethylnnthin es such a, caffeine
partofanimalbnimthatcontroiob"' athing,i t i,g!v,na, Nro nate s, newbom , ,•ndinfa ntshavel=tole ra nc, tocaf -
onepoMibl<re=nlorthethreelo ldincruseinSIDSin frine than do •dults U' No long -la,;ting fetal or neona tal
babies bo rn 10 mot hers who,moke he»il ]' '" In •nAu su-.lian elfectsha,,:beenroncluoi,,.Jypro,,.n.butphyoici ansrec-
ommendavoidi ngc • ffeine during p regnancy ."• As big •
::':!::~n~:~:t : t~:~~ 1~)DS, 8\ % had b«n e~ prob lema,;thedTectofc , ffeineduringpregrancyisthe
rontin\lroupo<ur<ofinbntsmd,mallchildr,ntoc•ff<in < • l'fqn•ncylnthemonthbdoreyouknew)'OU"'<"P'<g ·
products,<>peciallyicedt<•mdcoW,<itherdir,ctlyor nan1. howmE1ycig:,r<1t<>didyou>mok<IHowmuch
throughbrtt>tmilk befi , wine,orliquordidyoudrinkl ""
L-llkll{<l"') ThemothernevudrankorU><d,•nd,moked
Prevention thru or fewu cigarettes• cb.y in the month bdote ptegnmcy
Drugohave•magnifiedeffecton•f<tu,;throughoutpreg - - .. •ltll k (U"')Themothuu,ed • lroholinth< pa<t
nmcy,mdprudentmotl-.enu,;wlly abstainFrom•lln nnec- ,mokedthrttorfewercigu<t tesinthemonthbdorepreg -
.... rydrug<xpo< nr<.Pr<gn2Ittwomenwhodon..,•lrohol n,mcy,mdd idnotdrinkinthemonthbefonepregruoncy
orotherdrugo(AOD)muotbeenrouragedtornt<r a pr<rut•
tal cue progr•m •nd • drug tr<•tmrnt prognm iF th<ir u .. Hist, Rl*/34"') The motherdrankorU><din the month
i,problem.atic.ldally,both"'"ic-..,houldbe"' .. il•b lein• befonepregna.ncyand/or,mokedthreeormorecig:,rettesin
>inglefacilitylfthemother',u,;eislimited,infonnationon themonthbeforepregru,ncy. "'
thedEna.gingeffectstoherfetu,ofanyAODu«•houldbe Ext<mh-et<,tingolthisimtrumenth>s .. ublishedits<ff« -
pro,-ided tiven«o>ndha,prov<ntobele,,thr<at<n ingtopregna.nt
Providingtitttm<ntto•ddictedpr,grumtwomenisv!Lal.lf womenth.anman)·ofth, mor<romplexqu<>tionnair<>
•drug-abu,ingwo11UJ>i•fr<<0Fdrugsbythethirdtrim, .. Once identified , women at risk can be mor< ext<miv,ly
t<r,herb•bywillnotbebom • ddictedandwiUnotrulveto ><:r«nedandifn«<OS2J1'dir<ct<dtotr<>tmrnt.ln"'m<
under;:od<toxi6cation.Mo5tpr,ventionprol<Mioruol> • gre< ,,._,,. _ "n,t e, ''' b~ ;ent to tr<C
a tm<nt , me·' ]°" cu,;-
thotbec•nsethedTectsol• lcoholon • deve lopingf<tu••re todyofth<irchildtenor•reconvict<doldruggingbabies.A,
not yet lull)" known, clear w• mingo to • void AOD when ofJulyl . lOl~,th<>l•t<ofT<nn<SS<<canpro«cut< a "-oman
pbnning>pr<gn2Itcyorforthedur.ttionoftheprq;nmcy lora>oault if,heuk« a narroticdrugwhil<pr,gnmtmd
,houldbegi,-en thebabyisbornoddict<d,i,hanned,ordiesbeau,;eo/th<
drug. Thewomonc•navoidcrimiruo l charg<>il,h eco m -
Scrttningimtrumrnts•ndprognm••rethefintot<pin pl<te,>>l a l<tratmrntprognrm .""
identifying AOD 11>< in pregnmt women; once identified
trtttmrnt . b 'ef"nt<rve1 ti ,n, •ndprevent ' "' · mbe Th,r, Ha V=f rnl f,.., th.1,uch punitive m, .. ure,,nrour -
impleme nted.Dr.lr.tOamoff•ndhl>colbguesdev<loped ag< pr<gnmt addict> to avoid prenatal clinic• and doctoB
the~P\Plu,imtrumcntconsistingoffi,-.ba<icqu«tiom andgiv,birthoutsideof a hoopiulto»'Oidimprisonmentor
I0<5ofcu,tody0therjur00iction,u,etr<•tment .. m•lt<r •
• l\orontsDid<itherofyourparentsevuh.av<•prob lem
n>tiv<tojai l. Th<reis<Videncethatif•womoncankeepher
with• lroholordrugs>
babywhilegoingthrough tTtttmtnt,thttreotm<n t option
• l\onno,Dou)-Ollfpartnerha,,e • prob lemwith•kohol ismor<acc<ptablt • ndsucce"ful.Combin<dpr<ruotalc • re
ordrugs> andsubsta~usetr<•tmrntefF<ctivdyredue<•d•"'"l!•
• l\o<! H.av<)'OU<V<rdrunkbttr . wine . orliq_uor>

I\~F-~p,,,tn<WO
1""'"1"""""!910,
,. .• , .. .i,,,,,,,1,, 1- 1
ofpom,o,Jdko>Ml•«
""lo/••<>
ux-,-o1 ... ,_,.,.,..,,
 DrugUse and Prevention:FromCradleto Grave 8.27

The problem with surveys of high-school and college stu-

'Thesenursescamein and took mq childfromme. That
was a reallqpainfulexperience , and it'spainfulnow. It 3ets
overwhelmin3 , the feelin3sof wantin3qourchild, knowin3
that this littlepersonis ve~ dependenton qou, knowin3that
the meetin3of theirneedsrequir es qou to be cleanand sober,
requiresqou to be functional. "
29 -ye ar-old pregnant addict in recov ery
The need for universal screening of pregnant women along
with sufficient prenatal and drug-treatment facilities to
stop use and improve the woman's overall health is unques-
tioned .183It is estimated that only 55% of women of child-
bearing age are aware of fetal alcohol syndrome, although as
many as 375,000 children every year may be affected by their
mothers ' drinking and drug use. Reaching pregnant women
with appropriate prevention messages through OB/GYN
health professionals , prenatal and well-baby clinics, alcohol/
drug warning labels, and public service messages is essential
to reducing the effects of alcohol and drug use on babies .184
All studies indicate that during pregnancy complete absti-
nence is the safest choice .
Youth and School
"In hi3hschoolwe'dhavepartiesat friends'houses. We foundout
whose parentswouldn'tbe homeand wouldbrin3the beer,raid
the medicinecabinet,and havethe partqthere. In colle3ethe
dru3scenewasa littledifferent.Youcould3et a betterselection
of dru35.We wereusuallqtoo poorin hi3hschoolfor those."
19-ye ar-old co llege sophomore
In spite of all the headlines about crack , LSD, and metham-
phetamin e use among adolescents and college students, the
most frequently used drug remains alcohol. Tobacco is a
dents is that many users minimize or are untruthful about
their use of drugs even after repeated assuranc es that the
survey information will remain confidential. This is often
part of the denial process. It has been found that most fig-
ures on current or frequent use of illicit drugs in high
schools and colleges are underreported. 185 Statistics show
that underage drinkers account for nearly 20% of the alcohol
consumed in the United States.
"We weresupposedto put on a skitaboutdru3s, and the minute
we sat downwe said, 'Now whatdo the parentswant to hear
about that?' That's the3eneralattitudeall mq friendshavein
dealin3with these pro~rams:'What do the parentswant to hear
fromus?' And a lot of the peopleteachin3thesedru3proaram s
arealsotellin3us what theq thinkourparentswant us to hear.
It's all verqstereotqpical
."
IS-year-old high-school student
Survey data are sometimes compromised becaus e the term
problematicuse means different things to different people
and often depends on the drug. For example, if a college
freshman gets drunk only on Friday or Saturday night and it
frequently leads to a fight or unprotected sex , the student
probably believes that he or she does not have a drinking
problem even though that kind of drinking , by the definition
of abuse, is problematic .
If a stud ent goes on a three-day cocaine binge just once a
month , spends everything on the drug , and has nothing left
for food or textbooks , that too could be defined as abuse .
The true value of information from youth surveys is that
they show trends in drug use , making it possible to see
changes from year to year and to gauge where our society
is headed . Surveys also provide a benchmark to measure

close second and marijuana third . After five years of steady
increases in the abuse of prescription opioid medications
(especially Vicodin®), use began to decline in 2013, espe-
cially among twelfth-graders. 186
I
the effectiveness of prevention effons that we as a society
are paying for. It is difficult to pinpoint the reasons for
an increase or decrease in drug use: is it prevention spots,
interdiction , the maturation process, school programs, or a

Any illicit drug 26.60/o

Heroin 0.30/o
Steroids U.S.High-School
Seniors'
Inhalants 30-DayDrugUse- 2013
Coca
ine(includingcrack)
MDMA
Seda
tive-hyp
notics
Pain-killers
Hallucinogens
Amphetami
nes 4.10/o
Synthetic marijuana ===:::1
6.40/o Since 1992 decreased funding, greater
Smokeless tobacco 8.10/o availability of drugs, and a tolerance of
Cigarettes ~::::::::::::::::::: 16.30/o drug use led to sharp increases in drug
l============:i use among high-school seniors as well as

~=~==~==:;==~==~==~~=~=~
39
~
.2~•A~o
-~
Marijuana 22.70/o
eighth- and tenth-graders.
Alcohol Monitoringthe Future, 20 13
00/o 50/o 100/o 150/o 200/o 250/o 300/o 350/o 400/o 450/o
 U.S.ttigll.XhoolSffliorl'DrugUseTreodl974-2010

bad economy> Recrn~y. it ha• b«om, cl<2r that th<t< i, • tfa.,udrntreach<>theag,of2lwithoutsmokingand

a ,1ronga>oocia1ion betwttn howyoungp<op l< prn:<i,., wlthou tusi ngalroholorotherdrugs,h<or,h<prob-
thelwmluln<Mofadrugandtheabus,ofthatdrug.Whrn ahlywillnevahawaproblemwithth<substanc,c
th<p<rcrivedharmfoln<Hd<cr<>KS,alms,incr,as,,.Th,
~.\• ,. alsotrue: wh<np<rttptionincr<H<C• ,• bu0< ~th=:u~:~o::::: that exp<rimrntation is not benign

Adolescents and HighSchool

..,,
• triedcipm.t<>,83.7%a:r<,till<mokinginth<tw<lfth

• gotdrunk,!IJ .3%•r<•tillg<ttingdrunk
• tried fflmjuana . 76.i % are still ,moking pot

1:./°J::°'•~"=~:
~;: !J .b:..~~-::
t°~
In addition . adolescents whoux fflmjuana w«kly reported
thatthcywer<•lmost,ixtimesmor<lik<lytocutciassor

'7J:~t
~~~"::~:::}a~/t:: ,kip!iChoolthmthos,whodonotUS<C ."'
..,th Mucholth, a lcoholandothadruguxinhigh!iChooli,
~u,tl,,,<>:thanJ.,,,nthand<ii,litl,/YoJn· ap,rim<ntal.!iOCial,OThabitu.alwithboutsofabus, . Most
"---"""'""""'""""" >1udentshaveno1u,<dlongenoughforaddictiontooccur
Unfonunatdy . thry don) have much experience man2ging
.

Figure8-3ch•rt<tr<nd,i ndrugu s,by high -!iChoo!s,n i<>T> theirdrinkinganddrug-takinj;habits . !iOinappropriot<

Thenumbu,,howa dttttn<inhigh-sch oola lroholron -
UK , includ ing in toxication with bing< drinking. drunk
•umptionowr th<pHt 30 ~•rs . • ,imilar dtttt:u.e in ciga-
driving.andunsaf<KX,ismOTelik<ly.Another fac1or l<ad-
r<tt< ...,oking . but a ,1111.U'ncr,o., · ~;uanouK .10'
ingtoinappropriot<usei,th<atl<mpttocon1rol,motion.al
Although there~ been a dm<ntum in smoking . th< ahs.o- tunnoilbydrinkingortakingdrugs . Yoongpropledon\

=~'~
lut< numbers are ,ti ll high. FOTa• mpl <, the numh<Tof
apprrciat<thecollota:,ll"'ychological , ffectsoftry!ngto
"'nion who m,ok< is half of what it WH !n 19H, bu t that
>1ill•mountstomor<thanlmilliontw<lfth -grad<n i;:~rn;,~ ~~..:;~v1:ta:•i~~~:-'b': t':::.: a!::::
Th< report "M•ligrant Neglect : Substance Abus, md :~:::;: use, their le,,,el of concern i, lower than tha t of
America's Schoo l, " prepared by the National Centu on
Addiction and Substance Abu>< at Columbia Univ,,,;ity .
Th<majoriryo f t«nagenwhoe,q,<rimrntwithdrug,will
loundthelo llowing. ROI b«om< addicted; but for lhOK who do, th e legal
• Substanc,c abuS<C:md• ddiction will add l0%to th< root acad<m ic, !iOCi.al,p<ychological,andph)'sical<ff«tso fp<y •
of<l<m<ntary:mdS<Crond•ry< dua tionduetoviolrnce choactivedrug,willbe cataotrophic
•p,ci.al education, tachu tum,w<r, truancy . prop<rty
• 70%oft<rn,uicid<>in,'Olv,alroholordrugs
dam.og<. injury,andcouns,ling
• Tht Khoo! environment~ th e gr<at<>t inllurn« on • XJ%ofdat<r.tp<>!m'O lv,alrohol (victim mdl orrapist )
drugand a lroholuS<C • i0%ofd rowning, invo lve•lcoho!
 Drug Use and Prevention:FromCradleto Grave 8.29

Past-Month
Adolescent
HeavyDrinking
and
Emotional/Behavioral
Problems
Usedillicit 52.70/o
drugs :::::J3.30/o

Stole from 24.30/o

others ;===:::i 6.10/o Heavydrinkers
Nondrinkers
Tried to hurVkill 14.50/o
themselves==::l 4.40/o A survey of 12- to 17-year-olds
showed that heavy drinkers were
Skippedschool 54.70/o more likely to have emotional and
9.90/o
behavioralproblems.Some of the
Reportedsadness, 34.60/o problems led to experimentationand
depression 21.70/o eventually heavy use of alcohol,
whereas others were caused by the
Ranaway 18.10/o heavy use itself
from home 3.70/o
SAMHSA, 2000
00/o 50/o 100/o 150/o 200/o 250/o 300/o 350/o 400/o 450/o 500/o 550/o 600/o

Psychological immaturity is another problem. Just three
drinks consumed by a young person cause significantly more
mental impairment than in an adult drinker .
Crime
The most pervasive result of alcohol and drug use by adoles-
cents is crime. In some cities the youth guidance centers and
juvenile halls are clogged with offenders who were using or
under the influence when committing a crime . Nationally,
according to the Arrestee Drug Abuse Monitoring Program,
more than half of juvenile male arrestees tested positive for
one or more illegal drugs, usually marijuana .188 If the offend-
ers had also been tested for alcohol , the figures would be
much higher . Estimates put the cost of youth alcoho l abuse at
problems delays maturation. Drugs help a person avoid
handling life's problems .
"When qou beginto use drugsaround 12, 13, or 14, qou never
experienceritesof passage.You neverget inducted into the
adulthood of societf Manq people that we talk to who come
into treatmentactuallq began usingsubstancesat that age, so
their ritesof passagehaven't qet occurredwhen we see them at
30 or 35. Essentiallq, we'retalkingto a 14- or 15-qear-oldin a
30- or 35-qear-old bodq, and that's wherewe have to begin"
Counselor , Haight Ashbury Detox Clinic
If drugs or alcoho l are used often during adolescence to
avoid stress, to drown out emotions, or as a shortcut to feel-
ing good, young people never fully learn how to deal with

more than $62 billion , of which $34 billion is due to violent
crime and property crime, $18 billion to traffic accidents and
health problems, and $10 billion to miscellaneous costs.
"I went to jail a lot for beingdrunk, beingon drugs, for
committingcrimes- lots of assaultsand weaponsand things
like that. I was a whole differentpersonwhen I was using,
qou know. I wasn'tgivinga rat's ass about nobodq or nothin'.
I was just gang bangin'to the fullest; that was it."
17-year-old high -school student
The Effectsof Drugson Maturation
A college newspaper conducted an unofficial survey to
determine the number of years it takes to reach maturity . The
conclusion was, "To reach the emotional maturity of an
average 18-year-old worldwide takes youth in the United
States 25 years ." In a society where survival is compara-
tively easy, where entrance into the workforce can be delayed
by living at home expense-free, and where a person (with
enough resources) can stay in schoo l until age 25 or older,
the need to reach adulthood is not so pressing . Avoiding the
need to handle or solve any financia l, emotional, or social
I
life's conflicts without the aid of a psychoactive substance .
They never learn patience , they nev er learn that emotional
pain can be tolerated and can be used to grow, and they never
learn that doing things that must be done rather than doing
only those you want to do is part of the maturation process .
Risk-Focusedand Resiliency-Focused
Preventionfor
Adolescents'a•
,1•0
,1•1
Recent studies indicat e that a number of conditions put
adolescents more at risk for substance abuse and other
behavioral addictions:
• being subjected to physical, sexual, or emotional abuse
• emotional and mental disturbances
• lacking self-esteem
• being exposed to peer group tolerance of or encourage-
ment of drug use
• being in a family that tolerates use, has no consistent
rules or discipline, with absent or uninvolved parents or
parents who use drugs
• dropping out of school
• getting caught in the juvenile justice system
 8.30 CHAPTER 8
• becoming pregnant
• living in poverty
• lacking alternative activities
• attending a school that has no policies, detection proce-
dures, or referral services for users
"I believebothmq parentswerealcoholics.Mq brother's
an addictand alcoholic.It runsin the familq.So I
basicallqfollowedin mq father'sfootsteps-the drinking,
the runningaround."
Recovering alcoholic
Prevention specialists must develop programs that clearly iden-
tify the risks and teach adolescents ways to deal with them
while enhancing the protective elements that promote healthy
lifestyles and personal accomplishments. Researchers Steven
Glenn, Ph.D., and Richard Jessor, Ph .D., present four condi-
tions that help children avoid drug use (observable by age 12):
• Strong sense of family participation and involvement.
Children who believe that they are significant partici-
pants in and valued by their family are less prone toward
substance abuse in the future .
• Established personal position about drugs, alcohol, and
sex. Children who have a position on these issues and
who can articulate how they arrived at that position, how
they would act on it, and what effect their position would
have on their lives are better able to make positive choices.
• Strong spiritual sense and community involvement.
Young people who believe that they are individuals with
a role and a purpose in society, that their actions matter,
and who contribute to their community have the confi-
dence to say "thanks, but no thanks."
• Attachment to a clean-and-sober adult role model.
Children who have one or more non-drug-using adults
I
(other than a parent) in their lives, often a coach,
teacher, activities leader, minister, relative, neighbor, or
family friend whom they can count on for information
and advice have positive reinforcement in saying no and
seem less prone to developing drug-abuse problems.
Primary,Secondary,and TertiaryPreventionfor
GradesK Through 12
Prevention programs must always factor in risk and resil-
iency and tailor programs for specific age, ethnicity, gender,
and culture as well as any other elements that will provide
an environment where the message can be heard . Effective
programs have:
• structure-program type, audience, and setting
• content-information, skills development, methods, and
services
• a delivery system-specific plans and facilities for
implementation
SAMHSAsNational Registry of Evidence-Based Programs and
Practices lists a number of model prevention programs, such
as Dare to Be You, Team Resilience, A Family Matter, Lions
Quest Skills for Adolescents, Multisystemic Therapy, New
Beginnings Program, Project Towards No Drug Abuse, Seeking
Safety,and many others. 192Other popular programs include the
Caring School Community program, Classroom-Centered and
Family-School Partnership Intervention, Guiding Good
Choices, Alcohol Misuse Prevention Study (AMPS), Drug
Abuse Resistance Education, and LifeSkills Training. 193
Primary Prevention The purpose of primary prevention is to
prevent or at least minimize drug experimentation and use
beginning as early as kindergarten. Coordinated efforts
among family members, teachers, and other school person-
nel are of great value .
Parent/teacher sessions and the incorporation of drug pre-
vention lesson plans within the school's overall curriculum
are the first steps. School-based prevention programs teach
life skills, resistance education, and/or normative educa-
tion.194Unfortunately, primary prevention focuses on only a
few of the risk factors in a teenager's life, which include per-
sonal, genetic, psychological, family, and social problems.
Some schools focus on punitive measures, using drug testing
and zero-tolerance policies rather than emphasizing per-
sonal development. Zero-tolerance policies that punish any
use of alcohol or drugs are often used to expel students
rather than place them in appropriate treatment. 187
LifeSkills Training This program is taught in grades 7 to 10
and focuses on increasing social skills and reducing
peer pressure to drink. An evaluation of this program
showed a decrease in the frequency of drinking and exces-
sive drinking .62·196
DARE(Drug Abuse ResistanceEducation) This program was first
launched in 1984 and remains one of the most widely used
resistance education programs in the United States. The pro-
gram consists of 16 or 17 weekly one-hour sessions con-
ducted by uniformed police officers and presented to fifth- or
sixth-graders. The program teaches self-esteem, decision-
making skills, and peer resistance training. Early studies
found that the program had modest short-term (one-year)
effects on reducing drug use through improved self-assertive-
ness and increased knowledge about the dangers of alcohol
and other drugs. 197A study of students conducted 10 years
after they took the course found that the effects were not long-
lasting and that actual drug use was no different from that of a
control group. 187·198In response to criticism and to update
the courses, the DARE program was revised in 2004. There
are now programs for junior high and high school that present
more-lifelike situations to teach students to better handle peer
pressure. There is also a DARE program for parents to involve
them in prevention . The program has also spread to Europe.
The DARE program in Europe recently published a cross-
nationality study involving seven nations (Austria, Belgium,
Germany, Greece, Italy, Spain, and Sweden), 170 schools,
and more than 7,000 12- to 14-year-old students. The study
concluded that even this well-defined systematic drug pre-
vention program could not diminish rates of drinking or
illegal drug use among youth. The 18-month post-program
follow-up study did show that DARE was effective in pre-
venting drunkenness among young people, positing the pro-
gram as a more viable harm reduction effort rather than a
true primary prevention strategy .1"
 !l<ugUse ondl're,e«ior,:Fl'om Crde '1C,..,. I.J I

AMPS (Akollol Mio<IM_,,tion StudJ) AMPS is ano ther ISFP wa, du ign «l to improve par<n<>' family mnagrmen t
·,unc e«lucal·nprogr,mcoru'ti 'a'u~·on practi<<>andcommuni cation,kili>and children'spersonal

1
0
rurriculumforfifth - md , ixth -grader>. h«luc,te, a,well andsoci.o l ilillsandth eiTabilitytodealwithpeerpn,osure

=00~~
aftal6mo
':':o:: ,';;~
nth,throughgr.,d
r;:!•a ~d:u:
e U. »>.>01
t;~t~':
Follow-upSludi,s
=ment
lound that48 months after th, initial
. theproponionofnewmarijuanausa,among
)'Outhswhodidnot pa rticipat< in the!SFPw a, l .,t im,s
gm. ta th an it wa, a mong )'OUths who did pani<ipat<
Nonmfve,' ,· n · aotr.1· .;ythll t Zmst orontccterro-
Funhennor<, thedi f!<r<ncei n drugn><be tw«nyouth,who
neou,belief,abou tthtcpuvalrnetcandtheaccepubilityof
"'<teexpo,citotheprogr.,minth,oix1hgr.tdeandth00<
alrohoVdrugu,eamongpttro.Thi>,tr:1t<gywasfound10
;"how=:notwid<n<dinth,foury <>.B<incethe,tudy",pu -
be u 1rongadjuncttor,c5 tone,«!" ti ,,can 'ng,uhsun -
ti.oldrop, in a lcoholu,eamonghigh -,choolstudrn<> ."'
Themostpertinrnt a, pectofallofthe,eprognm,i,that s«ond.lry,._nllonAftere,qxrimrntalion . socialn«,habit -
primaryprnentionmuotbtcrontinu.ol:one-yearalt"1Ilpts uation,andoccaoiona l abusebeg!ns,usuall)'intheoixth . ..v -
atinoculatingotudtcnt,agaim t alrohoVdrugusehllnbttn enth,and<ighthgrade, (-·- 11yar liu ),,chool -ba.s<d
provenineffectin . Educationandilill-tr:lin ing booster,,._ primn yp="<ntionprogramsmustadd ,e oontbtyprevent ion
,ion,mustcontinuethroughhigh,chooland!ntocollege program, andpolici=JnnN>Thighandhigh,choolsmustbe
The most -ef!ecJ,,. prevention prognm, ar< those in which clearaboutenforci.ngstrictrubstanetcu,epol icie,.Teachen
studen<>aretaught,e\1-e,te=i,confidence,mdtobe and,taffshouldbetr.linedtoucogniudrug=andhll>·ea
mW r.tidol th eiTf«ling, thoroughunden;tandingoftheronwquencro. Trainingpar-
en<>torecognizeprobl<m5e1us«lbydrugn«,teachingthem
Becau,etherootsofmostaddictionocomelromthefam ily, to,upponth<irchildr<n,andprovidinginformationifth ey
family-Focusedprimaryprnentioni>anece,
to any ,chool-basedprogr,m
.. ryadjunct
. Progr.,rno,uch a, patental
,killu-.iningthroughthe,chool,ttductioninparenu l use
;:!: ::~.:uc':~~~:~;;,-:~ ;;:'.':.~o~~:
tial (but!iO m<tim<>neglect«l ) ><TVicnare follow-upafter -
oldrug,ora lcoholinfrnn tofthech ildren ,andgreat<rpo,i - C2:I<,supptomahsur<n«do<Snotrecur,andr<ao<ur.mcn
tivepan icipationofparen<>int heirchildren 'sl ive,have a thatemotional . social . andphy,icalprob l<mSkadingto,ub-
greatinAurnceonbehav ior. •tar.ceu,eare beingcorrect<d . Oftenthe,e,en-ice,area lready
pro,idedbycommunityo'&',ni ulions.ne gatingthen«dfoc
,choolsto,pendr<>eurce>hiringadditional,taff.
Othuprogramsfoundtobeeffec tiveinm inim izinge,qxri -
men tacionwithdrug,ar<peu«lucatOTprngr>.ms,prevrn -
tioncurricula, positiv< role mod<!,, he.althfaiB.Students
Against DrunkDrh-ing,andCalifomia'sFridayNigh t Llv,

Re,u l<> from • study by the Panna.hip for• Drug -F=

Americaindicat< tha tpartcntswho have repeattddi,cuo-

:~::-.::•~l;~;:;~~~
•::~~ ~ed7~~u~l:ta'::!'..::
drug Uli<C. About i'Yl. ofternaga,;who heard nothing at
home abou t drug risks used marijiuna in th e past yeu . Tha t
~~; ~~:: ::.:~::r :~«l :~:.1 ~~ «! a little at home
6 1
T«lllry-- Thi>le,,e l i,;de,ign«lfo rstudentswho
-W<"ttt""B"'·" ·';,,lid> . and"" "'Up,<t,1'1tlu,t""·,,,., , hllvtcaproblemwithdrug,andalrohol.Studenta,o.i,;wic,
pa'MJa!!<n~.,,,i,.t "-"•~- °"""""""'"t,,d~"'°t tl,,i"'.' progr.,m,thatir.clud,roun,ding a ndsocial,er.ic<> . Ai.ot<en
>a'Mj; "'"""i(tl,,~Jonta<t•sooJ"'f'<""' '"l,,"t°"jr< ando therl.k tepan onymousm«ting,a imedatt«nager,,
tal~'l:iahoot~orokoholtl,, ,,....,tl,.,tt °"jt,!lto"' andpee r in tav<ntiont<am>a im«la1gettingdrugabus<n
abootjt,.rl,,,.,,,,""."fP"IJloa<l~tofit./f,o,.!;,cttl,.,t
t°"jcontj«<tt,l(to"'on,:,,.J,,n"""'O 'f'""olio.Jjt
ullbt....,lino/'1jtwil/<t.:l.,jtl,u,fo,tl,,,,,t ofo,., I;,,, ~;:;:~::=:
in toe.arlytr<Catment a r<!iOmeofth,tactics=ployed.The
~;..:;;;:ven to be eff<ctive in rnchi ng stu -
TI,,~ .,,J to ,tart ,a n~and;i,,t kup 8""'!,-AMif~ "'lj The l'o,itive llehavionl lnt<rventions and Supports (PBIS)
~i= :~~·::;;~";:!~;.:.~.:~~~
-;,i':;i
cantpth""'!J"toa,td,nt"
methodundatheU.S.DepartmentoFEducationprovid<>
ouppon For schools that ,nntto,,.Wllish or •tKngtben
theirpreventionprogn,n,.ThePB!Sapproachhe lp,d,velop
progrEll5 a, beha vion l ,uppon for high -risk Sinden<>

One evlden cc-bas«I program for f.amili<, is the Iowa • adju,tments1otheen, ironmentth a1r<duceth< like li-
StungtheningFamili .. Program(ISFP) . Th,,.,..,n~io n hood of a prob lem
 8.32 CHAPTER 8
• teaching replacement skills and building general compe-
tencies
• implementing consequences to promote positive behav-
iors and deter problems
• crisis management or relapse plan (if needed)2 °6
A key factor of secondary and tertiary prevention is recog-
nizing the signs of drug use in teenagers . One Court
Appointed Special Advocates (CASA) survey found that
while only 12% of parents saw alcohol and drugs as a prob-
lem, 2 7% of teenagers ranked it their primary concern. 187
More and more public schools have implemented random
drug testing. Much of the testing is for school athletes, test-
ing for performance-enhancing drugs. Drug testing in
schools can work in two ways. Random testing can act as a
deterrent, especially for that group of students who are
using but have not yet suffered serious consequences.
Those are the drug-using peers with the most influence on
their schoolmates. For those who have serious problems, it
is a chance to intervene in the progression of their abuse. 207
Unfortunately, research on the effectiveness of drug testing
in schools shows mixed results. 208 More research is needed.
Home drug tests provide another means for parents to mon-
itor drug use. The tests are conducted when behavior sug-
gests that family rules have been violated; some teens view
this as a breach of trust and an invasion of privacy
Childrenof Alcoholicsand DrugAbusers It is estimated that one
in four U.S. children under 18 is exposed to alcohol abuse or
alcohol dependence in the immediate family.209 Teachers ,
counselors, and health professionals must recognize that
children are affected by drugs and alcohol even if they
don't use; they often adopt behavior patterns that help
them survive in an alcohol- or drug-using family. Many of
these family roles affect a child 's future drug use as well as
his or her personality:
I
• The hero (model child). This hardworking student tries
to bring pride to the family but is still affected by the
intense stress of having an addict or alcoholic in the fam-
ily; also known as the "chief enabler, " this type of child
often takes over the duties of dysfunctional parents.
• The problem child . This individual experiences multi-
ple personal problems , has a tendency to use drugs, and
demands attention with bad behavior.
• The lost child. This extremely shy child deals with prob-
lems by avoiding family and social activities.
• The mascot (or family clown). This child tries to ease
tension in a dysfunctional family by being funny or cut e
and has trouble maturing_21°.m
College Students
College presents students with new experiences and pres-
sures: living on their own, developing autonomy and self-
regulation, making new friends, coping with peer pressure ,
rising to higher academic demands, or simply being a small
fish in a big new pond . When a young person is faced with
the challenges inherent in fitting in to a college culture , prac-
ticing autonomy, or handling the stresses of a new environ-
ment, alcohol and drug use becomes an option. Transitions
from one culture (home, high school) to another (college)
are often times of high vulnerability.
Although illegal drugs , particularly marijuana, can be
found on most college campuses, alcohol is still the drug
that predominates. In a Carnegie Foundation survey, college
presidents ranked alcohol abuse as the quality-of-campus-
life issue that was their greatest concern. Drinking is embed-
ded in college traditions and norms. College students are
prime targets for the alcoholic beverage industry because if a
freshman becomes brand loyal at age 18, he or she will
generate $20,000 to $50,000 in sales over a lifetime .
Prevalence
Monitoring the Future surveys in 2013 found that 37% of
full-time college students had occasions of heavy drinking
(five drinks in one sitting in the past two weeks) while
3.9% drink heavily on a daily basis. Other data showed that
rates of daily smoking dropped from 15% in 1993 to 5.2%
in 2013, and daily heavy smoking dropped from 9% in 1993
to 2.4% in 2013. 186
A large national college survey by the Center on Addiction
and Substance Abuse at Columbia University found the
following:
• Fraternity and sorority members are more likely to
drink than unaffiliated students (88% vs . 67%), binge-
drink (64%vs. 37%), drink and drive (33% vs. 21%), use
marijuana (21 % vs. 16%), and smoke (26% vs. 21%) .
• Overall, 78% of college students who use illicit drugs
engage in sexual activities (one of the main reasons stu-
dents use drugs) compared with 44% of those who don't
use drugs. 2 13
• Consequences of drug and alcohol abuse on campuses
included:
• 1,717 deaths from alcohol-related injuries
• 97,000 victims of alcohol-related rape or
sexual assault
• 696 assaults by a student who had been binge
drinking
A change in federal law made people ineligible for student
financial aid if they have a drug conviction . In the first five
years of the program, 189,000, or 1 out of 400 , were denied
because of a conviction . An equal number who had a convic-
tion on their record qualified because they completed a drug
treatment program or had another exemption. 214 •214 A
SecondhandDrinking
Many problems that occur on campuses are related to sec-
ondhand drinking-the effect binge drinkers and heavy
drinkers have on other students. On campuses where more
than 50% of students binge, 86% of non-binge-drinking stu-
dents reported being victims of assault or unwanted sexual
advances, having sleep and study time interrupted , suffering
property damage , having to care for or clean up after an ine-
briated classmate, or being subjected to an impaired quality
of life on campus caused by others drinking .215
 !l<ugUse ondl're.e«Jon:Fl'om Crde »c, .....

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b,a,.,,a lo! ofpropkr,,.,1to porflj a ~ttl, !.t """' ~~;;i_"';i;,;;;:,;,:!;~:~;i~tl,,
alott,.dto<ln,,l;aloll!tOf,a.d~,tl,,alot..,,,rowd~
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,car,,to,;,,,,,,,l~b,/i,wtOOttO«j"r,m
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:!:~:.:·~~~:'4'~t:t.~>it
1
Prevention in College•
Coll,gedrinkinggam,s>nd50llg<dot<~ktoth,Middl,
=6:
~tt,~1:r::;;~"·'t;,::.':;~~~
t1,,.-l;,,,,-toa1""'1·
0....,,
,..............0 .. ............ ...,,,.,,c.ru.,,_ot
th~';,·.,~,.!".:-:::~~h:c:n.~,!,~;t::;~; ;::::~:~
m<nlp>r>dea1l-br.cml.•=•nri<>-0ldtnditionin<tituted AtHoban•ndWillWl>SmithCo lleg,sinNewYork,<tudi«
topr<v<ntdrunk<nrowdyb<h•vior . lnEngbndth,r«:om - foundtha168%0/<1udm1<b< li<>'«lthatth<irp,,nthought
m<nd<dw,,klyupp,rlimitlorcoll<g<<llldrnt<islidrinks /r,qu,ntintmcic>tionw ... acc,ptab lewhmin lactonlyl'4%
forwomrnandllform,n ." ' On,rnsontb<colltg<drink- f:ndd'.t ac<~J>l1bl_<.: ·' " In th\first 18 months~! ~:rog~•m
ingcultur<ishardtochang,isthtp<r<:q,tionthat"M>Wing
wildoat< "i nrolleg ,i,arit<o£p .. ,.g,towhich<1udrn1< through•,,.ri<tyofm<di>(including><:r<rn,.,.,r,onuni -
•rerntitled.Drug,xp<rimrntalionis•OOcon<id<r<dp•nol ,.,r,itycompol<n),th,r,wa,•l6%reductionindrinkingto
thi,rit<ofl"'sag, g<tdrunk.•21%r<ductioninf=iurnthavydrinking, •
31%redoction inmi55,dci.....,, . • J6%T<ductioninprop-
Cont<mpor:1rycoll,g<p=rntiondforuoriginat<fromth,
<rtycbm.ag,.•nd • -1()%reductioninunprol<eted><><
f<d<T:11Anti-DrugAbn><Actofl986that5<t.,id<fond<for
higher education md de,igruot<d th< Fond for th, lmt<adoltalking • bou1drug•ndalroholuS<,nOTIR1.tiv,
Jmprov,mrntoFJ>o,t.S,condoryEducationa,;1h,gr,nting HS<Mm<ntf ocus,,ontalking•bou tnotusing .Th,k,yis

~•=
og<ncythatr<vi<w<dpr,v,ntiongr,ntpropo<>l<andd is- tol<t>tud<nnlcnowwhatconst"tnl<• cmaluS<on•F
p<r,,dfond< . Mrnyoftodoy">drugrour«s>ndC2mpuspr< · ticubrc•mpu,r:1th<rthml<ttingth<irp<JC<ptionsl><col -
,.,ntionprogr,ms•r<th<r«ultolthatl<gi,lation.N,Wfi ~~=!o.';."~ ~:!~:',.th< m<di• or the <ugg<T:1tion<
~!:::;~~:=
·~:::~~c::ti!:1
..~:
Coll<g<SHW<llnprogramsbyindividn•lcoll<g"' ~';..,~"';~d ';~:c~~r::•gi« dir<ct<d at controlling
__ ,._......,..,,On,pn:,.,ntion•pproachthathashad
,nee<>• · normot'v< as5<Ssmrnt. Th', program 'ms to
chang,commonmisp<rc<ptionsthatdrugandalroholn><:
•mongpttroi,high<rtlunitre1llyi,.Normo1iv, • ..,.,.
:~=•~:~
•
• T<gul•t<campu,drinking(2 3%of campos,sbonb<<r,
liquoroncampu,,and9!!%prohibitk<g<

m<nlr<cogni,,.tha1if>tuden1<thinkth a1h<>.vydrinkingor • providealcohol-.tobacco-.•nddrug-frttdorms(well -

drugn><i,th<normalthingtodo,thcy • r<mon:lik<!ytodo ,,,.. hall<) (two-third< of campus,soffer ,uch dorms)
i11hem><lvu.lfth<yr<rogniz,1ha1h<avydrinkingorillicit - • prohibit alcohol at campus <V<nl< •nd fr•«mityl
druguS<i,notnormal,thcyaremon:lik,ly1o•bstain ,ororityporti<,
 • provi;"; •n<1
=t~ •~ohol-, ~rul drug.fr« ooci.,.V th.o1gooddrug<du cationwillencou ragesom<<,q><rimenta -
tionbutd<crus<abu.s< .wh il,baddrugeducationwillof1rn
• announc,andenf<>T«c ampu••leoholandothadrug incr<as< abU><. Fonunat<ly ... most college student>
polkies Trlllture, thei rdrug and alroholuseb«om,omor<S<nsibl<
• work with local rommuniti ,. to <n<ure th.at alcohol i,
"It", tit, f,,,l,,,,,n toal ar, tit,~ p,:ri
~- ..xall oftlt,m
not><TV«ltom ·n=
Tlt"lar,fm{romt/wp,:rr,oh·•"P'Mlimfortl,,fint!im<.
• •treng thrn academicrequirement> tit,~ "" ill anaciW>,9butIon,~ place. and ti,,~ lnj oot tlw
• ,chedulemOT<das><>onFriday """9' . Th=or,tl,,oo«l1njtol,,pan<1 1<00andl,,lp , ... t
• keepthelibraryandr<crution.al!.dliti,sopmlata ifl "m too>tli<t 11>,~;,,,tdrinloif-<"'"f'W•ndrn,,«OOClo..J
• =•rictalcoholpromotionson campu,
,,.,1,,"""'•ndt"'°"'"l'A,Jorm,.,p,M>O<ltumapamal
l..ind<<j<totl,,ol,l,,,tuJ,nt,1111,,,l,,,.,!,a,.,Jl,""'todrilOc
• notify par=t> when student> viol.at< alcohol/drug law, ""1do«tlwdoo,anJha.,a {,.,!,,,,. .,,"""' · /caOtbw>t
andngubtiom illlo tlwrooru;and/don"t'-'l.rttolu,l:b,l,;,ddoo,, , ... tl
Joha.,toprot,,:t!h,otli,,stud,nh/Joknoo,.,that..,l,,n
• ::~l~~::'!:"!:i:n.alcoholic bcvuag<> h< ,m"ro

• r.:::f:~tniningforbart<nder,;atcoll<ge-.;p:msorul
,,,.,,,,,.
tlt,•m"•!Wjim;~M,Jolrolx,l -f,u.lor11t>. tit,~ """ill>tanclij

• banorr,gulat<alrohol ic bcv,rag,adv<rt i,ingincampu,

newspaJ><n('50%ban,uchadv<rtising)
• 'nt<gr.,t<•"·, 1S<<ducati n'ntothecur ·culum
1
thrn, ·,~lv,s cl,.;,_r;,,d -<OO<ra nd wil~ model th~ kir.d
attitud <Sandb<h.o, iOTd<Sinoble in ap=rntio nprognm
1:
• h.ov,a,ubotanc,-abu..officeranda12>kforc,av.tilabl,
todalwithon-campus11><andabuS<
. ,.,.b li,ha higher-<ducation pnventionconsonium in Love,Sex,and Drugs
whichseveralcampu«spool1h,irknowledg,anddloru
(abou t 90,uchcon!i0!'1llais t) For crnturi,s alcohol wu th< ,ubstanc, mo,t a,sociat<d
• cr<at<progr. unstow orkwiththenrighborhoodandth< witho,xualactivity,glorifi<dlov,,andlust
community
"A~o{wi0<.oloafofb,,aJ.andtlioo"
• ·n·f«<>rlyd<tect · n.'nt<rve:hn,rn' um<nt,and
rd<rr alby~dmc,h.oll ... istant>.p «rcoun,elors,and n,,,-,..-,0-....,.,... (llOOA .D.)

halthandcouns elingcrnt<r,;
Atth<coll<g<lev<l,primorypnv<nlionalsoindud,swell -
publici,<d a lcoho! -ln,pan i,s.w «k long •ruJribbon"alco-
hol-a nddrug -h uc,ldm,tiom,and actfreoutreach acthiti<> Sadly.alroh olcan tak<on a lif,ofil>own andanyh<n,fii,
<>p,ciallythos,promotingW,.,x
lromalcoholcouldbecom,count<rproducti>·,
Foraprogramtob<eff,c t i,.,,th,thru lev,l>o fdrug-abuS<
pr,,.'<ntion (primory, o,condory, a r.dt<rtiary) musth< tai -
lored to 17- toll -y,ar-olds . Ontmi,uk<som,,ducator,;
rrw«i,notrerogni,ingthehighl<V<loFliOJ>histication
mostroll<g<stndmtsh.overegardingasp,ctsoFdrugs and
a lcohol Thi, can result in pr<0<nting • m,..,.g , th.at
a pp,an rondese<nding to th< ..,.,,..g<
student. Wh.ot
>tud<nt>donotfullyappr~dat<anth,long -t<Tmhealth
ro~uenc<Sofdrug and alcoholuS< Theadv,ntoFm,dicationstotr<at<r<ctiledysfunctionhn
p rod uc,cdthemostsignificanteh.ong<inth<useofdrugsto
ltpuul<,man)"th.otstudent>exaggerat<thedangersolri>ky enh.oncehumansexuality.Viagr a•( sildenafilcitr.tt<)in
h<h.ovior and in the '3Ill< hT<.ath ov,uuggaat< th< p<r ·
1998,thenCial1' " (tadabfi l) in200J , a ndfin.a!lylr.itr a•
cei>"roh<n,fii,,whichisther<asonwhyri,k)"h<h.ovioroftrn
(v.trdenafil) in 200 5 are medi cations th.at <nh.onc, nitric
·ns. "' Th<reare·mpr at' , ' ob' cu 'ou,oonundrum
oxideth.otevrntu allyrelaxes,moothmu,d,.inth<cOTpu•
lordrug<duca tion,wh ichu,u allyminimiz,. • n)1hingpo,i -
cavernosum<r«tileti55u e, allowinggr<at<rbloodfiow .
tiv,aboutdrug,OTa lrohol.1Fth<b<n ,fitsof drugsandalro-
holw<r<notov<r<><agg<r:ot<dandth<,id, ,ffttts w<r<not Not< th.at th,., medications and mostoth<r,ubswtC<s
undere:ugg,r.u,d . p,rh.opsth.otwould provide a basis of uS<dtoenlunc,c.,xu.olactivltiuar<nottrueaphrodi,iaco
knowl edgeth.otmatch<dstudent>'ap<ri<nc <>andp,o- An aphrodisiac i, a dntJ!orothaag<ntthotstimul at<•
hap,th<m,. .. g,.ofmodaationor abstin,nc,wouldb< (<nh•nce,) KXUaldesire r.uh<rtlunli<lm<thingth.otaug-
0 mmts ,.,xu.i abi lity. Most drugs uS<d to ent..nc, KXUal
::;.1:!~~i~r,;:,~~:n•:u::~~~o': ~~:~::::::::-~ p,rformonceh.ov,noeff,ct inthe ahs<nc,ofsexualstimu -
 !l<ugUse ondl're.e«Jon:Fl'om Crde »c, .....

l•rion ."' Th,ru,htode,;elopm<dicatiomto<nlu.nc<!i<XU •

•lity,wh,thubyincr<ningd<>ir<OTby<nlu.ncing!i<,rual 11,,,.,.,,,,""""'"tliotod1,1111i>t/"""'1J.,,.,,.,,,,
p,r'mEle<,confnn<> l.n-,tl,,om,toappro,,ch.Ooc,l'"s<licr«ltli,n
r"'"""""""'i., •,<kfifabl,,ondlcando~ul,11,,.,
Thelimiteddfo:1ofth<><drug,<TI1plaw:<>lh<complu:ity
olhnmEl!i<>nulity.Ourd<>in:lorfri,ndship,affection,kwe,
intimxy, a nd !i<X is a primny driving !on:< in men and
~:;::t:.i~,
~it:c:i:_; Aid that',,.i.,teot

womrn,rnddrug, • ff«ttlu.tprimaryfora,inmE1ydiffuent
rndcomplicat<dwoy,i . Som<p<y<:hoacth'edrug, , ,uchH
•lcoho l. marij1UI1.1., andecstHy , lowerinhib itions.Oth<n,
GeneralEffects
includi ng cocaine, amph<tamin<>, marijlUil.l., rnd som<
inlu.Wl<>, a reu><dto int<n<ifyandotlu:rwis<alt<rthe l'sychoactin drugs affect KXn•l dt<ire, excita tion . and
phy,iical..,nsation,of><Xnility,whil<,0111tcount<rlow OTJllim,Ph)-.ically , p<ychoacth..:drug,affecthormonol
..,ir.,««mOTsltyn<s< . Olt<np<ychooctiv<drug,,ubs titut< r<la><(l«l0>t<rone,«trog<n, a ndodrenalin<),hloodflow,
• ,impl< phy,iical sensation, or th e illu,io n oforu: . for bloodpn:,sun:,nuv e s,n,;itivity,andmusc l<t<nsionthotin
more-complex emotion, . ,uch ., d«ir< for intimKy and turn a ffectexcitation(=ti le • bility)andorg:,sm
comfon,loveofchildn:n,orre l=from•nx irty.Mrnyp<y • • Huoind«en<itia«prn;,lmd~nalnuv<rnding,
chooctiv,drug,monipul.ot<rui tunlbioch<mical, . 1h,r<by
• Alcohol diminish« ,pin.al rdlex« . thu, decre., ing
stimub,ting . c;unl<~<iting,blocking,OTmix ingupphy,iical
«mifr,itymder«til< • bility.
• Stuoid< incn:2>< l<<to<t<ron<, which ,timulat<s th<
Drug,lu.w•nimpact(bolhd<>in:d•ndund<>in:d)o n •ll fightcrn t<rofth<br.tin , moking•u«rmon:!i<Jrually
plu.s<>of><xu.alb<lu.viorfrompub<rty , throughdoting . to aggresm..:
!ntimxyinmorri•g<.Drinking a gl.,,o,1woolwine1og<1 • Cocaine and •mph<tamin<> rel<»< dopamin<, which
inth<mood . lightingup•cig,rett<•ft<rsa,u,ing•popp<T ,timulal<>thepl,..,un:crntuinth<limbic,y,it<TI1,th<
to"nt 'fy•n=t'on•ndrno,p,m , •mpl "n<>to
<En<<y,it<m,timu laledduringacitationandorg:,sm
delayej>cu lalion , moriju•ruoto<nlu.ncelh<nte,..,,.,of a
5t'-"lt'o n, orecsta,yto'ncr<2><<mf"th)·•reevid :<tlu. • MnlyJ>'ychoactP,..:drug, a ff,ctth<hypothalamu,,which
drug,n<d«irabl<toawiderangeofag«andcultun:,, c,ntrigguhormonalclu.ng,,
panicul.orlyiF,hyn<S< , lackofronfid<ntt , •ging,OTp hy,ii-
calclu.ng«lu.v<dimini<i><dontSd«ir<andabilitin
Tlu:u111tdrug,,whrnusedlongt<rmorinl.or,:,rdos«,
canalsoc•n"'th<r<vmeeff<Ct>:W:kofint<r<<t,phy•ical
dep=•ion . and inabili ty to achiev< •n a«tion or orgasm The actua l ,ff«toldrug,incontr.,1withth<i r <xp,cted
C<TWn drug, cm •l>o trigg<r ,oma l •ggr<>oion. !i<Jru•I dfecte1n,c,f}·rad icallyManyadd ictioncoun,elor<obs<Tv<
1u.,.,.m<nl , rap<(includingdat<r.tp<), a ndchildmole,ta - tlu.tr<egulardrugu«Bromhin<d!i<x•nddrug,tolo"u
tion . panicularlyifoneis • ln:adypron<to<uchb<lu.vior. :::::;::: t::", improvetheirp,rfoT1D2I1C<,andincrnse
Drug,canil,ornrour.1g< high-risk=lbelu.vi0Tlik<
multip le partner,, anonymous !i<X, unprotected><><, and
m• l !i<x. Prost itutionto,upponahabitis a nothuhigh ,risk "A,otu n•y,r/...,,-.-ortof,l,1,ondtli,.,,thmad...,f,dl
b<lu.vior. Allofthe,eb<lu.vionhav<th<pot<ntialto,pr<ad """"'f'<"""1rl. sup<rpr<ttlj.a.-up<'l'<"""Atthat"tl'lf,lt
!i<>ruallytnmmitteddi!i<..,.(<.g.,,yphilis,gonorrha,h<p- '"'l"wl:,.,.-Jandw,comfo,tal.,~;1J.:.,t tl,,d"'li "
.,itisB•ndC,andHIVdisu!i<)_ w

Tm mo,,,9,u1100~I'm with1"5!""'°"'/f,i,nd ot o timt

S.xmd lov<•re•uchcomplicatedproce,..,and,otiedto
r,,!,,,n..,;tlil,imfo,two..,nd,,-"""'_Tl,,on,~, ourm<ntal,tat<thot,omep,opltustdrug,no t onlyto
/.,,.,-..,;tl,fo,foo,"""'tl,," enhan«cth<i r saualitybutal,oto, hieldthem..,lv«from
th<ir=lity<>Tfrom<motionolinvolv<mrnt
The l960s•ndthe 1970.sawrnincr<2><inth,useandth<
rn,ilabilityolmorijn•ruo,•mphetamin«,and><V<r:o l otl><r
The Drugs
p<)'choactivedrugs--;allofwhich a ffect!i<JrualacthilyThe Drug -u,ingb<lu.viortak<son•lif<olitsown••tol<r>ne<,
, .. yavail.obilityofdrugs , roupl< d withl<s,restrictiv,atti - withdrawa l,•ndside,ffectsovuwhelm theuser S originol
tud«toward!iON.1.lactivity , incr<ostd!iON.1.lcontacts • nd intentions . Drug, aff«t><xu.ality b)'di,rupting th< neu-
drugvcp<rimrnution.Th<on!i<tofth,cocain e andcrock rotransm'tt<ro!i<roto 'n , dopnn'ne , •ndnorqineph 'n<
,pidemic inth< 1980scontinuingtothe lOOO,andth< S.rotoninaff«tsmood . • ggn:,•ion . md!i< lf...,,«m;dof" •
incre.osedu«ofm<thamph<t>min< . <csta<y,a ndotherclub mineisbeliev<dtoh<lpregulat<mood,<TT>Otionolb<havior,
drng,encourag<dhigh -ri<k,e,ru,loctivity.Th<drug,'mood - motorcontrol,mdorg;,,m ; a ndnon:pin,phrin,,timulat<,
ilt<ring<ff«ts,a longwiththen<edtofinanc-<th<pnn:ha!i< ~,..n rad« •:~~:::•body function, whi l< incr<a<ing moth-. -
oldrug, , addedtothecompl<xityofthisin«m:lation,hip
_,,
-o,,,~af-•nd""""''M,,o~ t.od,w;,
an.lp11rutfil,,opoo<«lfflfttd/W;lo,./.,...roo,
lil,ol.,,,.and,.,...M,,l;,,'l""M,o,.lil,a.1'9-•

..~~::,r.~:.:1:::~.=..~:.~-:::::~~
champagn< ta ccltbnnt . "1n< wnh I romantic dinner , •
nighlap l,don, -. Akohcl\ physical dftctt on Kllual
fun.ctioniJ>&uccic....lyn,lawl10blooclalcoholl<'"<'5.ho
....,,ta] ,fJnu, 1,owc..,,, "-'•....,,.to do with tho: UKO
~l11111ktupandiht1<11inJthaawllhth<.........,,
=::;:;,c:.rO<n ptt-n;lsd"I i.s .... •""" wh<n one Is under

·11-~-fttlhrlkr"°"",...,..i( . Ji-~l,,/-
•!1---,coJJ~•"'l-1-u,1 . Ji-~I,, .
~-~::t-~i..~~;::..~:.."!':~
-
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tht...toifMr,-roaloottl(o,tlttlll(j,t:

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tiomar,plattdon
n-sod<tlnmoN:taboos
a w<>man
andrutric-
l .,.u,,l!l)l1hanon1man\
M.onywom<n who drink htavlly usocta t< 1ho!, klontity u o
womanwlthth drsccual 1ctMl)'. BcauHalcoholdlm!n-
h he,,exual1rou .. 1,,.om,n c,,n sufTcrlowcred 0<lf..:otHm
andfullnl!'oflnadequ ocy.'fypla lly,on,lc:ohol tcw!!ld<ny
lhatdrink!ngaffceuh<rS<l<util1y.

relatedtodrinkingr>therthantol<>ff . lntlnll<}<<>rslmply
pleawre
--- The bmiliarrele'""'ollnhlblllonsln bolh
....,.danddeedislhekeyto.Jrohol\dualefftttonaman\
,,,nu.I artivity (i.e., mou de,i~puformancr) . In men•
bloodalooholroncentntiono/0.0'l(aboutlhrttbttnln
on<hour£o,-alOOlb.m.Je)ha,a.,.rymeauTablephyslcal
dJo,:tonperfonnance .~ y,akol>oldlminbhtsspl-
[..,, thouv, many.,:,mrn ttpOfl 1h11 alcohol...., inc,n,sa naln,llaa,tbmdeneasings,cmitivltyondntttlleablll1y .
!oCXIWpleawl't , quantlul!Yt m,,au,a ol ph)'Slcal Kwal Eftnalnrdrinle,WW<nlL>tostaonelnT!...Malts..'llha
artJUYJandahUlryiot.a...onotpSm<lccfCM<whenbbod long-1ttmhntoryoldrinklnghawde=mc,:itL>tOMtront
:.,~ha~~:.!'.
1s
:::::=;!::
In mtn, h<,,m-tt , 111<
1<1f•rtpomd fulinp and the oti;ective
andaninc~infemale><::1>l<n>id.
abnorma6titsln!i<llstttoidmnaholism
, ...,hasts1...tlol
..._...
, and

m<1>1&raolphy,ical1110...alwtttrnoft00Mis~t lnitiall,:alroholgi=mm.moneconlidmttbttaut<t1aou
o,:ilh,e...,,oltbebr.untbar.repl,,1a6«),1,frigb1,andfur ,
lnon<>1udyolfmu.ltchronicalcoholia.l61-0lldtheyh-.l lh<n,by promo<ing _....;- Early dlccu also al£ttt
orp,mslo<than,..olth<time.Thtonodyalsob.tnddu.1 th<rortial.,.,..oltheb'2intolowerlnhlbilions.Asalco-
~dy,fu.nctlon .... th<btflp~icco<olconlinucdl""°" holmrl many men fttl kM ~(possibly~
lens with aloohol abuM."' tt .. ry dnnlliq prod""" •--rmntanda~potloo-..!1halcnhol)
in<naoalnpla.nu.ttS1CSttt0nt , ••h lch,.nlnhibit0¥Ul,, - and1<nd1<>sltyn,,1yfmmtbebedmomandtvtnbtcom,
tionanddrttUKl<:rt11lry. ,,,_ lleavydrinklng also .. u.., ..,,au.1_[noneearlystud)·.impottnnc..._.reportedln601.
m<:""11..Wdi>turban«S, opon11neous JbonloM, mt,cor- ofheavya!roho]abus,r,_ lll
riq<>,andf<lllakoholspm.Nmdlso!dcrs. "'
Asdrinklngp"'!l-••lrohollcb<havlorlrtbochmen ·s.,,_1adlii- =...il.o.ta lcJ.ol.r .. ;.,,1....... ltod
<><=Ol!l'.ldo~-
and women t,, n:\nf<nttd , maklq lt difficult for an ala,,,
holictodo anythtqbutdrink. Scltb«omtsoomethl"ll
 !l<ugUs< ondl're<.e«Jon:Fl'omCrde »c,.-.., I.J7

Ad-andAkollolAkoholincr<.o5<>rukyandneckle .. oltmg<t a boo>tofco nfidencelromcocaineOTm<th>mph<t -

beh•vior inteeruoger, (whoare • lreadypronetori>kybeh •v- •mine,_Somronewhoh>,unu,u.alsexu•lproctic,swillbe
ior,),wh icholtenleodstoun sole«x.You ngt<ens(l2tol 5) mon:likelytoint<n>ifythosebehavior,undertheinfluence
who u,.ed alcohol, tOOilcco.OTmariju•na were provided with olthesedrug,
p~mcypK\,ention!nformotion•ft<r<tudiesconfirmed
th>tthelikdihoodol a nunpb.nnedpregruoncyincreased
withdrugU><C."' Anothastudy inEngbndfoundth>tchil- -,:;~.°!/~.:~t·:;:,~,
;,~~ht' 6

dren Uto Ii)"'"" old who dI2Itkat leHt once• wttk had
•IO-foldhigherchanceofhav:ingsexromp:oredwithnon-
drinktn.E>,enroneandoc ca>ioruoldrinker,hodoignificantly
~1}•;,.:;e
~';;l ,!·=i ~~~i:..."':i
'l""""'"·t,«>et"
higheroddscomponedwithnondrinkers. '~

Cocaine and Amphe tamines High-d<»<•ndprolong,dusehavequitetheopposit<ef!ect

Although cocaine a nd a mpheumine,;areu«d by h<tero- on«xuality.lnmrnheavyorprolongeduseofrocaine in
«xuals,thcy a reparticubrlypopubrwithga,·male,_During panicularoft,ncauses•dttn:...,insexuald"ire,difli-
initiallow-do«U><C . the«drug,incne:,seronlidence,pro- rultyachi<Vingan<rection,•ndd<layedtjaculation
1 ganattt 'on . 'ncruseenduronc e,and "n1, ·•, •n In women abuse can disrupt the menstrual cycl<. caus,
OTJ!2Sm,"CrysL>l"m<th inporticulorhll•cquired•reput1 - difficulty in •chiev!ngo'&"-'m, •nd decn,ase de,ir,c ." ••"'
t'on r 'nte 'f,i g som• l sensat'om. "' Coco."ne •nd
•mphewninesincr<easethe,upplyofdopm,in<•ndnorepi - Cocaineoramph etomine • bll><Cnuhibit•higherincidenc,
nephrineinthenervous,y<tem,inducing•rushofpln.,ure ol:mtisoclal •nd othe rp,rson ,tlitydisord er,"' well u a
number of pn:-eJristing 5<>Cial a nd emotional problem,,
by•ffecti ngcrnt<r,inthebr.tininvolvedwithsexua l acthity
m0<tly inthelimbic,yst<m. '" Thed iffenence betw«nthe ;:;;;::hi;!~:;~'.:.~::~:• effects of the stimulants
twodrug,isthedur:,tionofoction;mtth2mphetamintl .. ts
houBlongerth2ncocain,andthusprolong,the abilityto
su<11inKXualfunctioning(<rection•ndorgasm)
Judg!ngthesexua l dfect5of cocain<OT a mphet>minesisdil -
ficultduetoth<, -:uiabilityofthedrug•purity.theamount
octu•llytaken, a ndtheef!ect5ofmydrug,t1kma1thesam<
time,porticulorly•lrohoL Th<m)thol, timubnt ef!ecti,..,.
ne,sonsexuallunctioningoltmoutwrigh>thernlitywhen
controlled<tudies(which a relimi ted)>reconducted . One
dowru;.idetou,ingm<thnnphet>mineinporticuloristhat
theinitU.lse,..,.tionswene!iOpln.surabltth>tuS<rscame
todependonthedrugto<njoysex.Continueduli<Ccan
'°"""'
From Humphr~y Bogan puffing on on< cig:,r<tt< • fter
mother in Casabia0<ato Brad Pitt smoking in Fi~lr• Club,
then start the dmomwud spiral of =I dysfunction cig:,r<t1«hllv,playedaroltinro11Untic•ndS<XU • l•itu.

~7: ~::"i!":.:::~=~ei:~;~:::::!:;
tions in film for decad,,.. Not surpri,ingly, the tob•oco

;:,
industry enrouragesth,.,,displa ys . oftrnwithfinancial
pla,une, particularly lorwomen. PreexistingS<XU•l pro- ine<ntiv,,.,Th,,hotol•coupl<lightingup a fter«xbecam<
div!ties a n,dirtttlyre lat<dtotheeff<ct•n dth,,ffectiv<-
neosof a oydrugu..,whenitrd •t<•t oKXualbeh>v!or. i:'icr~";:7 •:: ~o~io:":ic:~ri~::ti~1:,"';i
Someone who is nonruolly shy OT sexually inhibited will Americaa nnouncedth>ttheu seoftobacco in •fi lmwould

Jl,i1antl->moitl,to1t"'1g<Wd!
pa,roJ .. .,,-,,,.11- rOM«of.u
Cal,fot•;.,•,ompait•

IWARNlNG
: SMOKINGCAUSESIMPOTENCE
I
beron<id=dwhrn<l<terminingth<film'>r>tingand<lut Sedati_.Hypnotic,;
"<l<pictions<hatglamoriz<•mokingormovi<swithp<rV2SiV< Mony><dativ<-h)'Pnotics,,uchutheberu:odiuq,in<> . bu -
smokingmay=:riv<rn'R 'r.t ting,"""Th< numb<rof.mo,i< bitur:1te,, •nd !i0m< ofth, Z-hypno1ics, hav< be<n call<d
''"""" in which rn actor or actors wu, >m<>kingw<nt from "alroho l inp ill form"•ndtout<da.sS<llua l <nhancers . Th,y
n<arlyHlOOinl006downtol,9J3inl009,butbackupto do low,r inhibi tions and mah tht usu f«I mOK r,J:oxed,
bu t th<y>l,o induc,physicald,pr<"ionthat lowa,th<
:.=.m.i:~~n~':';'1;::'~7i'."~~~ rC:~:~
abili tytopaformor=pond..,,ru ally
thing,>=rch<Isdo . Studi<>,how<hat)"oungpropl<anctwo
tothr«tim<smor<lik<lytobeginsmokingiflh,yhawbem
h<>vily<Xpo,rotoinag<>oltohacrous, inmo>i<>.' ~
Phy,ically,nico1lll,canbo1h,timulat<rndr<W<,d<p<ndlllg
onth<><t(mood•ndmenal,at<) rndth<><tting(loca -
i ,) . lnsoc' I 'tu•t'on,·1 · •gr,atd'tr.tct<r,!iOm<th'ngto
dowhil,figuringou t whattodo.Dn,,urveyfoundtha t ado-
l<>erntswho,mok<>r<mor<lik<lytopanicipat< inrisky Alongwithth,disinhibition,S<dative -hypno1ic, a l!i0impair
behavior, (multip l<><Xpartn<rs ) during their l<<n y<>rs judg mrnl . ffllling lh< user more ,usc,ptib l< 10 ><xu.al

~::'!:::!~~:·1:::r"'«::t.;:~!~:::',:"i.~:
~::
dy,fonctioninm<n•ndreducedf<rtili tyinwom<n , >lthough
ad= c« . A, the d= incr<»<•, the S<dati,., dT,cts uh
ov<r,makingth<US<Tphy,icallyl<><abletowardoff=u.al
aggr<><ion . Th< US<Tbecom,. l<thaT)!ic a nd si"l'J' while
exp,rimcing utemiv, muscl , r<W<atio n . With abu>< of
alcohol:~_ ,.,_,.~, ext<nl caused by <x=,;'v, coca·n, or
.., dative-hypnoticsrom,o><xu.aldy,fun ctionandtotal
apathytowudKXUal,timulation. 1"
Opioid,
Fewstudi,. have been done on thesvnul ,ff ,ci,ofth,
Downer, ar< oft<nu><d to lower inh ibition,, t houghth<
new<r ,1<,p medications, ,uch a,; Ambl<n,• Ro.zerem,•
p hy, iologicald,prnsiv,,ff<ctsoFtrn d, cr,H<pnfoo-
Sonata,•• ndL)Ti ca,•co llectiv,lyknownasth ,Z- hypnotics
=•nd<V<ntu.rly d,sire.Som,·nodoff"wh<nusing
bu1 t h<y>r<d<p,.,...nts,!i0itislik< lyth')·wi!lh<foundto
ot h<rs>r<rnagi,ed.Th<><diITm,ncncanbee,q,b inedby dim inishde,ir,•ndorg:,,m
><l<ctiwtol<r.tnceofdiff,rrntfunctionsolth,bodytoth,
df,ruofopioid, . A 1982studyofm,n a ndwom<nwho M0<1of1h,,hort -acting>«bti,.,.hypnoticsal!i0caUS< am1><-
<nt<TrotheH.aigh1AshburyFruClinicslorh<roinrna1 - •iao.S<xu•lpr<da10TScountonth<factthatth<viclimsth,y
m<ntfoundth.otmos1hadexp,ri<nced!i0m <><xuald;'>l unc - «du«•ndr:1p,willha,.,nom<moryofth,cv<ntor1he
tionbefor<usingthedrugandr<pon«l•n initi.al p<rp<tr.tlor . Flunitru,pam(Roh,'Pnol •) ,dubb«lthe"dat< -
improv<m<ntin=ualfunctioningwhrnth,yfirstb,ganto ,.p,drug. "is »':libbleonlyouWdeth,Vnit<dS tat<>a ndi ,
u><.M<nrq,ort<danincr<as<dd, lay in<jaculation;womrn mark<tro .. a,l«pingpill . ltcau .. ,proFoundamn,,;i,,and
r<ponedincr<as<dr<bxation•ndlow<Troinhibitiom.With loweredinhih itionsasw,llas a d,cr,as,dah ilitytor,si"
ro r ti du><,how,,.., ,,,orr1<=bec•m<d' 'nt<r<>ted ' n •=ualu,a u lt',."'(<«Cliap<eri)
><x,wh<r<><oth<rswantedtorq,atth<exp,rirnc, . Long-
GHI (fHIHIIO hfd roxybutyr ... ) GHB (chemically known ..
:~':x"::,"'porttd imp.air<dp,rformanceandadttttas< >Odium oxybat<) is• S<dativ<-h)'Pnotic and • dopamin e
<nhancerthat wasorigi nallyu><du a sl«pinducerand
pandmcically . 1orrutdifficulty, taylllg awak<(na rcol<p,y)
-Yoo,torttolool:,,.,, , ..,sculiN. Yooft<lootof'f""',ktn
butitbecam<popularonth<club>e<n <. hha,;b,entout<d
;::;,~
~j7/~r=~~ 1:;:"'1::1-
:-;:,::;J uad rugthatwilllo,.uinhibition, andHWl<><xmor<
plnsurabl, . ltwuwid ely ava ilabl, inh< >lth -loodstor<,in
thel980> a ndusedbybodybuilders.Slightincras,sin1h ,
amount of GHB used can man large diITer<nc,. in th,
ln t hel-!aightAshburystudy . 60%ofheroin•ddict,~rted
,ffects.Doublingth,d.,.,,tha t induc<>a plusa nt,fftttcan
anovaalld«=ind<>ir< . Whil,thcyw<r<highonha-
disruptooordination,caus..si«p . or inducecomawithin
oin,thatfigur,jump,dto90%oflong-l<fmu><r>.ln•noth< r
l OtolO minut<, ."' GHBisoft<nu><dwithoth<rdrugs
study70%rq,orttddelayedejaculationwhenu,ing,wh ich causing,yn,rgi,tic,ff,ct,th.otcanproduc,danguou,inl<r ·
iswhy!iOm<pr<matur<<j•culator,;>< lf-medi cat<. Th,oveo- action,,man)·ofwhichdi,rupt><xual activit)lTh ,a mn<>ic
allnt<oFimpot<nce(inabilirytoNrom,aroused)inon<
,ffectsolthedrug,wh ichcanb, therap,uticallyvalilml<
study oF mal, addkt, ...,. 39%, jumping 10 53% whm th ,
l~toitsuploita tion .. adat<-r:1p, pr<datorydruglik<
,ubj,cts w<r< actua lly high_.,.. .,., Reduced l<>losl<ron, in
Rohypno!. • 1t.,JlsforS5toSlOonth<str<<t H1
men ledtoimpot<nc ,i n!iOffl<,w hil,long -t<m1f<m.al<u><r,
r<port<dmemtrualimegulariti<> . frigidity,andr<ducedf<r - GBL(gamma -butyroa<Cton,l, a widelyusedch<micalorigi -
tility."' Thlsisduetoinhib itionofgon adotropin -r<l= ing nally!i0kl•• aheal th,upp l<mrnt,i , com'<n«ltoGHBin1h e
::=:n ,~; •n<urohonnon,thatr<gu lat<>th< t<>t<>a ndth , body•ndistoutedu•=lrnhancer.hhaobernsolda,
R<newtrirn1. • R,.,.;,,,.r.,nt,• andV itality •"' GBLis>lso
 !l<ugUse ondl're.e«Jon:Fl'om Crde »c, ..... 1 .39

found in "'m< paint thinnen like Blue Ni,n,, • which is ple><ur< from touching •nd ph)~ iail intim.ocy rathu ,rum
divuted •nd •bused . Liquid GHBH•v:o il.oble ><the pr<>erip- =ual experience. ''" In fact . man)" usen de!iCribe its effects
tion drug Xynm • fo, the t r<Olm<nl of exc=i,,. da)"time a,; incra<ing empathy for others without producing "")"
sleepiness . lfp=ribed . itiscl.oMifi«l><•Schedulellldrug. =uall« ling,of•rousal

Marijuan.1 Mo,tof1 he n:ports•bou1the«,ru • ldfectsofMDMAand

MDA •re anecdo taL frequent polydrug use (<>peci• llyof
),farij1Umha,;be<ncalledthe"mirrorthatmagniOO "b<ca u,e
• mphewnine . mariju aruo,a nd • lcoho!l,• n excitingenviron -
mE1yofitseff•--ryenlu.r.cement.nove lryenlu.r.ce -
m<nl . a nd• u«r ~ heightened awor<n<<Senhance the drug,"
ment.«emingprolong:,tionoltime,inc=<l•ffection•«
dfectsandputtheint<grit) · olthedota inquncion . PO«ible
bonding,disinhibition,diffu<ionolego,rnd>UU.1.lized
danger,fromexces,use includeh ighb loodpr<>sute . ropid
fanta•)"--<>Ugg<>t > pre=Htingdesirefo r the««Mation,
h<-"nrate . overheacing, a ndprolongeddi,ruptionofKro t o-
Mo5tolthereporteddfectsfrommariju•na•rernecdo121, nergicact" 'ty 'nthtcen tr •ln<TV<>< , cem. F someth
,uchul«ling,of=ualp lea,;ure.rathuthan,pedfics . lik< emo tionoln:,..:l.otion5broughto nb ythedrugprovetobe
prolonged ucitationordd>)'<d orgasm . M•rij=. more utttme lyups,:tt ing
tlu.nanypsychoactivedrug.illu5tr.tt<>thed ifficulty in,epa -
ratingthe>ctu>l<ffectsfromtheinAurnceofthemind -,e t Mephedrone
•ndthe«ttingwherethedrugisu,.ed . lfthedrugis,lu.red The new,., entry on the dub drug li,t i, mephedrone
·n•,oc '•l«hg . >1• 1"/0ron•d•t< . th ere 'srn,xpecta - (i -meth)"lm<thcathinone), known on thestr<<t u mrow -
tion t lu.1people will I>< more rel.oxed, l<S>inh ibi«d.•nd mrow . M-CAT. "drone ." "bubbl,._- and monyothu nick -
morelik<lytodothing,thcywouldnotnorm.allydo.lnone ruom<>.Mephed rone i, a syn th etic VUWlt of cathinone, the
ol1hefew,rud ies on drug,•nd><xu.alfunction . marij1Un.1. active ingrciie nt inthekhl.ts hrubfoundinSom.alil.•nd
w•• ><oocia1ed with inh ibited orgasm but not inhibited e20t<mAfric• . Th•drugbecamev=1pop ular inEurope,
desin,. "' Surprising ly,there • rev=1few ri gorousstud inon <>pecil.llyEnglrnd.duringthepa5tdecade"5 a dubdrug,
fflmjuano •nd =ualit)'. Smoking fflm juano to ace55 ofl<n witheff<rtssim il.ortothoseofecsusy . roc aine . OTm<th.om-
prev<ntstheuKrFromln.rninghowtolu.ve...xualrel.o- phttamint . By the lot< 2000. . u.se spread to the United
tionswitho uth< ing hi gh,"'1hec)"cl<olu,eisperpetua1ed Stat,.,wh<r<iti, legollp-oldu•bothsai t orp lrntlood.As
!;:u;::.:~ 7:~:~:;=:r::om
,.,.11 hmy ha,;hish u,e is
o/201\mephedroneha,;no t beenlistedundertheContro
Substances Act. Mephedrone i, • lleged toproduce ,e,rual
lled

•rousa l th.otl<adstohigh -risk,exual•ctivi tycmanyofth<><

MDMAandMDA(ecsla"'I) reports a nditsprofileoftoxic•nd<idedfeci.•n:•imilor to
Af«r•fewyarsoldedine.P""' •month • bus<ofec,tasyb)" those found with MDMA rnd m<thamphetamine ."'
tho,e 12yensrndo lduro«lrom0.l%to0.3%,then!ell
back to 0 .2% in 2012. " The 30 -d.y use by high -school
«n iors.however . dropped from l.8%in 200810 1.3% in PCPisnotu,u•lly .. oocia1edwith><X.butbta11><i t i,•n
2013. '°' U«rs '"'-Y !hot MDMA •nd MDA (at modeat< rn<>th<ticitha,bttnu,edto de, denthtpainofsome
des<>),unlike metlamphetamin<>. calm th em . gr,'e them unusu.ol !iOCU1.lp ractice,,mo,;tlyby,mall><gm<n'5ofboth
wum fttlingo toward othen, and indu ce • hd gh ttne d
=•u.olawueness . Thewarmf«ling,,upposedlym.oke :~:tf2 w";,';!~':i~: c;:,:::n~:= ti~~ i~i~~:.':~1:e u•,::
dosern:l.ot ion,withthos,aroundthempo,,ib le th ei nfiuence.but lowdo,,sha,,.b,ensaidtoenlu.nce
=ualde<ire•ndperfonnancein50me.po,oiblyfromthe
·1hod,., ;oi,;biwm. I""""' jt ""'~I, ~"'11n
-,, =I low<ringol!nhibi tion,. ""-"'

,!'~t:::z:~r::.t~
~:.:.::ir
/tool;,c<!a<ij" The elf': ~f psyched•i 1 lik~ LSD ""i""=i ni;.:t the

r«ultfewcontrolled>tudi,.h•vebeendone. The same is

Although the !« ling, of do«n<M a nd ,eru;uaiity •re trueofp<i locybinmushroom>>ndpeyol<
enhanced,theab ilitytohav,rn,r,:ctionondanorgasmis
~lat ileNil rites(amyl , butyl,andother.;)
:1m!=~:;! , h~; !7:'1ttol:~:Y·:;r;,i~~~n7t:t Vol.otile nitrit<> •re ,'Hodilalor> •nd mu!iCI< rela.o nts . If
t1Unipub tionof.., ,otonin . Rq,orted ly, i1m...:r,e,therrup- inhale d justpl'io r toorgas m, theyseemi ngl yprolongand
tak'·'tl, neurotnmm'tt<r, rnulJ g ·n•nexc:<>o 'nth enlunttth<K"'"'-t ion.Llk<Viagr:a .• thcyougmentuec -
,yra.ps,:rndddi>·ering•more calmingeffectthrnmetlam - tion<and>r<5>idtointen,ifyo'&"•mb)"dil.o tingblood,,. s-
phetamineennthough itis a psycho-stimulant . Supposed ly, ,el>inthepen i,.Abu«d»o')!a,;m int<nsifiersbybothgoy
,e,rual uc't<m<n l occur, more often when oom"ng down rnd,traightpeopleinthel9605,theygoinedtherepu tacion
fromthedrugthrnwhileunderthe influenc:<. • lthougho nly olb<ingy«•nothe r "lovedrug. • They a re • l>ou«dbtause
23%toXJ%ofusenreponedrn)"of1he«reaction, . A theyrel.ox•na l ,ph inct<r mu!iCl<>. The<idedfectsofdizzi -
,urveyof 100 MDMA usenfound that the drug induced ness . w<2kn<M. ..dacion. r. inting.and..v<r< headache,
oftendiminWlorcounterxt the desired effects ."' Long - lo,.,,o,lo,;tlShouldthesedrug,chongethementalorthe
termcont'nuou,u5ec01 ' 'toan· .-.cnca.,.e· ·• g10- ph)• ical.,pect,ofsexual ity >bthegoa ld e,ire,prolonging
binlevel,lha1can be1 oxic•nd ,o nrueoce2>iono ,fatal .,., exd,..tion, increa,;ing lubrica1ion. delaying orgasm, or
improvingthequalityofth<><>nule,q,erirnce> l, a drug
Nitrou,Oxide(laughinggas) lhat low ers inhibitionsm aphrodi>i>d Heroinoometime,
tsitroo,; mcide become popular at music dub. and r.m , t' ,psm, coc>n<"" ti e, ·ncr<eases 'ci < or p
pntie,lortheglddine,,itproduce>.lti,notu ,u.allyronsid- long,me=:tion,md• lcoho llowers inh ibitiom .there by
ffro•"'xuillyenhancing•nbotane< , il thoughreportsof increaoingde,ire;ohouldtheseb.coru;ideredaphrodi>i>c,>
"'xu.alh•llncina1iono . arousa l. andorga,mh•seocrurrciin
fug.-., • cu.1i, ," andlevitn • Facilitat<theabilitytohove
dentists'officeswhil eu ndntheinfluenc-efor a procedure
an,nctionby,nh,ncingblood0owbut•renotactual
Onestudyoll 5 dentalpn,onnelwho•bu<edthe,ubotanc e
loundimpot<ncein,evenc=s . Theprob lemw a,;reversed aphrodi>i>cs.Thereare='<rolpurponed aphrodi,i>c,
whenuseoftheg:,,wa,;,topped ..... • SJ»nish0y(canth>ridin,>tox indah .,dfrom a btttle)
•ndgroundrh in oceroshominita1<1h,urethroand1he
Psychiatric Drugs bl.odder, promo ting• J>"'Udo-sexual exdt<ment
Moot patie nts who u« Jl"ychi>tric medication, have pre - • The>erntolph<romones-hu~hormonesfoundi n
existingemotionolproblemothat•lre•dyimpair « xn•lfunc - p<l"'>pir.otion- hHbeen,howntoincr<...,desireand
tioning.Bytreatingtheme ntalrondi tion,thepsychotropic 1101uolstimulationbu1act•• •phrodi, l.oc,o nlyilth,y
drug,C2It•lso a ffectthen«T,«>nu.lfunctioning.For com,lromprop le withdifferingimmune,y,t<ms
ex•mple, mmtid epressantcanmoke• patientmore•bleto • Yohimbin,, •n • lkiloid obtained from ,everal pl.ont
engageinin1imo1<relation,andS<xuol • pprec i>tion, capa- oource,,produces,omeholludra.tiono•ndm ikleupho-
bilitie,thatwereimpairedbyth e depres,ion rioandh>,bttn uS<dinhighdo«sH > tr<otmentfor
impoten ce in men by incr<Hing bloodpressur, and
TheneurotnMmill<TS<rotonin~beenloundtob<
involvedwithmany.,~ofS<xu.albeh>,ior.Depending h<anr.u,.ther,byincn .. ingpenilebloodflow . ltcm
produc:< acut<mx ietyotlowd.,..ges ."•
fac!li~t<horinhib;,,.~[b<~vio,h"'d,seroto 'n can 'thn • L-dopai> a pru:ursor to dopamine in the bnin, •nd
dopam'ne· theneurotron, ·1t<r ·nv, ' ed·n ·'mrn -
Studie,imulv!ngtricydicmtidepressants , ,uch••d«ipro - tal experienceoforga,m. lti>U><d medically to trut
mine (Norpnm in •) • nd•mitriptyline(El • vil'),h>velinked Pukinoon,dise,o,;,.ndw:ostoul<da,;m aphrodi>i>c
them to decreliro desire. problems with erection, and duringth,1970. ;howcver. it h>snotbeenpro,.,n
dd ,y,dorgasm .l niti>lly.therelieffromdepr<Mionillow,•
u,utob<moreS<xu,llyinvolved . Mmyantide p""""-n" Ra ! or imagined "•onu.l rnhancers" lose th , ir effectiv<-
(SSRb), ,uch ., citalopnm (Cel,xa S), escitalopnm nu• over time beaus, oF th, body• urw:ing ability to
(Lenpro •) ,..,nraline(Zoloft • ).fluox<tin< (Pro=1') .and ad•p t toanypill , potion , orbr,cw
p • rox.tine (Paxil "), alw can., delay or inhibition of
orgasm and impaired,rectil< •bil ity ."'.,...,.. Prru ac 0 has
SubstanceAbuseandSexualAssault
il,obttn.,,o cia1edwithprofound5exu •l dioin1<res1.where
><xi>poss ib lebuttheuS<Th>snoint<restintheactiv!ty .'".,. ,
AntiJ>'ychotics ,,ucha,;thiori<W ine(Me ll:uil ' ),inhibiterro-
til<functionand,joculation.Oilorprom:uine(Thora.zin< ")
andh.aloperido l (H.llldol• )c•ninhibitde>ire.<rectilefunc -
tion,•ndtj•cul.otiorL lm pairedejacula1ion•ppeantobethe
mostcommon,ideeff«1ofthemo j ortrmquiliz<B(antiJ>'Y ·
choti cs) . Someindividua l,takinglithium(U><dlorbipolar
disorda )repo ndecreasedde,ir,c a ndd ifficultymaintaining
anerect'on.,thedo,age'ncrease,
Oneinevayth=womeninthi,countrywillbe•,-ictimof
There ar, numerous KXual ,id< effects .. ood•t<d with
><>n u! violen« in her lifetime. In one study of KXU•l
Tn2Itypsychiatricdrug,,butpatients•ren luctanttodis-
.. .._ults,victimsnponedu,ingdrug,onlroholin 5l% of
cus,themw!ththeirphy,ician.soth,problemsar,of1<n
th, cas,s; ,ubst•nceuS< byth, .... ibntswu found in
ignor<ed.'°'
about+t%ofthecase,. "' Anothn<1udyfoundtha1approx -
Aphrodisiac, ::~:r:,,~f S<xn•l offenders wer,c drinking at the tim , of
The search for true • phrodi,U.cs i> complicated by the
romplexityofthes,xual=poru,e.Th<J"ychologic •lroo ts lnmostcase,;themoleu.,,ilr,ady~trndenciestoWllrd
ofmostemotiono a requi1<complexand,ignificmtlymore improp<ror•ggr<>•ivebehovior, •nd•lroholo r ,nother
important 10 ><xu.alfunctioning thEl mrn, enhmc:,ment of drug«n"<d .. th,finiltrigg,r .T hetriggercan a lsobem
><=tiono . Tha1~notstoppedhum.onslromseekingdrug, emot"on,uch ., u 0 r,hol<.thene«' ' ontrol,. · ,oom e
guarmt<edto rockth<irworld. l,theohjective •ffection cases,lusL
 !l<ugUseondl're.e«Jon:Fl'om Crde » c, ..... 1.4 1

SexuallyTransmittedDiseases(United States)
.!t::;
·:,~,.~~:t~t~t:'.t"-'?';::; and SexuallyTransmittedInfections
~::;_~ndmidi"8 "1 thrir ""'!
p><j<I,, b,fo,,t°"j tad (international)
The Crnt<f:'ffOTDiseas<ControlandPrevention,stim.ot<s
...,._..,_,
_..,,,,....,.,._
MV--1"' that20millionnew~ofS T Dsoccur,xhyarinth<
Unit«ISta1<0. m.rr• r1><WorldHalthOrganiza1ion,stim.o1ts
that int<rn.otionallySOO million c..,, of t h< four m.ojor
~':~';;~h:t:n:n~::•l:::::~':':;~;hoactiv< drug< STb occur nch ye.,- (chl•mydia. gonorrhea. syph ilis . and
trichomoni>sis).Aboutl % o/thos,propl<will<ventu.lly
• Alcohol lowm inhibitions and muddl<> ration.al dielrom1h<infection . lncon1ru1 . J 5 millionprop l<•r<liv -
thought.makingth <uS<rmor<lik<lyto actoutinational ingwith HIV/AIDS, •nd • lmost a llofth<mwill<ven1u.lly
orin.oppropri,t<d,sir,s di< from HlV-re i>t«l disuS<> ."' ln •ddition . 530 million
• Cocaint and methamph<tamin< incn:ase ronlidrnc, ha,., the HSV-2 vlru,; (h<rp<> ,impluviru,; l)"p< 2) that
:!u~~:::n . makingamal<uS<Tmon:lik< l)·to ca"-'<>grni talh <rp<>,>ndl90millionwomenhov<•human
p;tpillorno,iru,(HPV)infection

• ~.:::: ~:~~~~~i;::i,::;'!~ mor< pron< Epidemiology

• Marijuorui makes uS<n mon: sugg,s tihl< to S<Jru•I
ti 'tyandmon:S<: "ti etotouch
• PCPandheroinmak<a><nles,~itiveorindiff<r<nt
topainmdthen:lor,mor,li>bletoph)-.ic•llycb.nag<
lh<irpartnmorlh<m><h'<S
• StuoidsC2Itincn:..,aggrnsion•ndinationolb<havior.
ln,omec=ofcb.l<r.tJ><,lh<man ~ initialintrnlma)"b< j u.t
•·roUinlheha)· ." bu1 ifh<isn:IU><d0Tdoesn\g<1hiswa,· , h,
b<com,smgryandak<swhath < f«isisrightfullyhis.Th<
act ofnp< is motint<d by• nttd to ovupo wu. humiliate,
•nddomina1t•victimnth<Tthmbyad<,ir<tohattS<X
-=~~;·,,"::.;,~~n:::;;~~~ -~-«
ofa ll....,..,nwl,,,or,b.,tt<r<ilar,rap,db.jth,;,..,~..,t,
""""'""
......_.,.,.... dl,,,,.,.,,,_...,,-.....,.~c,.,,.,
S,,xual•buse , nddo111<Sticviolencecau0<thtkindofemo-
tioruil painandtnuma thatint<nsify a victim~ need to
~~:=~l:,~~~- which c•n ltod to the m:ld< .. us,c of drugs
Thednigerso/s,xu.ally tnmmitt<dd- · -uch.,cht.
myd ia.gonorrh<a,syphili> . andtrichomoni>sis(th<most
common). aiongwith geni tal h<rp<>, genia l warts, HPV
(human pa pillornov!ru,;),andh<patitisBand G-a r<w<ll
known u •r< th< moruldnigusofHIV ln,pit< of this
knowledge•ndin,pit<ol a ,pat<ofunw•nt<dpr,gnonci,.
mdn<winfections , lhepractic,ofunsafrorunprotect«ls,x
intheUnitedS tat<>byhigh-schoolandcollegestudrnts•nd
)'Oungadultsrontinu<> . V<ryoftrn • lcoholorotherdrug<
pi>y • role!nthisb<hovior.AboutSO%ofailSTDsoccur in
J><Oplebrtw«nthe •g,.ofl 5 andH. 1"
A studybyth<Notion.a!UiltaonAddictionandSubstance
AbuseotCo lumbi> L'ni>'<f:'fityu::1min<dthehobi15ol3-4 .000
t<=gus ingrades 7 to !land found that>tudentswho
dr:ankmdu«<ldrugswer<fiv,tim<0mon:likdy1obese,ru -
•llyacti,.,,b<ginningH<arlyHmiddl<<ehool . Theywer<
•OO t hr<<timesmor<elik<lytoha,-.hadsexwithfouror
mon:p;tnnrn; "nth<pr ·ou , tv.'Oyars ."'
Gi>'<nth<><statisticsitisnot,urpri,ingthat•lmosthalfof
•ll t«ru,gm who.,-everyS01uallyoctivehav<hodcht.
mydia , lh< r.. ,,. ,- , preadingS T D. E,q><Ttsbelie,,., thotH
mEIY"'4 millionAm<ricm,ha, ·e contr.tet<dlhedisuse,
oltrnwithoutkoowingit . lnl012th<r<v.'<r<l,422,976n,w
n:port<d . Women di:lgnoo«l with chbm)"di • outnum -
bumrn thr« toon< . About 33-4,816 Americans hav<gonOT•
MoJloN.
00
rha,andl 5,989h •v<syphilis. 1"A n .. tim.ot«l20%olall
,.,ry svmally active men and v.'Om<n ha,., genia l h<rp,s.
The inciden«of,yphilis . adisa><th.1haddimini,heddr:a -
m.oticallyinthep;tst '50 yar,,hlls tart<dtoclimb•g:,in.Th<
numbuofJ><ople infected byth< h,patitis Cviru,; (about
, million) outnumber HIV-po,iti, ., peop le four to on<,
• lthough th< numbu of new caS<Sha, dropped dr=tically.
Th<n:wen: 49,273newd iagnoo,:,ofH\Vinfectionsand
32,0 5 2di>gnos,:swithAlDSinthe l! nit<dSat<sin20ll." '
The useofcr ackcocaine . m<th•mph< tamin<,•ndmari j U:1n.o
incr=high -risksexualactivityduetoint<nsifi«lsrn .. .
tions.a loweringofinhibition,,andimp;tim!judgmrnt.ln
oddition,1h e veryn:,tur<olse,nulactivitycloudsjudgmrn 1,
.. do most drugs . Drugsa \50 a ffect memory: ifu5<f:'fdo
501Il<thing cbngaou, while unda th< influrne< . t hey might
 Sellaly TulnsmllfdDiseases

~orNOJ
("""""""LllilvmJ
Hooonol~llllop,on"""5.ond"'"""'' p,:temol"""olffllllr/
G<mn+ioiidoP:·oose1 2toJ1Jdi!< Diid'\or1<from""""orrt<l!rn.po<1...,.,_Lm11>"!1;""""""'"'-
~,oq,le,. lor l (<Did""'-le.erbi;i,, ) 2to20dij< Ponli~onif!'IIIIO ornn.ch.l<Yer , rraloo,_-~iior,d<
ld\.,.....,,,,ondbunpjsl,,~onl""'"-...,.OIOI.Ch.ond-
~ch.o,on,enul,.""""'-ondn,s;"'on<iorf"'ii< :dll=1iSh.hw

~ll< Bond( (!ffllllhepi,m) Wt>900.,S 'leb,sl,,ond..,.,_ilorl:......__,,,-.""Ploss.h:loirw-iolpo,1

l to30dij< - -"'~,r:tq,ondixmrc; mtnC=oli<rno~

-- ~=-==
=--{m<>rroni,!1·,gNN<

P\Jboclic,{"cr1>,:-ro-j 21t>300.,S lklq,.,.,. '¥:!'("") onp!l)l(hw

1<1"5("........,...-cd,j 14u,4\dij< ltlqitr-o,it(~ ond>IIT""'on,I.,
M<riil(""""""'re>") -lhd - 1·,rnol~ondodq; '""'""""""'""~

==(l'rl>'lettk"""""""
..-.---
1-.,,
...
,.-."""""..
-IOglrialikhorg<ond_..,.O<b;mencomoll,nr<>~

Hr1ff<Cllon('....tr,.,m
1J

~=~-"""""""""""""'11'111.
__,,._nl
notr<memhffitorwillnem<mhffitin•monebrnignlight taken intr.mcn ou<ly,,ul>cu,._n<ou,.ly, a ndintr:omu<eu larly
lf=sar<uno" .. "'ofth,ri>ksofth< action,thcyuke,th < N«d le kil>contoining,yr!nge,,oo t ton . rubb<rti,s, ,coo ker.
groundworkhllbttnl,id forr<p<t ition of t hat b<h, vior. a lighter . and•ruor bl ode , r< called"outfil> ,"" fil>,"" r!g, ,"
"'works ,"" poinl>,"mdmo n)·otherrame,.lntr.m,nou,drug
u,ei> ,OO calledmoinlining . geezing,,bmming . •ndhitting
up.Haz,rd.crut«lbyn eedleu,ecomefrom~wnlsouru>
lnadd itiontod elivering•brg,,mountof•drugin toth<
bloodstrum in• short period of time, nttdle, c• n a lso
inject,ubsuncesthat•reoft<nll>Cdtocutordilutedrug,
suchupov,-.ndmilk,proc•ine,andAjax. • Theycanalso

,i~:::~
injectdangerou,bact<ri•andviruse,th.otconwniruoteth<
!,:~i=i; :r.:::~:l:~~ couon, or on other
Theri, koFS TI>s,includingHIV , fromtradingKXfordrug, 1 1
i> •ll too common ,mo ng the drug -• bu,ing population
Th<><•r<proplewhowilloftrndo a n)1hingtorai«moncy HepatitisA,B,andC
tobuydrug,to•vo id a cocainecra,;hor , h<roinwithdmv•l
Some of the most common di,a,.. trammitt<d by n«dle,
ar<thevniousstnin,o/hepotitis-vir.tlinfection,o/th<
·1,-,,1~"!/dop,andnwl, SJ.OOOo,$4.000o.,,,l
lh-.r.Hq,otiti, Ai> oft<ntr:on<mill«lbyfec•lmattermdi ,
l...d100t11<nco..:"8m""_Ti.,.,""""'""""co """8 as,oclatedmor<withunsafe,ex•ndpoo rhygienethamwilh
afu,..,_lm,an.1 p, (><S°1,h>iool.at
!x,tl,,id,,ofit.·
drugu ,e .ThetwomointYJ><Sofhepotili>>MOC latedwilh
drugu«,sp,cifically intravenou,(l V) drugu,e,ar,h q,o titi ,
BandC.Hepotiti>Bi>markedbyi nflunm,tionofthelh-.r
STI>sh.oveaddoyedincubationp,riodb<fore,ymptoms
app,ar . 110For,tim<•dis<:1se canb<unknowinglyt=s- :!~•:t:•~,d~i~:•i::~~:.;~ ~"',~;; '~r'
I~~: .. :: ;
i;,:,~~::r.::::.~;=
::~:::~::·:d:,:,•,~
1
po,itiveforhepotiti,B.Ofthos,•bout l0%, r,chronic
carri<n , guarmt<cingt h<c ontinued,piudol1hed- .'"
(<.g .. HPV,ndHVC)
Theblood -bom<hepotiti,Cviru,(HCV)i,m<>r<dmga-
Needle-Transmitted Diseases ou, • ndc • n cau«cliv<r di.,...,_including a,n c<r. Some
Mon)" ,e xu,ll y tr ansmitted di>u= can •00 be tnmm itted prop l< carryth<di>e>S<for\OtolO~anwithon t <xp<ri-
throughcontominatedhypodermicn«dkswhrndrug, • r< <ncing,ymplomo,whichinclud,!o,,;o /a pp,tit< . ja undic:<

The arm of a typical injection drug user shows extensive scarring,
multiple scabs, and a few open sores.
Courtesyof the CaliforniaHighway Patrol.Used with permission.
abdominal pain (right upper abdomen), low-grade fever,
dark urine, nausea, vomiting, and a general malaise. Testing
for HCV antibodies is the only way to confirm the presence
of the disease. Chronic flare-ups can cause inflammation and
scarring of the liver.
The positive rate of the hepatitis C virus in IDUs is 50% to
90%. Of those infected with HCV, 20% to 40% will develop
liver disease, and 4% to 16% will develop liver cancer. 281 ,282 ,283
The spread ofHCV has become so severe that NIDA issued a
special alert to increase counseling, treatment, and preven-
tion education about the infection.
• Worldwide 130 million to 150 million people have
chronic HCV infection. 284 ,285
• From 2. 7 million to 3.9 million Americans are living
with HCV, the majority of whom are young adults age
20 to 29, although chronic infections are highest among
30- to 39-year-olds.
• About 16,000 new infections occur each year in the
United States.
• About 16,600 people die each year from the disease .
• Sharing needles is responsib le for almost two-thirds of
the infections in the United States.
• New IDUs acquire HCV at an alarming rate: 50% to 80%
are infected within six to 12 months. The average incu-
bation period is six to seven weeks.
• The risk of sexual transmission of HCV is much lower
than the risk of transmission from IV drug use. About
20% of the cases are reportedly due to sexual activity,
particularly among those who have multiple partners.
In long-term monogamous relationships, the rate is very
low-0% to 4%.
• The risk of an infected mother passing the infection to
her fetus is about 5% to 6%.2s1 ,2S2,2sJ ,284
Drug Use and Prevention: From Cradle to Grave 8.43
Abscesses, Cotton Fever, and Endocardit is
Needle use can also cause abscesses at an infected injec-
tion site. Users can also inadvertently inject bits of foreign
matter into the bloodstream that could lodge in the spine,
brain, lungs, or eyes and cause an embolism or other prob-
lems. Needle users are at risk for cotton fever, a very com-
mon disease . The symptoms are similar to those of a very
bad case of the flu. Its cause is unknown, though some
believe that it results from bits of cotton (used to filter the
drug) that lodge in various tissues or from infections (viral
or bacterial) carried into the body by cotton fibers injected
into the blood. Starting in the mid- to late-l 990s, more and
more cases of necrotizing fasciitis (a flesh-eating bacteria),
wound botulism, and gangrene have been reported.
"'/ startedusin9druB'when I 9ot toaetherwithmqex-boqfriend ,
but thenI quitusin9thembecauseI would9et thesebi9absce sses
on m~ armsand stuff and m~ veins; when I fjO to the doctor to
aet blood drawn now, the~ can't use m~ veinsin m~ arms."
22 -year-old recovering hero in user
An IDU initially injects into veins in the arms, wrists, and
hands. As these veins become hardened due to constant
sticking, the user will inject into the veins of the legs and
then the neck. When it becomes difficult to locate a usable
vein, an addict will shoot under the skin ("skin popping ") or
into a muscle in the buttocks, shoulder, or legs ("muscling").
As a last resort, an addict will inject into the foot, the neck 's
jugular vein, or the dorsal vein in the penis.
"I'maddictedto needles . like stickin9anqneedlein mqvein
willprettqmuchalleviatemqdopesicknessevenif it'slike
speed or even water.That would make it 90 awa~ for a little
while - just thepartof mq brainthat would make me think
that everqthin9is all ri9ht."
I
17-year-old heroin addic t
Injection drug users risk developing endocarditis, a some-
times-fatal condition caused by certain bacteria that lodge
and grow in the valves of the heart. IV cocaine users seem
to have a higher rate of endocarditis perhaps because
cocaine's rush dissipates more rapidly than the high from
heroin or methamphetamines, so more injections are
required. 286 •287
HIV Disease and AIDS
Human immunodeficiency virus (HIV) causes AIDS, the
acronym for acquired immune deficiency syndrome. AIDS is
identified by the incidence of one or more of a group of seri-
ous illnesses, such as pneumocystis carinii pneumonia,
Kaposi's sarcoma cancer, or tuberculosis that develops when
HIV has taken control of the patient 's body and lowered its
resistance. In 1993 a new qualifier to diagnose AIDS was
"having a T-cell count below 200. " T-cell counts measure the
level of effectiveness of one's immune system.
AIDS is fatal because HIV destroys the immune system,
making it impossible for the body to fight off serious ill-
nesses . Usually, death occurs from a combination of many
di><~•ndinf«tions . M•nylDl',t<>lpos itivefOTHIV/ tion . Hispanic,sr<pr<><ntl3%of1h,popubtionand20%of
;;;~;,~•=ul1of,h>ring•ne<dleu5<dby50mron<•lrtody lh<new=;White,mak<up27%ofth""•fl«t<d ."'

~s.~,::::~=~~:~::
Mrnwhoiw,,,uwithoth<rm<n•r<r<sponsihl,forth<

·11:noot,r,.,,ol"f~tl.,t/did,,.tll'tAIDS"cou><oiotof ;"C/;h:f 1mong ""mrn

prophthat 11:,,,w=d '"~ ,.,,JI,. and tl,,n ti,,~ """'1dP"t Communicable di!in>,. stan slowly . ev<ntuolly raging
tl,,ml>xlln ""ld,ann,,dk,.,,d/didn11:noot,1hattl,,1...,,,
throughthemost.u>ttptibl,.,gmmnofapopulotion.ln
"'".'li'"''"-Andl/Wttl,anl;Godtl,ot/d;J,,.t!Jffo'"ld<><"'" theUnil<dStat<> .t h<5<gmmlmost,u,ceptibl,toHIVIAIDS
orlml>O!.hodrif/tt,.,.., .·
wo,; th, gay community, prifflmly tho.. prxticing unYI,
=;inothucountri«h,t=lhigh -risksvnu.lactiv!ty
It is impo,,ibl< to ov<T<TI1phllize th, danger, of using ,p,,..dth,disa"
infect<dne<d l<>. IV1H<Cof•drugbypa...,,allofth,bodyl< Onc,th,mostvulnerableha,.,b,rninfect<d.th<r<isu,u -
notu,..ldd<RK!l , .uchubodyh>iro . murou,m<mb...ne, .r ly a lullinthe,prtodofth<di><»<.Duringrnchlult.•
bodyacid,;,andenzyme,;•ndonc<contrxt<d,the,iru, r.1., "''"' of 5<rurity, •long with doud<d judgm mt
d«lro}"' th, body's as, line of dd,m,c : the immune ,y,t<m bunch« a neww,v,ofinfection.Th,majorityofnewc>S<s
Rec,ntre,, .:uchconfinns1hat,in•ndof1h<m><hu , opioid, ofHIVinth,Unit<dStat<>( n inth<r«toftheworld) • r<
andotherdrug,of • bu><=w••k<nth,immun<•y,t<m ."' amongthos,inth , h<t<ros<xu• l •nddrug -uoingrommuni -
Thiscoup l<dwithth ,m.alnutri tion • nd1h<unhal1hyh>bil5 ti« . Continuingpublic,ducationandpublich< • lthpr<·
char:,ct<ristic of rompul>iv, drug us, compromi= th, vent' nact' ·,- , .,., cruc' I to st<mm'ngtb, ,ad of
body>•bili1ytofigh1oflan)·illn<M AIDS andev,ryoth<rs,xuallytnn,mitt<ddis,ase

1"1wonLj""'ltl,,attit..fu.,,dpr<>eti<<>towarJAIDS"""'1J

~;~i~f d"':~~'.::;,~~a~
..
O..:,tl,,wi,,~in'P''"""'l,,x~J. 'r"'l,m,m,><"j><nou,
Kid<~"'""""""'rubb,""" '"tl,,lfi ndoo ttlidrfat l,,,l.,,-it
'I"" l:noot,.J.at I ..,an~ P""P"' '°"""'"'
"" onu ti,,~ /ind
tl,,i,_J,,,1.,,-jlo,tl,,;,!,,,,tl,,,l.,,-jlo,tl,,~i.,,..,it·
oot
Worldwid, th<rt wa, an <>titn1.t<d 3~.3 million propl<
livil\l! with HIV/AIDS in l012. MOT< tlun two-thirds
(l5million)livein,ub-S • -Afric•andl.3million • r<
newlyinf,ct<deachyeu.Therat<ofnewinFection ,is Numerou,;str.u,gi<>•r<inpa<:eto<topth,,prudofAIDS
goingdown,lowly.Mo<1rontr:1 ctt h< inf« tionbyth<ag,of part irullllyin th<drug -uoingcommunity
l5•nddiebdor<th<i rthirty -fifthbirthday.Byth<<ndof • impro,.,ddiognosis•nd tr<atmmtofSTD,
l0\2. the d,.oth toll hit 15 million propl<. "' Women
• rnatm<ntondefflE!dfOTdrugaddictionto<ncour.tg,
accoun t<dforjustovahallof•llodu lt,livlngwithHIV
usentogi,.,updrug,
worldwid, . lndiv!du.ot.rng:,ginginh<t<ro5<Jru•IOThomo-
:~wi': .~~,1V drug U5< >pr<ad •nd rontr:,ct HIV/AIDS • :i7.::-,-voch>ng<progr.tm>tocontroltr.tn,mis,.ionof1h<

• c=tionofouu-...ch activiti«1oconnecthigh -riskdrug

In th, l'nit<d Stat<>,more than l.lH million Am,ricaru • re
ns<n ' thth<tr<e atm<ntrommu ·).
inFectedwithHIVorhav,AIDS:i t is,.timot<dthatbyth<
rndofl0H,700,000willhavedi<dfromth<di!in><>inc, • educatio n androuru,lingprogr.,m>th>tt<ac hth <dan -
itfir,t•pp< • r<donth<sc<n<in\981. ,.. Sinc<th<b,ginning ::c~~igc~::~kn~ • ctivityandAIDS a nd how tous,
ofth,AIDS<pidemic,mortth>non, -thirdof•ll AIDScn«
inthe l' nitedS at<, invoh=IIVdru gu.,(fromd ir<ctU«or • no-<:e<tanti,ir:,J drug,,,uch u AZT•nd other med i-
lrom5< xwith•ninjectiondrugU><T) . In Ru55ia>nd th, c:uiom . lorH IV-po,itiv, pr,gnontwomrnand a nyon,
Ukain,,th,n><eofi nf,cted ne<dl«hasmor< thandoubled <xpo,,dtoth,v!ru,; "'
• vocationallnin ingtocount<T>Ctpov<rty.• pn,d i,po,ing
AIDSa,oociat<dwith!Vdrugus,occount,for•Lugupro- facto rt odrugus,•ndHIV inf,ction
ponionofcas<,>mongadol<>e,ntandadultwomrnthon • =yacc«storondoms>t a r<>SOnobl,pric<
amongmrn . Sinceth,<pidemicb<g:,n,~7%of•l1U.S.AIDS • ·ntm!i•'onandbwec'~ ,mrn1 , ti>f<>tol' ·11h<
cos« •mo ng womrn h>v, b<rn a ttributed to IV drug u,.e or flowofdrug,intoth,community
5<Xwithpartnerswhoinj,ctdrug,
ln,tudi«ronduct<dbyth ,C ,nt<rsforDis<a,,Contro l and
Racial•nd<thnicminoritypopulo tions inth ,l'n itedSUt<, othaog,nci« , drug -• bu.,tr<otm<ntalongwith,ducation
n<th<mosth,.a ,ily aff«t<dbyAIDS .<>p,c iallyinm:rnt and n« dl,-a:chang< prognms that ""' tied to outr<ach
y<>rs. Almost '50% of new HIV infections in lOll w,r< components haw proven to be th< mo,t effecti~, HIV
Afric•nAm<rican,,thoughthcy>r<on ly13%ofth<popnl •- dis<n<J>KV<ntionstnt<gi,,;
 !l<ug!Js< ondf're.e«Jon : Fl'omCrde »c,..... us

n.,c,..,,..,f.,.Duto;,C""'rol...:!Pm ·<n1l""l"l""'"lofoll!oftt'""'',li;,""'i"'lltU,i lttJ >!..,.. n., .,.mM,ofr,opuli.,;'l!wltltHIV/

A10,r..,,,..,, .,...iu .. ,11..,,,_n.,"""""'of"""=ua,,•J,,;•IJ""""""'"' ' "°"'1;-.•;'l!,.w,wmv;., ,....,. .~,

Harm Reduction Educating= • lreadyintreatmenti>!mportant, butth ere

In June 2003 the Hn.lth Mini,try 0£ Canad,. approved r=im • much latj!u s,gmrnt of IDV• who are not ready
North America's fint legal uFeinjection,ite for illegal - fortrtttment(andaretherefore at high<>trukofrontr>cting
drug u1wn in Vanrouvn . Brithli Columbia. The government AIDS). U>a>• lieruotedb)'thetre•tmrntcommunityorwho
shielded the center from m)·law enfOTCemrntagrncies, • reindrni.alarehardtoeducate,prompting,omedinicsto
•llowing•ddictsto,hootupunderthe,upe,vi,ionol • reg- institute• mor, tolenn t policy r<egauling nlapse and
i>1<Tronu=.Thepurpo,<wastoprevrn1overda,aand towa rdu..,,.. whowereun • bletodeon up during their
reducethe,preado/HIV . hepotiti> , andotherblood -bome initlal attempi, . Thehop, i, t hatt he= willmruoinin
d~ ... ,bypro-.idingcleanneedl<>to1headdic1< . Thedl« - oontactwith a facilitythatcanintuven< . pre,entimponant
(vrnes,ofthe,tntegywas ·ncor' ' •e. bu1therour1< · ' • t'on . andevrntu•ll) · -~e,'i nt ' ntotI<Catment
ruledinfavOTofkttpingtheoiteoprn.ln2009therewue6-4 Edu cationdouwork.lnthe l990sSa nF ra nru<:olounched
newc=sofHIVamonglD V, oomporedwithl3 7j u,;tnine • progr.tmtoedu catedrugu ,e r< •bo utthedangusof AIDS
)-Ur>n.rl ier,healthofficW,creditthem:luctiontotheprov - mdt heneedtocl ,.. nth eirneedl<> . Aw, ren=olthecbngus
inc:,',harmreductionprogr•ms . whichir.cludetrtttmrnl ."' jumpedfromafewp,rcenttoB S% ovu a ,honperiodof
l'stimatesputrostuv:ing,ot SISmillionovalOyeanand tim e. TheHIV -po,iti,-e,egmrntolthe IDUpopulationin
•d«re...,of3 S =ofHIVandthlledn.thsperyn.r.
:son
SanFr>nci>coi>l3%to\7%comparedwith60%1080%in
Similar programs ha,·e been tried in Swiuawid . the
/ork Ci::,tone lor the diff~n«.i::;,;;;e H!V
Nethub.nds , md Au,tn lla. Result, from those programs
we remixed,,howlngadecr,aseinoverdoli<Cdeothsandthe proactiveeducationaldlon,b)'thedinic:,i,th eSa n Fr.tnci>co
,pre • dofdion.s,,butnotinaddictionnte, HealthDeporunent.mdthegaycommunity In New York
therearemore ",hoo tingg:,lleries " md a limitednumbero l
lnSan Fr.mci>co,everalHIVpre,..:ntiongroul"'h"' -e out -
treatmrnt faciliti<>ccle•nnttd les ared ifficulttoob tain ,a nd
:;~-p~=t:~:;~e~.:t~h1~.;•c::,::~ :,:: ':i:~ :::"o~~:"~t~::~ <Xist-;a ll m.,on, fOThigher num -
AIDSeducationalmaterial,,frttbottleooFbleoch,andfne
oondoms,>i,it "•hootinggallerieo ." cnckhous,,,dope ln addition 10 AZT. one ol the orig!nol AIDS drug,, mon)"
p•ds . •ndotherar,astodiotributetheli<C1111.terlal••nd newdrug,havebeendevdoped a nd,howpromNinslow -
provide t reatmen t nfernls whenrequeoted.Dthagroup,
di>tributefrttnttdleo. ""T hes,prog rams•reronsidered ~:::;;:;t;~t~f~1n:f~~ei~!!:;;'.~ed1;;"~~:~~':
m 'nter., ti , ·ntodrugrelatedbeh•'or
ingintodrugus,
·11-.- ·ntuvrn -
. Thedrugus,inter.·entioni,landledb)'
the county's Community Bdu .,ior> l Ha lth Services
:t':'~~~c:::~
fov!r.Antiretro,-iTilldrug,
~~~,.ta~:~~:id t::
a ndprot<2><inhibitoninitial1)·
,howedpromis<, butth<rompl icatednegim<noldoz,nsof
pillsWC<ndaily•ndth<><V<ne,id,dT«ahav,dimini,hed "'fiel,tp,runto{f.,il-6""al'111.5%o{port
-tim<""pbj«>
tl,atw,t«t<Jatmriou<i...w,,,,....,,,,wr,nt""'iJabu,,,.·
som< of th< <orly int<= t. Rcc, ntly. • group of WOTld-d • "
int<rn.1.tioruolsci,ntim ,, upponedbyth<Bill • r.dMdinda
Got<>Foundation.call,dforth < cne• tiono f•globolini tia-
riv< to,p<ed th< discovuy and th< t<stingofn<wAIDS 1"'1tirnj
-lloop<J"C<nto{.,.,,;,,,.,1a1,Jaro
-...-l:tf,d'"!lakol.ol
voccin<>, • prog ra mthotwouldb<similorin,rop,toth < =•fftt:t<dtllrirjol,p,rfo,""'nu ·
SJbillionHumanGmom<Proj«t. "' Barringth<cr<>.tionof
• voccin,,th,foundat ionc •ll•fo r!nt<r 1S<p=rntionmd
trutm<ntprogams From• drugpo,itivityn11<of!J. 6%in 1988to • noven,ll
rat<of • bout }.3%inl01l,drugu><inrompaniesthot
Studi<,,howthatp<opi<t<stingpositiv<ForHIVwhost•y
conduct drugt<>ting hnllp<r<d down and l<V<l<d off
dun-and<50b<r and mainain • hulthy liF<>tyl< with
>Ft<rvcp<ri<nci ng••igni!icantdeclin ei nth<l990s
pltntyoFrut,goodfood,and<XffriKwillavoidfull-blown
AIDS for ynro long<r {in 11UI1ycasu 10 to l0 y,•ro or • Th< u« ofrocain< ho<declined, bu t th<u.s<o f•mph<t -
more);ev<nlhOS<whohovethemone«riou ,A IDSd iagno- •min,shosrio.<nsignificantly
siowilllh1'y<nslong<r . lmpro,.,dtrn1mm1formyoppor -
• :1:i;;'.,_~o~.pi:~~";,dd~, <>p<eially opioid pain
tun ·,fc ·' ionsttc•nb<l<tholto•n·mmnn<, t<m
::i~~d::i, ~AID SC2I1•lsoaddynBolli,utoinf«ted The ronc:,pt of• drug -free workpl oc, that indud <> prtc•
<mploymrnt drug t<>ting. employe < ..,i,tanc< progr.,m,
(EAP,),and>grttl<rnnd<r<t>ndingofthe,ffecaofdrug
abu«has l<dto • neductionin illid t -druguS<butcontrib-
utedtomincras < inth< • bu.s<ofprescriptiondrug,
Positi,,et<s t rotes ha,,e decrusedinprn:<n l>.g<b<can><
illicit-drugu!iff5donot • pplytorompani<>th>t~uir<
drugt<otingorthothoveotrictdrug-fre,workplacepro-
gr.,ms.J...,t<adtheyworkinfield,tha1g,nerallydon\t<>l
lordrug,, likesom,rons truc tionfirms•ndth<lood«rvie<
indus try\£youinclud<.:t l workeB,notjustthos,who•re
inindustri<,thott<"-.8,9'l,ofthoseemptoy,dfull•tim<
Tr:1gically,forynrs11UI1yrountri<•withthehigh<otHIW

!~:
: : ;:t::.i 1,licit-drug n«n whil< 8 .8% • dmitt<d to heavy

~;:;ii!:'.,i"~~is
c;:'%
1
0
c':i;';d '!:ti:;,;'.:;,::::
pin,nordidth<yhavethen,,oun:estofullytrutth < ~ n=topublicp<=ptionso l unemploy<ddrugor .:tro -
1
opportuni<ticinf«tion ,tho t • ppur .. • r<•nltof • wnk -
<n<d!mmnn < sy,t<m.,olif<<>tp<et>nd<>""'"'dramati cally • 67%oFillidt-druguo,cn •g< !Borold<rworkfoll - or
r<duced. Fonuno tdy,the l' nit<dN • tions,othercountri<> parMim< H do H.7% ofhn.vy drink<n
andtheAlr ic• nUnion•neprovidingth<S<negion,withmo n, • 60.~ of ti><»< actu.oUy diagnosed with • ,ubounc,-
<ducation • r.db<tt<r>cc<>0toth<drug,,incru,ingth < abu.., disord<r • r< employ,d
:u~::,; ,:,•;~~~ ': .'! l thaapy from 1 million in 1003 Theh ighe<t a t,so/illicit-drugns< >neintheconstruction
0
:;!!~~::~~::;::;i;:r;~
,~::L:,m,..":~ waitm md
Drugsat Work
Co"'
>l.udi<>onth<impactof•kohol•ndotherdrug • bus<inth<
·:i.;::,~O:r,1::7
~~ti:iw:!~'i:7d:~•j~~•~ Am<rican WOTkpbce <>timot< that ,ubst>ne< >bus, cost,
industryabout$100billio np<r)Uf.Bru ce\1/il k,ru.on of

;;:;~~"~.
1:,;,~::
~~:'~1~
]~:-1;:·::,~"J Workp bc ,Con<ulants«timot<dthero<ttoth<<mplo,u
ofan<mploy«who
Sl~,600mmul ly.,.,.
• bus<sdrug, >1b<1wemS8. 000 md

""""""""'
""""'·
-' ·"""' Loss of Productivity
"l °'9"ntonooc,1i.,rb«.w,,l..,,"""!Jmarii""""""" Compar<dwith • non-drug -•busing<mplo,1'<. • •nbowtee-
dmj-to-dmjb..si,, '"'l"""tion<""'""°"-~ ra l'1'"'1tltoo/l't •busing<mplo,·«i•
proc<>«<"""~do..,,,_ In tlw,l,ct, onic< b.t,;.,,,
'I"" ,,a11 ,limp/,
~ i.,., to b, thinki,,,, .. • ~nt 3 to 7 tim<> more often • r.d J 10 tim<> mon,
,,___..,,,..""11
_ "'......
, likelytob<•bs<ntforlongerthanrightcon,ecutiv,day,
 DrugUse and Prevention:FromCradleto Grave 8.47

LegalCost Increases
Summary ofRecommendations
fora Drug-Free
Workforce As tolerance and addiction develop, a drug-abusing employee
often engages in some form of criminal activity in the work-
Toachievea drug-andalcohol-free
workforce,
a companymusttakea
comprehensiveapproach.Theapproachshouldincludethe following: place , resulting in:
Awrittenpolicyclearly
defining
the reasonsfora drugpolicyandthe • direct and massive losses from embezzlement, pilfer-
consequencesofa breachofpolicy age, sales of corporate secrets, and property damaged
during the commission of a crime
Anemployeeassistanceprogramthatprovides counseling
andreferral
programs
operatedbyeithercompanystaffora contractor • costly improvements in company security, more person-
nel, product monitoring, quality assurance , and intensi-
Employeeawarenessandeducationaboutcompany
policies,
drugs,and fied employee testing and screening
drugabuse
• lawsuits , both internal and external, higher legal fees,
Supervisor
trainingonsubstance
abusesothatthoseclosestto the problem
court costs, and attorney expenses
canbecoachedonthesigns,symptoms, behavior
changes,
performance
problems,
andintervention
concepts
attendant
to drugandalcohol abuse • negative publicity because of drug use and trafficking
in the workplace, employee arrests, and loss of goodwill
Drugandalcoholtestingprogram to detectanddeterdrugand/oralcohol
useorabuse; testingisadopted,it shouldconformto properprocedures due to the perception that there are more substance abus-
ers than just those arrested
Sanctions
and consequences
forviolating
the policy
Adearlydefinedappealsprocess Preventionand EmployeeAssistancePrograms
Evaluation
oftheprogram
intermsofcost-effectiveness
andsuccessful
employeeoutcomes "Reallq,what I'vefound now that I'm clean-and-sober is that it
wasn'tthosejobs that wereintolerable;it was whereI waswith
Adapted from Guidelinesfor a Drug-FreeWorkforce(DEA, 2003A) mqself I neededto lookat mqselfand do someworkon mqself"
Recovering cocaine user

WorkplaceDrug Testing
• responsible for more job mistakes
Businesses attempt to control drug abuse through drug
• likely to have lower output , be a less-effective salesper-
testing (the most effective is pre-employment) and employee
son , and be less productive despite more hours put forth
assistance programs. The cost of private-sector workplace
• likely to appear more frequently in grievance hearings 304 drug testing is estimated at $300 million to $1 billion per
year_,os
"If qou're doin9coke,qou reallqdon't likeauthoritqoverqou.
• Since 1988 the percentage of positive urine drug tests
Youwant to takeqourtimeto do what qou haveto do; and if
among American workers (combined general and
a personhasanq kindof input. qou havea tendencqto rebel.
safety-sensitive workforce) dropped from 13.6% to
I usedto 9et in troublea lot."

Recovering cocaine abuser
About 21% of workers report being injured, having to redo
work or cover for a co-worker, needing to work harder, or
being put in danger due to a co-worker 's drinking; however,
60% of alcohol-related work performance problems are
attributed to occasional binge drinkers rather than alcohol-
dependent employees. 303
Medical Cost Increases
Substance abusers as compared with non-drug-abusing
employees :
• experience 3 to 4 times more on-the-job accidents
• use 3 times more sick leave
• file 5 times more workers' compensation claims
• overutilize health insurance for themselves and
their family members
• increase premiums for the entire company for
medical and psychological insuranc e
• endanger the health and the well-being of
co-workers 303 -304
I
3.5% in 2012.
• The percentage of positive drug detection using hair
analysis in U.S. workers showed somewhat higher rates
than urine testing. Drugs remain in hair cells much lon-
ger than in urine, thereby increasing the chances of drug
detection even if no drugs were recently taken.
• In 2011 positive urine drug test rates were hug e-26.1 %
-when workers were tested for cause; rates were 5.4%
for post-accident testing, 4.94% for random testing, 1.3%
for periodic testing, and only 3. 7% for pre-employment
testing.
• Marijuana was the most common drug found by urine/
hair testing in the general workforce in 2011.
• In federally mandated safety-sensitive industries such as
transportation, the rate of positive drug tests is about half
that of the general workforce .300
EmployeeAssistancePrograms
Responding to the problem of drugs in the workplace and
the resultant drain on profits and productivity, many employ-
ers have instituted an employee assistance program.
Successful EAPs balance the need of management to
 8.48 CHAPTER 8
minimize the negative impact of drug abuse on the busi-
ness with a sincere concern for the better health of employ-
ees. In 1980 there were 5,000 EAPs; in 1990 that number
had grown to 20,000, and the number of covered employees
grew from 12% to more than 35%. Today 45% of full-time
employees are covered. In large companies with more than
500 employees, 70% are covered. A majority of Fortune 500
companies offer EAPs. 30 6,,o,
Designed as an employee benefit, these programs often
encourage self-referral by the employee or a supervisor's
referral as an alternative to more-stringent disciplinary
action for poor work performance . Successful EAPs support
a broad-based strategy that addresses the full spectrum of
substance-abuse prevention needs and share two overall
design features:
• They frame the EAP drug-abuse services as part of a full-
spectrum prevention program that minimizes employee
attraction to drugs and helps those with problems get
treatment.
• They provide a diverse range of services for a wide scope
of employee problems (emotional, family/personal rela-
tionships, financial, burnout, workplace safety, major life
events, healthcare concerns, and even work relationships
issues).
These two design features lessen an employee's fear of being
labeled a drug abuser, prevent drug problems before they
start, and identify drug problems for employees in denial
when they approach the EAP for help with another personal
issue. An EAP comprises six basic components:
• prevention/education/training
• identification and confidential outreach
• diagnosis and referral
• treatment, counseling, and an effective monitoring
I
system (including drug testing)
• follow-up and focus toward aftercare (relapse
prevention)
• a confidential record-keeping system and effectiveness
evaluationJos,309,310
In a full-spectrum prevention program, the EAP provides
primary, secondary, and tertiary prevention.
Primary Prevention In the most effective EAPs, both corporate
and individual denial are addressed with a systems-oriented
approach to prevention. Education and training about the
impact of substance abuse is provided at all levels in the
corporation: administration, unions, and line staff. These
segments agree on a single corporate policy on drug and
alcohol abuse .
Secondary Prevention Both education and training focus on
drug identification, major effects, and early intervention,
which are incorporated into the prevention curriculum. The
corporation's legal, grievance, and escalating discipline poli-
cies are designed to reflect EAP goals. Security measures
(testing, staff review, and monitoring) are established in a
manner that is legal and humane. These measures operate
both as deterrents and as methods of identifying the abusers
and getting them treatment.
Tertiary Prevention The EAP formalizes its intervention
approach, allowing for confidential self-referral, peer refer-
ral, and supervisor-initiated referral to the EAP. Many
EAPs outsource the actual counseling and follow-up. A diag-
nostic process is established, along with a number of appro-
priate treatment referrals. Treatment is confidential but is
monitored by the EAP to ensure proper follow-up aftercare
and continued recovery efforts. The employment status of
workers is evaluated on work performance and not on their
participatory effort in the EAP
Effectivenessof EAPs
Well-conceived successful programs have demonstrated
great effectiveness and cost savings to businesses. For every
$1 spent on an EAP, employers save anywhere from $5 to
$16. The cost of providing EAP services ranges from $22 for
outsourced programs and $28 for in-house programs per
employee per year compared with $50,000 or more for
recruiting and training a replacement employee .303 ,310 Several
major corporations have documented a 60% to 85% decrease
in absenteeism, a 40% to 65% decrease in sick time utiliza-
tion and personal/family health insurance usage, and a 45%
to 75% decrease in on-the-job accidents as well as other cost
savings as a result of an EAP system in place.
"I stopped using [marijuana]and I noticed a majordifferencein
how I felt-the fact that I was able to get up in the morning.
You know. I wouldn't driveto work draws~,and m~ thought
processeswerea lot clearer."
38-year-old phone company worker
There are a number of different types of EAPs, often deter-
mined by financial considerations.
Internal/In-House Programs These EAPs are usually found in
large companies that can afford the expense. The staff is
employed by the organization and counsels employees on-
site. In 2008 only about 31 % of EAPs were internal programs
(7% internal staff and 24% contracted vendors). Of the 69%
external EAP programs, 40% were independent EAP compa-
nies and 29% were health plan EAP services. 307
Fixed-Fee Contracts The company contracts with an outside
EAP provider for such services as counseling and educa-
tional programs.
Fee-for-Service Contracts Outside EAP services are used and
paid for only when employees use the service.
Consortia Smaller employers pool their resources and con-
tract with an outside EAP service provider.
Peer-Based Programs Peers and co-workers provide educa-
tion, training, assistance, and referrals to troubled workers.
These programs require considerable education and training
for employees. 311

Drugsin the Military
The U.S. military has been successful in reducing the use of
psychoactive drugs in the workplace. A survey conducted by
the Research Triangle Institute in North Carolina found that
from 1980 to 1998, 30-day illicit-drug use dropped from
27 .6% to just 2.7% of military personnel. 312 By 2008 that
rate had dropped to just 2.3%.314 These figures are lower
than those for the general public.
• In 2008 the annual Health and Related Behaviors survey,
commissioned by the Department of Defense (DOD),
added questions about use of prescription medications
for non-medical reasons; it showed a large increase in the
past few years .313 •314 As urine tests for these substances
become pan of standard military drug screening, it is
expected that the misuse of prescription drugs by mili-
tary personnel will decrease .
• The rate of heavy drinking showed a smaller drop, to 20%.
• Although there are no solid numbers yet, in 2014 syn-
thetic marijuana and bath salts (synthetic metham-
phetamine) are frequently being used because many of
them cannot be detected by testing. 318
• Inhalants represent the third most commonly abused
class of drugs in the military, but they are not tested for
and often not screened for. Inhalant abuse is often misdi-
agnosed as fatigue or some other condition. 315
• One of the strongest reasons for the drop in drug abuse
is an intensified program of urine testing, established
in the early 1980s, with a positive result as grounds for
referral to rehabilitation or, if that fails, discharge .
• The military conducts about 3 million drug tests each
year and enforces a zero-tolerance policy. In the past,
drug users were treated and kept in the military,
but zero tolerance provides no margin for retaining
impaired people and discharge is the preferred option.
• A second reason for the drop in drug use is that most
drugs lost favor over that period of time . The exception is
abuse of prescription drugs, which has witnessed a five-
to seven-fold increase in the general population over the
past decade; and, based on the 2008 survey, misuse in the
military has also increased.
• The drop in smoking from 51 % to 33 .8% over the same
period was attributed to military smoking bans, an end
to free cigarettes for Gis, and smoking-cessation pro-
grams as well as an overall decline in smoking in society
as a whole . The smoking rate has actually gone back up
over the past few years .
• Heavy drinking still occurs at a higher rate than in the
general public: 15.4% in the military vs . 12% in society
as a whole . The highest rate is in the Marine Corps, and
the lowest is in the Air Force. The challenges of reaching
heavy drinkers, who are mostly young enlistees, are high
turnover in the ranks and a historical acceptability of
Drug Use and Prevention: From Cradleto Grave 8.49
drinking. In a recent U.S. Navy study, the prevalence of
DSM-IV classified alcohol abuse was 28 .2% of men and
15.1 % of women . Rates of more-frequent heavy drinking
were about half those percentages .316
• The military has the prerogative to discharge anyone
whom it defines as a danger to other military person-
nel and it can conduct testing whenever and wherever
it chooses .319 Because the military attitude toward drugs
other than alcohol is well-known, applicants seeking
to join the U.S. Armed Forces know that any drug use
will be closely examined. Consequently, the rate of posi-
tive results for amphetamines, methamphetamines, and
ecstasy is extremely low, about one-fifth of 1%.320
• During the Vietnam War, drug use, particularly of heroin,
was high . It was readily available, stress was intense, and
the environment was strange and permissive. 321 During
the Gulf War, drugs and alcohol were difficult to obtain,
and as a result there were fewer disciplinary problems
among the troops. 322
• Each branch of the service has its own program to address
drug and alcohol use: the Air Force Alcohol and Drug
Abuse Prevention and Treatment (ADAPT) program,
the Army Substance Abuse Program (ASAP), and the
Navy Alcohol and Drug Abuse Prevention (NADAP)
program. The navy's program includes a zero-drink pol-
icy for those under 21, those who are driving or steer-
ing a vessel, and those on duty. For others consumption
is limited to one drink per hour. All programs include
prevention, education, treatment, and urinalysis . These
policies have been in place for more than 20 years.
• ASAP,along with the army's Substance Abuse Rehabilita-
tion Department, provides individual counseling, family
counseling, command consultation, outpatient counsel-
ing, arrangements for inpatient care, and coordination
I
with self-help groups such as Alcoholics Anonymous .
The army also has an EAP for Department of the Army
civilians .
The wars in Afghanistan and Iraq and the heavy use of the
National Guard caused several changes to DOD policies :
• Institute minimum 100% random testing for active-duty,
guard, reserve, and DOD agencies, including 100% ran-
dom testing of troops deployed in Afghanistan (reports
of officially sanctioned amphetamine use in the Iraq and
Afghanistan wars still circulate).
• Require mandatory drug testing of all military applicants,
to include testing within 72 hours of entering active duty.
• Institute policy to process for separation from military
service any military member who knowingly uses a pro-
hibited drug.
• Change the mandatory test panel to meet the new threats
(e.g., prescription drugs and dextromethorphan)
• Institute minimum 100% random DOD civilian testing
and unified laboratory support.
DrugTesting ><n>itivity.,p,cific ity,andaccurxy•longwithoth<rpot<n •
tial a r.omali« . Th,drug,mostoft<nt<<t<df0Taream p h<1-
am in<0, cann•binoi d, . cocain<, opioids, phrncyclidin<
For)'Ur><mployer,t<,t<dloron ly a hmdfulolpsychoac - (PCP),andalrohol.Otherdrug<common lyt<<t<dfor a r<
tiv,drug<,p rimari lyrocain< . opioid,,mdfiv<OTsixothu,; b.arbitunt«. "'""' Nnrod i,np in<• , and m<thodont
Tod.oy >tr<<t ch<mist> . ,nd ><mi-l,gal labor:otori<, •re Tho><th ot cmbet<>t«l!o r butu,u•lly a r<not includ,LSD
d<V<loping new drug, at an astoni,hing r-.tt : th,.,
!rnwiyl.p,i locybin,).IDA,andde,ignerdrug,
drug,umainundet<ctabl,un tilt«tstodet<ctth<m•r<
d<V<lop,d lnlOIO t«tsw<r<d,,,.,lop«ltodet<ctlh<<ynth<t icTHC -
lik<ch<mic • lsinth<Vfflou,herbalincen«cproducts(< .g
Astnd)"ofpo,itiv<r<>ults>t•majordrug -t<stingW:ilityov<r 1<2,Spic,Gold . Kush ).Rfirntde,ignerdrug, . synth<tic
a l7 -yurp<riod(l988-lOO'l)wa.romparulwithchangc, in THC, in herbal in=" · a nd ,ynth<tic stimulants 50ld .,
><11 -r<port«ldrugn«in•national,urvcyR<><.:trch<nfou nd bath,alt>hovecrat<dmajorchall,ng«fOTdrugt<<ting
thatwhiledrugt<otingshow,da66%dtttt..,inpooit ivu Monyofth , ,ubstanc«haveno, u nd:m ltot<>t•g:,imt;•nd
.,lf .ncpon«ldrugusehadi n cruscdby30% ."' Th<rea,on,
><>m<a r< 50pot<nt . ,-.,n though th< dT«ti>'< dos, i,"'
lorthi,diff=n<:<arethatmanydrugus,,,.avoidapplying ,mall,thotthcyar<a lmost impo><ibl,toidrntifyinth<bod)"
Forwo rk at bushxs.,,thatr,quiredrugt«ts . andth<T<•r<
l=u r>l<l<>t,alsor«ultfromd~ ... stat<s . pr<gruoncy.
a numb<rolmethod.sfo r chutingonadrugt<st,,ucha,
dilutingone'surinewithw:,tu(althought<st<ncanu..cnc - :.i«:,~~.~o~~~:,~~ :~~;::• of pr<>eribed drug<, and
atinin<l<>lingtocheckth,"'1id ityof,ampl<s).Fin.a!ly,th<r<
isaninc=da,. ,. r,,.,..ofd<t<ctionp<riods,5050m<= Th<metabolit<,of a drug,reoft<nlh<Wj!<tsofthet<st,so
>top~ngth<irdrugwithin,uffici,nttim<toa>'Oidd,t<ction h<roinist«tedforbylookingfOTmorphin, . Curr<ntl)". "'m <
by a ,chedul«ldrugt<st_ twodo.z<nm<thodsar,us«lto a n, lyzebod)·,ampl«forth<
l="'.:nc•ofdrug, . Non<~:tal lyfoolprool . Th,lo llowing
Drug1« tingh.,h<ro111trommonforma ny,i tu.otion, . lt
ha,;longh<enu,«ltod<t<rmineth,blood . urin< . a ndbr< ath
~:~:11,vc l ofdriv<n,n<p<ct<dofdrunkdriving. T<>ting
Thinl.ayerChromatog raphy(Tlq
• in busin<M . lor caUS<C,period ic, post -• ccident, pr<· TLCo,orchuForawid , vari<tyofdrug,otth<~<tim<
<mploym<nt,rmdom,mdr<tumtoduty and' f" ly.,ns't"vetoth<;>e<ol, nm'nulHmounl5
ofch<micals. Th< major drawbackisitsinabilitytooccu -
• forrehab ilito tionofex<0nvictso r f,lonsonprobation
orofoth<rssu,p,ct<dol,crim< ,.t<ly differ=tlat< among drug< thot may hove similar
ch<micalprop<rt i<>. fOT<nmpl<,<ph<drin<,•drugus«I
• forcomp li,nceinaddicts whoar,i n t rttt111tnt leg:,lly inmonyOTCcoldm«l id=inmon)"S lal«.moy
• bym,dicalexamin<r>tod<t<rmin<•caus<ofd,ath b<mi,id<nti/i«la,;mill<galamph<tamin<
• tog<twelfarere<ipi<nts intotrnlrnrnto r drnyb.en<fits
forth0><who1«tpo,iti>'<fo r •bus«ldrug,(•bout \l Enzyme-Mu ltiplied Immunoassay Techniques
,ut<,a!lowthiskindoft«t ing) (EMIT),Radiolmmunoassay(RtA),andEn,yme
Th< f«l<.-..1gov<m m <nt ; .. uromand • t<• in 19118and 1998 lmmunoas,;ay(EtA)
For a drug-Frttworkplace.Althoughth<r<eisnowacon><n - AllimmunoliS>ysn>< a ntibodi<>to5ttkout,pecificdrug,
su, that t<sting i,,ffectiv< . th<r< ha,., b<en a numb<rof EMIT tuts a re extr<m<ly o,nsitiv,. v,ry r:opidly pa-
r<gulations a ndlawsenactedov<rth<past\0y<>.Btha t lim it Form,d . andfairly,asy t oronduc1,a lthoughtheycanr.ot
r>ndomt<sting u,uallyd<t<rmin<th<ronc<ntrationofth<drugpr<5< nt
Also . •,q,ar.,t<t<stmustb<conduct<dlor<ochsp,c ific,us-
At pr«<ntth<mostwidupre,duo,ofdrugt«t ingisin
J><Crul drug . lmmunoa«ayt<chni qu« a r<u5<d lor mElY
th< mil itary. in the f<d,.-..1 gov,mmrnt, in pr<~ p loymrnt
hom<-t«tingkii, _ Som,cant<stfor5<Vualdrug<atone<
drugt<ot ing . inp ublic-saf<typo<itions(mo>tlytr-.nsporu-
tion),andindru,gtuatmtntfacil itiu . ).lo,tm<diummd (<.g..ascrndmu lti-immunoas,•yl
larg,bu,in<>=routindyn><pr<-<mploymrnt testing to EMIT t<stscan,lsomistak<noruobusedch<m icalsfOTabused
,cr,rnoutdrug -u,ing•pp licmts(h<can><one<th<y•r< drug,(< .g .. op ioid , lkaloidsinth<poppy=dsofbaked
hir<d, th,prob lemsth,y can><canbev,ry<xp<n>h'<) . Mony goodslorh<roinor•noth<ropio id) . On,ofth,ch<mical,in
busin<>= forgo r>ndom testing of employ«> b<caus < th<r< Ad, i l' •nd).lotrin • m.oyh<mis tak<nfOTfflmju.ona . •ndth <
have bttn many legal challengu to th< prxtic <. Random
tutingis>tillronduct<dforthM<Cinjobsinvolvingp
,af<ty,,ucha,;bu,drivers,poliC"<m<n,mdpilots
ublic ::,~!=~d~~J:,~
~~:nt
siti,.,tlutbn.oth
;,,V~c!::.:i:n ~~:,'.'.
ingth, , ir ot mostrockconCfil>will,how
a po,it"vetroc<'mari;oaruoc-...nwh,nnon<w••rmokM
TheTests Th<><mistak<>areknown as fals<positiv<0 . Thi,ov,r>,<n,i -
Mon)·diff<r<ntlabor.uorypl'OCrour«•rcus«l tot<otfor tivityiscomect«lbynri,ingth<5<n>iti,-ity levdofth<l<5t50
drug, inth< urint . blood . hair , ul ivo, , wn.t , and other thaton lycurT<ntu5<rswillt<stpo,itiv<, but itmoy mis,
body1is,uu . E.achtyp<of1«1las inh<r<ntdiffer<nc«in d<t«t ion in,omen><T>(fal><n<gativ,,)

GasChromatography/MassSpectrometryCombined
(GC/MS) and Gas LiquidChromatography(GLC)
The GC/MS test is currently the most accurate, sensitive,
and reliable method of testing for drugs. This test relies on
gas chromatography separation and mass spectrometry frag-
mentation patterns to identify drugs. It is very sensitive and
can detect even trace amounts of drugs in urine and requires
skilled interpreters to differentiate environmental exposure
from actual use . It is very expensive and requires highly
trained operators, and the process is lengthy and tedious
compared with other methods.
The GLC test separates molecules by migration similar to
TLC. This process is somewhat less accurate than GC/MS.
Another variation is a liquid chromatography-tandem mass
spectrometry (LC-MS-MS) method , which can test multiple
urine samples at one time.
Hair Analysis
Chemical traces of most psychoactive drugs are stored in
human hair cells, and so long as the hair remains on a per-
son's head, drugs can be detected for years after a drug has
been taken. Hair analysis provides a picture of the degree of
drug use over a period of time (to differentiate occasional
use from chronic use) .325 Sections of the hair are identified
and tested ; a single strand of hair might undergo three or
four different tests. Radio immunoassay techniques are used
for screening hair samples, and GC/MS techniques are used
for confirmation. Because several tests are done on a single
strand of hair, the cost can be high; however, hair testing is
being done more frequently today because it eliminates
many of the specimen manipulation problems that occur
with urine testing.326
Saliva,Sweat, and Breath
Less accurate tests look for traces of drugs in saliva, sweat, or
exhaled air. These tests are less invasive, but they are much
more prone to contamination by environmental traces of
drugs . Saliva and breath tests can be useful for on-the-spot
testing of drivers involved in accidents or suspected of driv-
ing under the influence (DUI). Confirmation tests are almost
always mandatory because of the inaccuracy of the tests and
probable court challenges. For alcohol DUI situations , breath-
alyzers are a valuable tool and are admissible in court.
A study to gauge the accuracy of saliva testing vs. urinalysis
found that testing oral fluids is more accurate , although the
cutoff level used for the saliva is crucial to determine drug
use. 327 An on-site saliva-testing device with a high detection
(cut-off) level was compared with saliva testing by a GC/MS;
of 66 drivers , 18 tested positive for THC using a GC/MS but
only one tested positive when the on-site device was used.328
An on-site device using saliva (which is easy to do under
close supervision) could be valuable in a DUI situation
because the presence of THC in saliva is a better indication
of recent use than urinalysis; so chances are if a driver tests
positive , he or she is likely to be experiencing the pharmaco-
logical effects at that time.
Drug Use and Prevention:From Cradleto Grave 8.51
Sweat collection testing can have higher levels of drugs than
urine or saliva testing because sweat is collected over a period
of days, concentrating drug use in the collected sample.
Detection Period
Many factors influence the length of time that a drug can be
detected in blood, urine, saliva, or other body tissues.
These include an individual's drug absorption rate , metabo-
lism, rate of distribution in the body, excretion rate, and the
specific testing method employed. With a wide variation of
these and other factors, a predictable duration of use would
be, at best, an educated guess. Despite these variances, spe-
cific estimates were adopted. Urine testing estimates are
divided into three broad periods: latency, detection period
range, and redistribution.
Latency
Drugs must be absorbed, circulated by the blood, and con-
centrated in the urine , saliva, or hair in sufficient quantities
before they can be detected; this process is called latency. It
takes two to three hours for most drugs (except alcohol,
which takes about 30 minutes) to be concentrated in urine .
Someone tested 30 minutes after using a drug would proba-
bly (but not always) test negative for that drug, even though
he or she might already be under the influence . A chronic
user, however, would have enough chemicals already present
in his or her system to test positive even if tested within
30 minutes of use .329
DetectionPeriodRange
Once sufficient amounts of a drug enter the urine, the drug
can be detected for a certain length of time by urinalysis.
Rough estimates for the more common drugs of abuse are
shown in Table 8-7, but there are wide individual variations.
A person who delays taking a urine test for five days because
I
of cocaine abuse will probably, but not definitely, test nega-
tive for cocaine.
Redistribution,Recirculation,Sequestration , and
Other Variables
Long-acting drugs like PCP and some marijuana can be dis-
tributed to certain body tissues or fluids, be concentrated
and stored there , and then be recirculated and concentrated
back into the urine weeks or months after stopping use.
Although unusual, this can result in a positive test following
negative tests and several months of abstinence.
Accuracyof Drug Testing
Despite many claims of confidence in the reliability of drug
testing, independent blind testing of laboratory results
continues to document high error rates for some testing
programs. For this reason many companies and agencies
use a medical review officer (MRO) to review positive
results and rule out any errors in procedure, environmen-
tal contamination, or alternative medical explanations.
The MRO usually interviews the testee, checks the chain of
custody, and/or asks to retest to search for explanations of
a positive result because the results can greatly affect the
 8.52 CHAPTER 8

1'\~eR~ \.eAA
10't~ laeri, ~W(, ~1\.1..Y,
ARe1~~! , ~'to~ R\Q\11H~sOUR!MN!
PJ\%e~ fl1J. !
UP~ wrn.e! ~WT ~f..e.~
OU~UR\t\t~! ~'!\1',
f\GKr,f\G\\t! 'r\1$RAAt>Otrl l

' ))
.~~""";:., -~,w,.~W;P~-,
,
® 2002 John Trever. Reprinted by permission of
Cagle Cartoons.
Iffie.\'IS
\ieNi, >J,1,0W Sl\lDa\r ~tiS l
person's future . In some cases the MRO will look at indeter- False-negative results, rather than false positives, consti-
minate results where manipulation of the specimens is tute the bulk of urine-testing errors. These are the two most
suspected (e.g., when the urine sample diluted, suggesting common reasons:
tampering) . • Many laboratories are overly cautious when reporting
positive results.
False-positive tests could result from the limitation of testing
technology Dextromethorphan, for example, is found in • Testees sometimes manipulate their specimens.
many cold medicines and has been misidentified as an opi- Manipulations, some effective and some just folklore, are
oid. Herbal teas have been implicated in producing a false- used by drug abusers to prevent the detection of drugs in
positive result for cocaine. Poppy seeds in baked goods have their urine . Methods include substituting a container of
been mistaken for an opiate.

Urine fermentation is a major cause of false-positive urine

alcohol tests . An individual with diabetes or pre-diabetic

I
syndrome may pass enough glucose in the urine that, when DetectableLevelsAfter Ingestion
exposed to yeast in the atmosphere, it may ferment into alco-
hol even though the subject used no alcohol. To correct this
potential problem, the testing industry developed the ethyl
glucuronide (EtG) test. EtG is a liver metabolite of alcohol
that results from alcohol ingestion and not from fermenta-
tion of glucose outside of the body EtG also persists in the
body for urine testing much longer than ethanol (up to 72
hours), so it gives a better indication of alcohol use beyond
the usual seven- to 24-hour ethanol detection period. In
2006, however, SAMHSA issued a warning that EtG testing
was so sensitive that it could result in false-positive tests
from minute amounts of ethanol absorbed into the body
0 10 15 20
from hand sanitizers and hundreds of other products that
Daysafter inges
tion
contain ethanol. 331

Errors also can result from the mishandling of urine and

other specimen samples . Tagging the specimen with the
wrong label , incorrectly mixing and preparing the testing
solutions, errors in calculations , mistakes coding the sam-
ples and the solutions, logging and reporting incorrect
results , as well as exposure of samples to destructive condi-
tions or to other drugs in the laboratory-all have resulted in
inaccurate tests.
This graph compares the length of time that cocaine,alcohol, and
marijuana remain at detectable levels in the blood. For purposes of
testing, there is a cutoff levelfor certain drugs, so even when some of
the drug is still in a persons blood or urine, it will not be detected by
the standard test.
© 2014 CNSProductions,lnc.
 DrugUse and Prevention:FromCradleto Grave 8.53

Detection
Period
Range
forUrineTesting
SUBSTANCE DETECTION
PERIOD
RANGE
Alcohol 12hoursto l day
Amphetamine./Methamphetamine 1to 2 days
Barbiturates
short-acting 2 to 3 days
intermediate
(pentobarbital) 2 to 4 days
long-acting 2 to 3 weeks
Benzodiazepines
short-acting
(triazolam) 24hours
intermediate-acting
(donazepam) 40to 80 hours
long-acting
(diazepam) 7 daysor more(upto 30days)
Cocaine
cocaine("coke,"
"crack") 6to8 hours GLENNMCCOY©2009 BellevilleNews-Democrat Dist By UNIVERSA
L UCLICK.
Reprinted
withpermission.
Allrightsreserved.
cocainemetabolite
(benzoylecgonine) 2 to 4 days
LSDanditsmetabolite
ISU-LSD 2 to 4 days
Marijuana l to 7 daysforsingleuse
commonly used to mask drugs in the urine . Positive results
7 to 10daysforregular
use for these substances are reported as possible suspected use
MDMA 1to 2 days of abused drugs even if no abused drug is detected .
Nicotine 12hours The Internet is awash with false information regarding ways
Opioids to beat a drug test. There is no proof that taking large doses
buprenorphine 48to 56 hours of niacin (vitamin B3) will allow someone to defeat a urine
test , but that has not stopped the blogosphere from singing
buprenorphine
conjugates s to 7 days
its praises. Unfortunately, excess niacin can occasionally net
codeine 1to 2 days someone a trip to the emergency room .332
heroin(morphine
ismeasured) 2 to 4 days
With the technology available today, the most reliable drug-
hydromorphone
(Dilaudid
~) 2 to 4 days testing program would include direct observation of the
methadone
(limited
use) 2 to 3 days body specimen and a rigid chain of custody of the sample.
methadone
(maintenance) 7 to 9 days It would also include testing for a wide range of abused

morphine 2 to 4 days
oxycodone
(OxyContin
'") 2 to 4 days
PCP
casualuse 2 to 8 days
chronicheavyuse upto 30days
AdaptedfromWarnerandSharma, 2009, Verebyand Meenan, 2011
urine from a clean donor, injecting clean urine (usually
their own) into the bladder, and using creative devices to
make it appear that the urine being delivered for testing
came from the individual under observation. Attempts to
manipulate urine tests have created a class of enterprising
entrepreneurs offering products like "clean pee " (drug-free
urin e), which has become a profitable black market item.
Substances such as aspirin, goldenseal tea, niacin, zinc sul-
fate, bleach , Klear,®water, ammonia , Drano ,®hydrogen per-
oxide, lemon juice, liquid soap, vinegar, and even Visine®
have been used to mask drugs in urine . Most are ineffective .
Today drug-testing companies test for substances that are
I
drugs , using the most accurate testing methods available
(e.g., GC/MS), and a mandatory second confirmatory test via
a different method. It would include the use of an MRO
along with a detailed medical and social history with which
to int erpret the lab results.
Consequencesof FalsePositivesand Negatives
Concerns about false-positive test results are well publicized,
debated , and feared. People could lose their jobs, be denied
employment, be disqualified from or lose performance
medals in athletic competitions, or even land in prison due
to an erroneous positive result . Less publicized or feared
but just as critical are false-negative results that prevent
the discovery of drug abuse and reinforce the users' state
of denial. A free pass permits the addict to become progres-
sively more impaired and dysfunctional until a major life
crisis occurs.
Pros and cons aside, drug testing is still an effective inter-
vention, treatment, and monitoring tool , especially when it
is used to intervene with heavy users and to discourage
casual use . Addicts often regret not being tested and identi-
fied before th eir lives were destroyed. Drug abusers in treat-
ment often request more-frequent urine testing to help them
focus on abstinence and resist peer pressure to use. They can
 8.54 CHAPTER8

say, "Hey, I can't use. I have to be tested." Treatment pro-
grams use testing to overcome denial and dishonesty in
addicts during early treatment . Recovering addicts holding
jobs that expose the public to high risk would not be accept-
able without a reliable drug-testing program.
Although drug testing in junior and senior high schools is
controversial, it can help prevent drug use by non-users and
even casual users.
"Whenwe talkedto studentsin schoolswherestudentdrug
testingisgoing011, theq willtell qou that it's likecarrfng
theirparentaroundin theirbackpocket:theqcan bring
theirparentand slap them 011 the tablewhentheirpeersare
encouraging them to usedrugsbecausetheqcan saq, qou know,
'I'm in that drug-testingprogram,and if I get discovered , I'll
get kickedoff the footballteam.' It's a waqfor them to push
backagainsttheirpeerswho wouldencouragethem to engage
in the behaviorcasuallq."
Hon. Andrea Barthwell , MD, former deputy director, Office of
Demand Reduction, ONDCP (Barthwell, 2005 )
overuse, abuse, and addiction will grow, as well . The largest
numbers of youth drug-abuse problems in U.S. history are
attributed to the Baby Boomers. Many experienced early-
onset substance use disorders during the tumultuous 1960s,
others during their midlife decades, and now more are
expected to suffer addiction and related disorders during
their senior years .
From 363 million filled prescriptions in 1950 to more than
3.8 billion in 2009 (costing $300 billion) , the increase in the
use of prescribed medications has been fueled by a more
extensive medical care system, a longer life span, and the
discovery of hundreds of new compounds. 334 This surfeit of
available remedies for the illnesses and the problems inher-
ent in aging have also increased the chances of adverse reac-
tions from medications and the chances of abusing drugs
with psychoactive properties . In addition, use of OTC medi-
cations is most prevalent after the age of 65, and these can
have adverse reactions and interactions with other drugs.
Because more than four out of five people over 65 suffer
from some chronic disease, 83% take at least one prescrip-
tion drug per day; an astonishing 30% take eight or more.

Drugsand the Elderly
'Theq nevertold me when I wasqoungwhat indulgencesof
mq qouth I wouldhaveto paq for. Mq compulsiveeatingearned
me two heartstents;mq drinkinggaveme a liverthat doesn't
workas wellnow that I'm 66; and mq smokingthreepacksa
daq in mq teensand twentieshasn'tgot me qet, but mq dad
died of throatcancerfromsmokingeventhoughhe had quit
15 qearsearlier.Mq motherdied of lungcancerat 73, and
she wasstillsmoking.
"
66-year-old male
ChemicalDependency
Up to 17% of adults age 60 and older abuse alcohol and
legal drugs. 335 In addition to drinking or using socially, some
abuse these and other psychoactive drugs to deal with
problems: loneliness, feeling unwanted and rejected by their
families, and lack of respect in the workplace . Events such as
retirement, illness, the death of a spouse , loss of physical
strength and appearance, financial worries, and ageism can
also increase drug use and abuse. 33 6
Although most older adults (87%) see physicians regularly, it
is estimated that 40% of those at risk do not self-identify or
seek services for substance-abuse problems on their own. 33 7

I
Scope of the Problem
OverallDrug Use
In 2011 the first of America 's Baby Boomer generation moved
into the senior citizen category Census data available in
2010 documented 12% of the U.S. population as 65 years
or older, and that figure was projected to increase to 21 % by
2030 .333 By 2050, 85 million Americans will be over the age
of 65 . As the population grows, the problems with drug
Physicians have a difficult time identifying alcoholism and
drug abuse . In one study only 37% of older alcoholics were
identified compared with a 60% identification rate in younger
patients. 338 This is partly because most older adults live inde-
pendently ; fewer than 5% live in nursing or assisted-living
facilities where supervision and physician contact is con-
stant. In addition, many manifestations of drug abuse can
be attributed to other chronic illnesses often present in
those over 55; and because so many drugs are being used
legally, adverse reactions due to the misuse of psychoactive

DrugUseforSelected
Ages,
PastMonth,2012
23

SUBSTANCE ALLAGES 50 TO54 55 TO59 60 TO64 65 ANDUP

Anyillicit-drug 9.2% 7.2% 6.6% 3.6% 1.3%
Nonmedical
useof Rx-type
drugs 2.6% 5.5% 4.00/o 1.8% 1.2%
Marijuana 17.3% 5.1% 4.8% 2.4% 0.9%
Tobacco
(cigarettes) 22.1% 24.5% 21.5% 16.9% 10.00/
o
Alcohol 52.1% 58.5% 53.2% 53.1% 41.2%
Bingeuse 23.0% 22.7% 16.7% 14.3% 8.2%
Heavyuse 6.5% 6.6% 5.0% 4.3% 2.0%

drugs can be masked . Even family members often attribute
the symptoms of drug abuse to the normal effects of aging or
the side effects of legal prescription drugs.
"We thought Dad wasgetting Alzheimer's becausehe would
forgetstuff, seemedaddled much of the time, and hurt
himselfin little accidentsaround the house. We final/~looked
at how man~ meds he was taking:Ativan,® h~drocodone
with acetaminophen, cough s~rupin the winter, and evenan
antidepressantin addition to his heart meds. When he cut back
and eventual/~stopped takingthose drugs, except the heart
meds, all those s~mptomsweregone- not just better- gone."
38-year-old son of a 68-year-old
To compound these problems, society's prevailing attitude is
"They've lived a full life and made their contribution to soci-
ety, so why disturb their lives now? If they want to abuse drugs
at this age, whom will it harm? " This assumes that the unhin-
dered abuse of psychoactive drugs is desirable; but because
addiction is a progressive illness for every age group, contin-
ued use leads to progressive physiological, emotional, social,
relationship, family, and spiritual consequences that users find
intolerable . Addiction means unhappiness and a lack of
choice , regardless of the person 's age.339 -340
Physiological
Changes
"M~ mother had mental problemsand used a numberof
ps~chiatricmedications.She also self-medicatedwith alcohol
and smoked PallMall®cigarettes, and that's wherethe problems
came in. She eventual/~died of lung cancer, but her liverwasn't
in the best of shape. A numberof times, I had to take her to
the emergenc~room and even to the hospitalonce to have her
stomach pumped. The alcoholiccirrhosis, the edema, the injuries
from falls, and the confusionseemed normal when I growingup."
42-year-old son of alcoholic who died at 73
The human body 's physiological functioning and chemistry
are not as efficient in the elderly as they are in young peo-
ple and midlife adults, which results in an abnormal response
to drugs. The enzymes and other body functions become less
active as a person ages, which impairs the ability to inacti-
vate or excrete drugs, making drugs more potent in older
people. 34 1 For example , diazepam (Valium®) is deactivated
by liver enzymes, but after the age of30 the liver slowly loses
its ability to make all these enzymes. Thus a 10 mg dose of
Valium® taken by a 70-year-old will result in an effect equal
to a dose of about 30 mg taken by a 21-year-old .
The drugs most commonly abused by the elderly besides
alcohol and tobacco are hydrocodone (Vicodin ®), narcotic
cough syrups and other opioid analgesics, prescription
sedatives (e.g ., Klonopin ®), and OTC sedatives and sleep
aids . Today increased use of psychiatric medications, such
as fluoxetine (Prozac ®), sertraline (Zoloft ®) , and buspirone
(BuSpar®) to treat many of the symptoms and conditions
common in the elderly, has reduced the abuse of psychoac-
tive drugs . Another recent change was the removal of
Darvon ® from the U.S. market in November 2010 , when
Drug Use and Prevention: From Cradleto Grave 8.55
research prompted by the FDA definitively linked its use to
potentially lethal heart problems 342
Many problems with medications fall into the misuse cate-
gory. A patient may not understand dosing directions,
especially when several medications ( often prescribed by a
physician unaware of a colleague 's treatment) are involved .
Age does not endow a person with immunity to the negative
effects of drugs or chemical dependence.
Patternsof Senior PrescriptionDrug Misuse
It is the consumption of medications in a manner that devi-
ates from the recommended prescribed dose or instructions
that causes problems. Common patterns include:
• overuse-taking many types or more drugs than necessary
• underuse-failure to take appropriately prescribed drugs
at the correct dosage
• erratic use-failure to follow instructions (e.g., before
meals instead of after) , missing doses , taking multiple
doses, taking the wrong drug, or taking a drug by the
wrong route of administration
• contraindicated use-incorrect drug prescribed, result-
ing in either a severe adverse reaction or inactivity or
complications with other drugs being taken
• abuse and addiction-continued use of nonprescribed
or prescribed drug for nonmedical purposes despite
negative consequences 343
Common Drugsof AbuseAmong Seniors
Despite the concern over the misuse and abuse of prescrip-
tion, OTC , and illicit drugs by seniors, the use of alcohol,
nicotine, and caffeine pose the greatest threat to the health
of the elderly and every other age group .
Nicotine Whether it is the carcinogenic properties of ciga-
I
rette smoke, the constricting effect of nicotine on blood ves-
sels , the effect on blood viscosity that increases plaque
formation, or the increase in blood pressure, the unhealthy
and deadly effects of smoking on the elderly cannot be over-
emphasized. Some 16.5% of those over 50 smoke and share
the same negative health risks that have been well docu-
mented in every group of nicotine addicts. 23 About 94% of
all 490,000 premature deaths from smoking are people
over 50. All the major causes of premature death among the
elderly-cancer, heart disease, and stroke-are associated
with smoking . Elderly smokers have twice the mortality
risk of cardiovascular disease of their nonsmoking peers.
caffeine The majority of seniors use caffeine daily, with an
average consumption of 200 mg per day. Current research
demonstrates that caffeine-related toxicity, anxiety, high
blood pressure, heart arrhythmias , insomnia, and irritabil-
ity in susceptible people occur at doses as low as 100 mg
per day (one medium mug of brewed coffee). Caffeine
dependence with withdrawal headaches is generally seen
after 350 to 500 mg per day (two to four lattes or espressos) .
Caffeine use by seniors has also been tied to loss of bone
density, resulting in an increased risk of hip fractures .345
 8.56 CHAPTER8
© 1999 Carlson. Reprinted
by pennission of Universal UClick.
All rights reserved.
Alcohol Today 80% of seniors treated for substance-abuse
problems in publicly funded programs listed alcohol as their
primary drug, making this the most prevalent drug of abuse
by seniors. This may change as more Baby Boomers turn 65.
In one classic study, about 6% to 11 % of elderly patients
who were admitted to hospitals display symptoms of
alcoholism . These figures (which are still relevant) do
not include primary diseases that are aggravated by the use
of alcohol.
Age-related changes significantly affect the way an older
I
person responds to alcohol: a decrease in body water, an
increased sensitivity and decreased tolerance to alcohol, and
a decrease in the metabolism of alcohol in the gastrointesti-
nal tract. For these reasons the same amount of alcohol that
previously had little effect on a person can now cause intox-
ication.341Alcohol abuse and other licit-drug problems are
often missed or neglected by medical providers. They are
not rigorously documented in elderly patients' medical his-
tories; patients are often confused about the history of their
consumption or reluctant to discuss use due to embarrass-
ment. Some health professionals neglect to ask relevant
questions in the mistaken belief that older patients, espe-
cially women, do not drink. 347Impaired coordination, inju-
ries from falls, confusion, memory problems, irritability,
digestion problems, vitamin/mineral deficiencies, severe
liver problems, legal problems, sleep problems, and serious
interactions with therapeutic medications-all are conse-
quences of elder alcohol abuse and support the position that
education and treatment services targeted for the aged are
as important as those for adolescents. 348
Over-the-CounterMedications Seniors are the major consum-
ers of OTC medications and dietary supplements. The
OTC medications most misused and abused by this popula-
/iAP
,~ _,_~~
~6
tion are sedatives, cold and cough aids, and stimulants.
Sedatives like Unisom,® Sleep-Eze,® Nytol, ® and Sominex ®
contain an antihistamine for their sedating effects; those that
are liquid also contain alcohol in concentrations much
greater than wine . Abuse of these substances by every age
group is well documented.
Cold, cough, allergy, and even motion-sickness medica-
tions also contain antihistamines and alcohol and are
sometimes abused for their sedating effects.
Stimulants like No-Doz, ® Vivarin, ® and Keep Alert® and
medications for diet control like Xenadrine ®usually contain
caffeine , herbal caffeine, or ephedrine as the active ingredi-
ent. Abuse of these medications is rare, but in a health-
compromised senior even minor abuse of such stimulants
can cause problems.
PrescriptionDrugs Estimates of prescription drug abuse in the
elderly range from 5% to 33% of the population. Precise esti-
mates are impossible without an unambiguous definition of
what constitutes abuse. There are some in this age group that
believe that it is okay to take a drug that has been prescribed
to a friend for the same ailment. Some research found that
one-third of residents in intermediate care facilities were
receiving long-acting medications that are not recommended
for use by elderly patients.
Sedative-HypnoticMedications The use of benzodiazepines by
seniors, 71% in the over-50 and 33% in the over-65 popula-
tions, is of particular concern because their use has been cor-
related to confusion, falls, and hip fractures.
Opioid Analgesics The most rapid increase in diversion of
prescription drugs for abuse has occurred with prescription
opioid pain medications like oxycodone (OxyContin ®) and

hydrocodone. In 2008, 6.9% of adults older than 56 and
14.6% of all individuals treated for substance abuse were pri-
marily opioid prescription pain medication or heroin abus-
ers. Hydrocodone (Vicodin, ® Lortab, ® and Norco®) is the
most widely used and abused prescription opiate among
seniors, a dubious distinction that used to belong to codeine-
based prescriptions. Since 1990 there has been a 500%
increase in the number of emergency room visits due to
hydrocodone. Because it is often co-formulated with acet-
aminophen, the abuse of the combination for the psychic
effects of the opioid can cause liver damage from the acet-
aminophen-a particular problem with seniors.
Seniors, especially those using a cane or another walking aid,
are often approached by younger opioid abusers and asked
to pass off forged prescriptions for controlled opioid anal-
gesics. Seniors are less likely to be questioned or challenged
on these prescriptions and receive either cash or medications
for their efforts. Though data regarding age and abuse of opi-
oid prescription cough medications are lacking, anecdotal
reports indicate that seniors who are prescribed Hycomine,®
Tussionex,®or Ambenyl®or any cold and cough medication
containing hydrocodone, codeine, or an opioid on a contin-
uous basis are likely using for reasons other than relief of a
seasonal cold or allergy.
Illicit Drugs Current and past data indicate a low prevalence
of illicit-drug use (e.g., heroin, cocaine, meth , and mari-
juana) by the elderly. In 1979 almost 14 million (27%) Baby
Boomers, then ages 21 to 33, reported current (within the
previous 30 days) illicit-drug abuse. The prevalence of illicit-
drug use sharply and regularly declined in this population
over the next 10 to 12 years. During that period illicit-drug
use leveled out to an annual prevalence of 5% and has
remained stable ever since . Age-comparable individuals from
the previous generation have a 3.8% annual prevalence of
illicit-drug use. It is expected that as more Baby Boomers
reach old age, a larger number of illicit-drug users will be
part of the elderly population. 23-350
FactorsContributingto ElderlyDrug Misuseand Abuse
Aging is associated with a growing burden of disease that
disproportionately exposes the elderly to prescription and
OTC medications. This coupled with age-related physiologi-
cal changes and medical issues places seniors at greater risk
for drug-abuse problems. 351 -352 Abuse of alcohol or drugs by
the elderly causes many health problems, such as liver dis-
ease, increased blood pressure, some forms of cancer, a
higher risk of falls, incontinence, cognitive impairment,
hypothermia, emotional problems, and self-neglect.
Compared with younger adults, substance-abuse disorders
present more often as medical or neuropsychiatric problems
in the elderly Current diagnostic criteria for substance
abuse are based on younger populations and may not apply
to seniors. The criteria of increased alcohol or drug toler-
ance with progressive increased consumption, for example,
may be invalid in seniors because of age-associated changes
in pharmacokinetics and physiology that may alter their
drug tolerance .
Drug Use and Prevention:FromCradleto Grave 8.57
"Dru9useand misuseamon9the elderlqcontinues
to be a ne9lectedareaof researchin the peld of social
9erontolo9q.Standardtextbooks,for example,devote
littleor no attentionto the topic."
Petersen and Thomas , 1975
Though written more than three decades ago, this statement
is as relevant today as it was in 1975. Substance misuse by
the elderly continues to be minimized in our culture.
• Of total hospital admissions for the elderly, 20% are
directly due to prescription or OTC drug reactions
exclusive of alcohol and illicit-drug admissions.
• About 20% of seniors who were regular drinkers exceeded
recommended limits; 5% to 12% of men and 1% to 2% of
women are problem drinkers. 354
• Up to 80% of senior arrests are for drunkenness.
PreventionIssues
PrimaryPrevention
Because social drinkers and even those who abstain can
develop late-onset alcoholism, often in response to age-
related problems, older people must be re-educated about
the dangers of excessive use of alcohol and other psychoac-
tive drugs and be provided with counseling on how to man-
age the problems associated with growing older without
using psychoactive drugs, and, in the case of alcohol, using
in moderation. Volunteering in the community , maintaining
an active social life, and taking advantage of educational
opportunities are ways to encourage primary prevention.
People who deliver services to this population, such as
nurses, physicians, and social workers, must be provided
with prevention information customized for the elderly.
I
SecondaryPrevention
Secondary prevention for the elderly focuses on recognizing
the early stages of alcoholism or drug abuse and employing
appropriate intervention tactics . Frequently, there is strong
denial by this age group because many of this generation
perceive alcohol and drug abuse as a sin or moral failure.
Drug abuse often goes undetected because of the seclusion
and the solitude in which so many elderly live, so a mobile
professional staff and vigorous outreach programs are neces-
sary Home visits are particularly effective. Alcoholism and
addiction must be recognized as primary diseases that
must be treated.
Brief alcohol interventions lasting only a few minutes usu-
ally take place in a doctor's office and are repeated a couple
of times. The objective is to get the patient to cut down or
stop drinking. This tactic has been proven effective for mild-
to-moderate drinking problems. 352 -355
It is important that anyone in contact with older adults on a
regular basis and intimately acquainted with their habits and
daily routines should also be aware of signs of developing
alcohol-use problems; this includes friends, family, drivers ,
and volunteers at senior centers .
 8.58 CHAPTER 8
TertiaryPrevention
Treatment frequently involves different procedures from
those used with younger clients. This age group is not
responsive to abrupt, coercive, confrontational therapies.
Conclusions
Prevention efforts should be measured in terms of results
(are there fewer smokers today or are there simply more
smoker groups?) rather than in terms of activity (there
were 1,348 smoking-cessation programs in the United
States last year) . Prevention activity without results has lit-
tle impact on the problem. Studies on the effectiveness of a
campaign are often inconclusive because so many factors are
involved and it is difficult to attribute inevitable trends in
society to specific efforts. To do nothing, however, is worse .
One recent direction that has promise is the use of massive
alcohol/drug prevention advertising campaigns that are more
effective, more honest, and more pervasive than earlier
efforts. If print and broadcast ads and marketing campaigns
can persuade people to eat unhealthy food, drink beer, or
smoke cigarettes, ads and campaigns that focus on preven-
tion should be equally as persuasive.
There is profound disagreement about drugs and drug
policy in our society. Some see every drug as an inherently
evil substance that must be regulated by law. Some see drug
use as a matter of choice (free choice in the case of legal
drugs and eventual decriminalization or legalization in the
case of illicit drugs). Some see drug abuse as a disease requir-
ing treatment. Regardless of the view, there is hope that cur-
rent and future prevention strategies will succeed.
Current PromisingDirections
Today prevention is considered a shared responsibility. The
I
most promising approaches are the ones in which various
segments of a community work in unison-youth , mer-
chants, police, professionals, schools, parents, the govern-
ment, and the media. An entire community arrives at a
consensus about what it must do to prevent drug abuse, then
agrees on the specific models that would best serve individu-
als and the community as a whole.
People are at risk throughout their lives. They are exposed
from cradle to grave, so prevention efforts must extend
over a lifetime .
• Primary prevention can prevent a child from being
born addicted by treating pregnant women who use
drugs. Prenatal care programs provide parenting skills,
teach the importance of touch and unconditional love,
and provide information about community resources.
Toddlers can be given activities that increase bonding
with their parents or caregivers . If the child has been
exposed to drugs in the womb, rigorous early care can
minimize long-term effects.
• The family is a crucial prevention delivery system for
children. Parents who avoid drinking or using, especially
during their child-rearing years, and who model life-
enhancing behaviors set an excellent example for their
children.
• Elementary schools can integrate prevention into the
curriculum. Developmental skills can be taught, includ-
ing resistance and decision-making skills. Students can
be taught how to process moral dilemmas and how to
talk about feelings.
• By middle school many children stop listening to adults
and start listening to other children and often begin smok-
ing, drinking , and using drugs. Peer educator programs
identify natural leaders who serve as models, teachers,
and guides for in-school peer prevention efforts.
• In high school and college, prevention must assume a
higher level of sophistication to counter experimenta-
tion, social use, and habituation because there is greater
exposure to drugs. At this level a continuum of preven-
tion efforts must include curriculum infusion, normative
education , support services, environmental change, pol-
icy formulation and enforcement as well as alternatives
to alcohol and other drug use in social occasions.
• Workplace prevention must be continued through EAPs.
They must be proactive and provide ongoing prevention ,
referral, and treatment opportunities. Prevention educa-
tion should be provided as part of the normal course of
job training. Pre-employment drug testing helps prevent
future problems.
• Programs must be developed that address and publi-
cize the health risks of drug use, such as the potential
for sexually transmitted diseases, including HIV and
hepatitis C from needle use , as well as heart disease from
cigarettes, stimulants, and overeating.
• For older people, pre-retirement training sessions and
grief counseling can help prevent alcohol and other
drug use. Outreach programs must deliver prevention
messages to the people who are housebound or are not
part of the school/workplace/community avenues of
access.
• Prevention must be adapted to the needs of specific
audiences. A program for a rural Midwestern town is
not appropriate for a school in inn er-city Los Angeles.
Secondary prevention designed to inform experiment-
ers about the dangerous effects of drug use might actu-
ally stimulate experimentation in a primary audience.
Because no single prevention program can demonstrate
universal reproducible results, existing programs must
be modified to fit particular situations.

Prevention
• Prevent ing abuse and addiction, whether it is drugs or
behavioral compu lsions, is always more effective than
trying to stop the flow of drugs or treating the abuse
or the addiction after it has occurred.
• Addiction is a disease- and it is the disease that must
be prevented , not just the use of opioids or cigarettes
or diverted prescription drugs.
• The push for legalization of marijuana and some other
drugs has not yet been proven to be a viable solution .
Because drug use affects people throughout their lives,
many drug educators believe that prevention shou ld
be practiced from cradle to grave.
Conceptsof Prevention
PreventionGoals
• Historically, substance-abuse prevention has ranged
from total proh ibition, to temperance, to harm reduc -
tion. Scare tactics, drug information programs, and
skill-building or resiliency training are some of the
methods used over the years.
• The three main prevention goals are primary preven-
tion-prevent the development of the disease in non-
users; secondary prevention-stopping inappropriate
or potentially destructive use in non-dependent users;
and tertiary prevention - reversing abuse and addic-
tion in dependent users .
• These levels of prevention are also known as un iver-
sal, selective, and indicated .
• The three main prevention methods are supply reduc -
tion-enforce legal penalties and interdict drugs;
demand reduction-reduce craving for drugs; and
harm reduction - minimize harm without requiring
abstinence.
• The most important group of users to target for pre-
vention are non -dependent users. These are the users
whom beginning users will emulate.
History
• Attempts to regulate drugs , particularly alcohol, have
wavered between moderat ion of use (temperance)
and outrig ht prohibition .
• The conflict between moderate use of alcohol/psycho -
active drugs and moral/legal abhorrence of any use of
any amount persists to the present day.
• The Eighteenth Amendment prohibiting alcoho l
was passed in 1917, enforced starting in 1920, and
repealed in 1933.
• Prohibition did reduce health problems, domestic
violence, certain crimes , and consumption. It also
Drug Use and Prevention:From Cradleto Grave 8.59
lowered deaths from cirrhosis of the liver. Criminal
organizations that existed before Prohibition flour-
ished .
• The Amethyst Initiative was an attempt by college
presidents to lower the drinking age from 21 to 18 to
eliminate the burden of policing their students' drink-
ing habits and to make regulations match the reality of
life on campus.
• Illicit-drug use jumped from 2% in 1962 to 31% in
1979, and back to 23.9% in 2012.
• Offering skill-building and resiliency programs ,
addressing risk factors , and developing support sys-
tems seem to be more-effective prevention techniques
than scare tactics and drug information programs
alone .
• Changing the environment by changing family
dynamics, peer group values, and the influence of
media looks beyond the individual to community-
based, systems-oriented programs . This involves the
entire neighborhood in prevention .
• The public health model approach attempts to con-
trol addiction by affecting the relationships among
the host (user) , the contrib utory environment , and an
agent (the drug or addictive behavior) .
• The family approach attempts to control addiction by
changing family dynamics, using support , skills train-
ing, and therapy.
PreventionMethods
• Supply reduction is suppo rted by a dozen agencies,
including state and local police departments , the Drug
Enforcement Administration (DEA), the Treasury
Department , the Department of Transportation, and
even the Department of Defense (DOD).
• Activities include interdiction, limiting precursor
chemicals , increasing legal penalties, and strengthening
borders .
• Primary prevention tries to anticipate and prevent ini-
tial drug use. Early-onset drug use is the best predic-
tor of future drug problems .
• Secondary preventions adds intervention strategies to
educat ion and skill building, such as drug diversion
programs.
• Tertiary prevention uses group intervention , indi-
vidual and family therapy, specific prevention and life
skills , medications , and development of aftercare sys-
tems.
• Harm reduction , such as methadone/buprenorphine
maintenance and needle exchange, tries to minimize
damage from drug abuse and addiction.
 8.60 CHAPTER8
• The impediments to prevention efforts include the
abundance of legal drugs, the availability of street
drugs, the slow success rate of prevention programs,
the lack of tools to measure the efforts, and the lack
of adequate funding, awareness, and education about
addiction and its treatment.
• There is no quick fix for drug abuse and addiction.
Prevention must be ongoing.
From Cradleto Grave
• The age of first use and high levels of overall use are
associated with the development of drug problems.
Drug abuse is not related to any race, socioeconomic
class, age, gender, or level of intelligence.
Pregnancyand Birth
• Drugs cross the placental barrier and affect the fetus.
An infant can be born addicted and go through dan-
gerous withdrawal. Drug effects continue after birth.
Almost 18.6% of fetuses are exposed to just alcohol,
17% to marijuana, and 17.6% to tobacco.
• Drugs can aggravate health problems in pregnant
women, such as diabetes, anemia, sexually transmit-
ted diseases (STDs), and high blood pressure plus
infections caused by infected needles or from infected
partners .
• Pregnant addicts often have no prenatal care and often
live a chaotic lifestyle, which can harm a fetus .
• Fetal alcohol spectrum disorders (FASO) include a
number of conditions, such as fetal alcohol syndrome
I
(FAS), alcohol-related neurodevelopmental disorder
(ARNO) and alcohol-related birth defects (ARBO).
• Opioid and stimulant use can force the neonate to go
through withdrawal when born.
Youth and School
• Alcohol use is the number one problem in schools,
followed by tobacco and marijuana. The abuse of pre-
scription drugs, especially opioids, is on the rise .
• Counteracting alcohol abuse involves recognizing
risk factors, demystifying perceived benefits, bol-
stering resiliency, and using normative assessment.
Prevention efforts are effective when taught at every
grade level.
College Students
• Alcohol is still the number one drug on campus,
although marijuana use remains high.
• 3 7% of college students binge-drink (five or more
drinks in one sitting in the past two weeks).
• Fraternity and sorority members are more likely to
drink than are independents.
• Secondhand drinking is disruptive to nondrinkers
living in college housing.
• Normative assessment is an important tool in educat-
ing college students about the reality of binge drink-
ing and drug use.
Love,Sex,and Drugs
• Viagra,® Cialis,® and Levitra ®have changed attitudes
toward human sexuality.
• Drugs can affect various aspects of sexual function-
ing, such as lowering inhibitions and stimulating or
depressing sexual functioning.
• Most drugs used to enhance sexual performance have
no effect in the absence of sexual stimulation.
• Drugs can trigger or magnify sexual aggression and
domestic violence .
• Contaminated needles spread sexually transmitted
diseases (e.g., HIV/AIDS and hepatitis). The most
common STDs are chlamydia, gonorrhea, syphilis,
trichomonas, pelvic inflammatory disease (PIO),
human papilloma virus (HPV), venereal warts, and
AIDS.
• Worldwide, 130 million to 150 million people have
chronic hepatitis C infection; 35 million are living
with HIV
Drugsat Work
• Substance abuse in the workplace costs businesses
and society more than $200 billion per year in lost
productivity, lost earnings, and increased healthcare
costs.
• Pre-employment drug testing is one strategy to keep
drugs out of the workplace. Medical marijuana and
legal marijuana make maintaining a drug-free work-
place more challenging.
• Employee assistance programs (EAPs) are in place
to help workers gain control over their problem.
Most programs are contracted outside the company.
Such programs save anywhere from $5 to $14 for
each dollar spent .
Drugsin the Military
• The U.S. Armed Forces have implemented effective
drug-abuse prevention programs since the 1970s.
• Illicit-drug use has dropped from 27.6% in 1980 to
just 2.3% in 2008.
• Heavy drinking of alcohol showed a much smaller
drop. The current level is around 20%.
• The wars in Afghanistan and Iraq caused the military
to increase levels of testing.
• Synthetic marijuana and to a lesser extent bath salts
are being used because it is difficult to detect many of
the newer compounds.

• Each branch of the service has its own drug abuse
prevention program .
DrugTesting
• The workp lace (e.g. , pre-employment and for cause),
the military, treatment clinics, sports organiza tions,
and the pub lic-safety sector (e.g., pilots and truck
drivers) commonly test for drug use.
• Workp lace testing includes pre-employment , for
cause, random, periodic, post-accident, follow-up,
and return to duty.
• Lab tests include thin-layer chromatography (TLC),
enzyme-multiplied immunoassay techniques (EMIT),
gas chromatography/mass spectrometry combined
(GC/MS), and hair analysis.
• Machines and kits test saliva, sweat , and breath but
results are less accurate and usually must be confirmed.
• False negatives on tests often cause more problems
than false positives because the person believes they
have gotten away with something and continue to use
with increasing problems .
Drugsand the Elderly
• The elderly are more susceptible to the pharmacologi-
cal effects of drugs. Alcoho l abuse and prescription
drug abuse are the biggest problems.
• Abuse of street drugs drops dramatically above the age
of 65.
Drug Use and Prevention: From Cradle to Grave 8.61
• Up to 17% of adults age 60 and older abuse alcoho l
and legal drugs .
• Physiological functioning and chemistry are not as
efficient in the elder ly as they are in young people .
• Because the body becomes less efficient as it ages,
even low doses can have strong effects.
• The most commonly abused drugs by the elderly
besides alcohol and tobacco are opioids-especially
Vicodin, ® narcotic cough syrups, and other opioid
analgesics-and benzodiazepines , especially Xanax®
and Valium .®
• Alcohol abuse and other drug problems are often
missed or neglected by medical care facilities .
• Elders must be educated about the dangers of drugs
in general and prescription drugs specifically. Doctors
need to recognize signs of alcoholism and drug use .
Conclusions
• Prevention efforts should be measured in terms of
results , not in terms of how many prevention pro-
grams there are.
• The place of drugs in society is changing in the light
of legalization and advertising .
• Current promising directions in prevention include
prenatal care for expectant mothers, giving support
to families, more prevention programs throughout
life, and more programs for seniors. These programs
need to be tailored for specific groups; one size does
not fit all.
I
Posterfrom the Narcoti
ChemicalCo., Springfield,
Massachusetts,advertising
a curefor the tobacco
habit.
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 9.2 CHAPTER9
'Treatmentis effective.Scientificallqbaseddru9 addiction
treatmentstqpicallqreducedru9 abuse bq 40% to 60%.
These rates are not ideal, of course,but theq are comparable
with complianceratesseen with treatmentfor other chronic
diseases,such as asthma, hqpertension,and diabetes.Moreover,
treatmentmarkedlqreducesundesirableconsequencesof dru9
abuseand addiction, such as unemploqment,criminalactivitq,
and HIV/AIDS or other infectiousdiseases,whetheror not
patientsachievecompleteabstinence."
Alan L Leshner, Ph.D., former director, Nationa l Institute on Drug Abuse
Some treatment outcome studies targeted for methamphet-
amine addiction (e.g., the Matrix Model) as well as those for
other drugs of choice demonstrate up to 80% to 87% one-
year continuous sobriety rates. Such positive treatment out-
come rates compare favorably with treatment rates obtained
from treating most other chronic diseases, such as diabetes,
asthma , and hypertension. 3 Another indicator is the percent-
age of days abstinent (PDA) from alcohol during a period of
time following treatment to gauge treatment outcomes.
In 2011 the Butler Research Group found a 95.33% PDA
12 months following treatment at Hazelden compared with
37.91 % baseline before treatment. 2
A Diseaseof the Brain
Mental illnesses, nervous system diseases, brain tumors, and
physical head traumas are the first things that come to mind
when most people consider pathological conditions of the
human brain; but in reality chemical dependency and addic-
tion are more prevalent than other brain diseases and have
a much greater impact on the fabric of society. Among
people age 18 to 54, the one-year prevalence rate of:
• anxiety disorders is 18.1%,
• mood disorders (major depression, bipolar disease, and
affective disorders) is about 9.5%,
• schizophrenia is about 1.1%,
• any mental disorder is about 26.2%.4
I
This compares with:
• illicit-drug use by 8. 7% of the U.S. population age 12 or
older in the past month (underage alcohol use [age 12 to
20] ranged from a low of 17.5% in Utah to a high of 40%
in North Dakota),
• nicotine addiction in 29.1% of the population over the
age of 12, and
• gambling addiction that affects 2% to 6% of adults. 5 •6
Chemical dependency may also be the number one con-
tinuing public health problem in the United States.
• More than 443,000 Americans die prematurely every
year due to nicotine addiction, and another 53,000 die
from secondhand smoke.
• Another 80,000 die prematurely from alcohol depen-
dence, abuse, overdose, or associated diseases.
• 6,000 to 10,000 die of cocaine, heroin, and metham-
phetamine overdose or dependence .
Each day 1,740 Americans die from a substance use disorder
(SUD) or related causes; that is more than one death every
minute.
• 35% to 40% of all hospital admissions are related to
nicotine-induced health problems.
• 25% of all hospital admissions are related to alcoho l-
induced health problems. 7,8 ,9
These figures are startling when compared with other major
health problems such as AIDS, prostate or breast cancer, and
stroke. Many of these illnesses are often the result of drug
abuse and addiction.
Psychoactive drug abuse also has profound effects on social
systems, family relationships, crime, violence, mental health,
and every other area of daily life. If the impact of addiction
were reduced , the quality of life worldwide would be greatly
improved.
Current Issuesin Treatment
Eight aspects of chemical dependency and behavioral addic-
tions treatment dominate research, clinical practice, and
discussion.
0 Medications are used more frequently to treat addiction.
Because addictive use of substances alters brain chemistry,
the search for medications that lessen the impact of those
chemica l and structural changes is ongoing. These include:
• drugs to lessen withdrawal symptoms
• drugs to lessen craving
• substitute medications that are less damaging than the
primary substance of abuse
• nutritional supplements
• antidepressants
8 Researchers use the latest imaging systems and diag-
nostic techniques to visualize the structural and physi-
ological effects of addiction on the human brain.
Until the advent of sophisticated imaging techniques, gene
identification technologies, and sensitive neurochemical
measurement methodologies, addiction was easy to deny
because compulsion was considered a behavioral disorder
with few if any physical indicators that could be examined.
New imaging techniques have identified multiple brain cir-
cuit systems involved in addiction (e.g., survival/reward,
motivation, memory/learning, and control) and are able to
visually display those changes. 10-11 These are most common
imaging techniques used to examine changes in the central
nervous system (CNS): 12
• CAT (computerized axial tomography) scans use X-rays
to show structural changes in brain tissues due to drugs.
• MRI (magnetic resonance imaging) uses the positioning
of magnetic nuclei to produce two- and three-dimen-
sional images of brain structures in great detail, reveal-
ing subtle alterations of brain tissues due to psychoactive
drug use as well as brain anomalies that indicate a sus-
 Treatment 9.3

ceptibility to drug abuse. For example , an MRI study at

the University of Southern California showed a smaller
prefrontal cortex (11 % smaller on averag e) in individu-
als prone to rage and violence. This diagnostic technique
proved as accurate as psychological testing techniques_l3
• fMRI (functional MRI) is a variation of MRI technology
that provides information about the metabolism of the
brain . fMRI tracts function in different parts of the brain
while the testing is being conducted. Whereas MRI pro-
vides only structural information about the brain and
how drugs affect brain structures over time, fMRI pro-
vides functional as well as structural information about
how the brain is affected by SUDs.
• PET (positron emission tomography) scans use the Diffusion tensor imaging (DTI) shows brain wiring in a healthy
metabolism of radioactively labeled chemicals that have human adult. The thread-lik e structur es are nerv e bundles, each
been injected into the bloodstream to measure glucose containin g hundr eds of thousands of nerve fibers.
metabolism, blood flow, and oxygenation to visualize the Courtesyof VanJ.Wedeen,M.D. MGH/HarvardUniversity
effects of naturally occurring neurotransmitters that
are affected by drugs .
Addiction Medicine Patient Placement Criteria (ASAM
• SPECT (single-photon emission computerized tomog-
PPC). The growing number of SUD diagnostic tools coupled
raphy) scans also use radioactive tracers to measure
with a greater acceptance of assessment tools to help deter-
cerebral blood flow and brain metabolism to show how
mine the severity of withdrawal symptoms provides a
a brain functions (or does not function) when using
guide to medical detoxification treatment.
drugs; they are similar to PET scans but are less expen-
sive and easier to administer. 12
• DTI (diffusion tensor imaging) is an MRI technique that
0 There is a deeper understanding and appreciation of
the neuroscience of relapse and recovery.
can provid e information about connections among brain
regions . It can image the tracts of nerve fibers through In 2005 scientists discovered decreased activity in five dis-
the brain 's white matter and show how parts of the brain crete areas of the brain 's neocortex that correlated to a high
communicate with one another (e.g., the survival/ rein- risk for relapse in methamphetamine addicts who graduated
forcement circuit communicating with the control areas from 28-day residential treatment. In addition to the sur-
of the addiction pathway). vival/reinforcement circuit of the "old brain " and the control
circuit of the prefrontal cortex that causes people to abuse
'There's somuch that thesescansand ima9es ofthe braincan drugs and then blocks the ability to stop using, differences in
offerthe fieldofaddiction.We can showchildren,teena9ers , the brain also impaired the ability to "stay stopped " (remain
and adultsthat dru9shavean impacton theirbrains.It's much abstinent)_ 14, 15
morepowerfulthan showin9them a pictureoffriede99sand
bacon.It's verqhelpfulwhenconfrontin9denialto actuallqsit in 0 There is a greater emphasis on evidence-based best
frontofa computerscreenwith somebodqwho has beenusin9 practices in treatment and a diminished appreciation

dru9s, and theqsaq, 'Oh, therearereallqno problems.'And
qoucan saq, 'Let's lookat qours.'And it reallqhas turnedmanq
peoplearound."
Daniel Amen, M.D. , founder, Amen Clinic for Behavioral Medicine
€) New tools effectively diagnose addiction and better
match clients to specific treatment interventions .
Researchers developed questionnaires and techniques that
objectively identify and evaluate the severity of alcohol or
other drug-abuse behaviors; this has resulted in the valida-
tion of several dozen diagnostic tools. These range from
simple four-question self-report instruments like the CAGE-
AID test to the comprehensive 200-item Addiction/Alcohol
Severity Index. Valid diagnostic criteria are now vital to
matching a client to the appropriate level of treatment inter-
vention, resulting in better outcomes while making optimal
use of the limited resources available . The most widely used
and most practical of these is the American Society of
I
of practice-based clinical management .
Driven by a view that substance-abuse treatment is ineffec-
tive when it is based on personal experiences, intuition, par-
ticular styles of communication, or folklore, evidence-based
best practices is now the paradigm for both substance-abuse
treatment and prevention practices. The overall goal of evi-
dence-based efforts is to ensure that treatment consistently
provides the best potential for positive outcomes . Because
there are insufficient treatment resources, evidence-based
practices are designed to provide the most cost- and time-
effective treatment services. There is no consensus, however,
on what constitutes or fully validates an evidence-based
practice or on the quantity or nature of the evidence neces-
sary for that designation .
The Iowa Practice Improvement Collaborative provides a
useful understanding of these issues in the form of a 13-point
criteria metric to evaluate new and existing treatment
practices (evidence-based practices). 16
 9.4 CHAPTER 9
This PET scan project was designed to lookfor dopamine receptors.
The images revealedthat extra dopamine receptorsadded a protective
factor to subjects who had a family history of alcoholism. The left
scan of a nondrinker with a strongfamily history of alcoholism shows
excess receptors(red and bright yellow). The right scan of an
alcoholicwith no family history of alcoholismshows a shortage of
dopamine receptors(dull yellow and no red). This is just one of the
many important uses of brain imaging to study addiction.
Volkow, Wang, Begleiter, et al., 2006.
The Substance Abuse and Mental Health Services Admin-
istration (SAMHSA) created an inventory of recommended
prevention and treatment interventions known as the
National Registry of Evidence-Based Programs and
Practices (NREPP). This registry currently describes more
than 160 programs as model, effective, or promising . In
spring 2006, the NREPP was expanded and revised to
include program listings for treatment of mental health
as well as addictive disorders (visit www.modelprograms
.samhsa.gov).17The lack of consensus on what constitutes
valid evidence-based criteria, however, resulted in several
states establishing their own list of acceptable evidence-
based programs and practices, which varies significantly
from those listed in the NREPP.
Many of the most effective of these evidence-based practices
were developed and in practice long before there was any
process for validation and prior to the concept of evidence-
I
based (Alcoholics Anonymous, Narcotics Anonymous, and
the 12-step fellowship model). The process to validate a par-
ticular practice as evidence-based is expensive, and it would
be a great loss to the recovery field if the many outstanding
practice-based interventions and programs were aban-
doned for lack of validation resources.
0 There is sustained evidence that coerced treatment
(e.g., drug court) is as effective, if not more so, as vol-
untary treatment in promoting positive outcomes.
Coerced treatment is mandated participation by the criminal
justice system (CJS) through drug couns, mandatory sen-
tencing, probation/parole stipulations, and state or federal
legislation requiring compulsory treatment. Defendants who
complete a drug court program often have their charges dis-
missed or probation sentences reduced. Currently, all 50
states operate drug court programs, and at any given time
more than 70,000 clients are being served. 18
Findings of a five-year Drug Treatment Alternative-
to-Prison (DTAP) program in New York uphold several
previous studies that measured the effectiveness of
coerced-treatment outcomes. The DTAP study demonstrated
significant reductions in the re-arrest rate (33%), reconvic-
tion rate ( 45%), and return-to-prison rate (87%) compared
with prisoners who had not participated in the program.
Also, 92% of DTAP participants were employed upon com-
pletion of the program, whereas only 26% were employed
before their arrest. 19 •21 These reports funher document the
cost savings from treatment compared with the cost of
incarceration for the same length of time.
California drug courts cost an average of $3,000 per client
and save the state an average of $11,000 per client over the
cost of incarceration and associated court expenses_22 In
Oregon positive outcomes continue to result from drug court
interventions; and a study found that drug courts reduced
crime by 30% over five years, and the percentage of crimes
committed by participants 14 years from the time of their
arrest was significantly lower."
Of the more than 100,000 people who enter drug couns,
50% to 65% graduate or remain active participants. These
courts keep felony offenders in treatment at about double
the retention rate of community drug programs because they
involve closer supervision and the threat of incarceration.H· 25
The growing number of coerced-treatment initiatives may
have an adverse effect on treatment availability for the gen-
eral population because so many treatment slots are funded
by these new initiatives and are reserved for those involved
with the criminal justice system. The recent downturn in the
U.S. economy resulted in the loss of a number of substance-
abuse treatment programs, so addicts who are not involved
with the law have fewer treatment options open to them
even though legislation states that CJS treatment slots will
not replace any non-CJS slots.
() There is a lack of resources to provide the treatment
that has been proven effective.
According to one 2010 study, only $28 billion was spent to
treat the 40 million people with addiction. In comparison,
the United States spent :
• $44 billion to treat diabetes, which affects 26 million
people
• $87 billion to treat cancer, which affects 19 million people
• $107 billion to treat heart conditions, which affect
27 million people
Costs to federal, state, and local governments amount to
11% of total spending; 95¢ of every dollar pay for the conse-
quences, and only 2¢ go to prevention and treatment. 26
Studies show that for every $1 spent on treatment, up to $39
is saved, mostly in prison costs, lost time on the job, health-
care costs, and extra social services.27-28 •2' Other research
shows the effectiveness of matching treatment modalities
to each client's needs. 30 ·31 Finally, studies indicate that the
more services such as healthcare, psychological care, and
social support that are available, the better the outcome. 32

Limited community, state, and federal resources; more reli-
ance on managed care; and a general reluctance to spend
money on treatment for drug addicts prevent cities, coun-
ties, and states from providing sufficient treatment to those
who desperately want it. Data from the 2008 National Survey
on Drug Use and Health estimate that during that year
17.4 million people who needed treatment for abusing alco-
hol and 6.4 million who needed treatment for illicit-drug use
did not receive it. The two reasons most often cited by more
than half the participants of a survey of people who wanted
treatment but did not receive it were an inability to pay and
not knowing where to obtain treatment. 9 •33
The lack of accessible treatment services worsened after the
economic downturn that began in 2007. In response, state
and local governments made drastic funding cuts to mental
health and SUD treatment services, causing many programs
to close and a reduction in license renewal requests from
addiction treatment professionals.
The Mental Health Parity and Addiction Equity Act, signed
into law in October 2008, established substance use disorder
as a medical condition and is targeted to end disparities in its
medical treatment. The Addiction Equity Act became effec-
tive in October 2009, but regulations for the act delayed its
full implementation until the 2014 rollout of the Affordable
Care Act. Symbolically, the Addiction Equity Act was one of
20 bills attached to the Emergency Economic Stabilization
Act of 2008. 34 Its most important impact is its recognition of
addiction as a full medical disorder and not a moral weak-
ness or lack of intelligence in those affected.
0 There is a continuing conflict between abstinence-
oriented recovery and harm reduction as philosophies
of treatment.
Most treatment professionals believe that users who have
crossed the line into uncontrolled drug use or the practice of
compulsive behaviors can easily refuse the first drink, injec-
tion, or bet but find it hard to refuse the second. This group
believes that abstinence is absolutely necessary for recovery
because the very definition of addiction is based on the con-
cept of loss of control. Results from a number of studies con-
ducted by the Haight Ashbury Free Clinics showed that
when a client slipped (e.g ., had a drink, took one hit, or
smoked one cigarette), it turned into a full relapse in 95%
of the cases .35
"Moderation?A drinkof liquoris to m~appetitewhat a red-hot
pokeris to a kegof dr~powder.. .. When I takeone drink,even
if it is but a taste, I must havemore,evenif I knewhell would
burstout of the earthand engulfme the next instant."
Luther Bensen 3 7
Another segment of treatment professionals believe that
harm reduction is a viable treatment alternative to absti-
nence only The problem with evaluating the effectiveness of
harm reduction is that it means different things to different
people . One definition of harm reduction is "a willingness to
work for incremental changes rather than requiring com-
Treatment 9.5
© 201 1 DaveGranlund
plete behavior change." Another is "any steps taken by drug
users to reduce the harm of their behavior. "38 ,3 9
Harm reduction includes:
• drug replacement therapy such as methadone or
Suboxone ® maintenance instead of heroin use, or meth-
ylphenidate maintenance instead of cocaine use
• needle exchange, safe injecting sites, and naloxone dis-
tribution to opiate addicts
• designating a nondrinking/non-drug-using driver, wet
hostels, or sobering stations
• substituting "less harmful" drugs for "more harmful"
ones (e.g., marijuana instead of heroin)
• testing illegal drugs for users to prevent use of a danger-
ous, misrepresented substance or additives
• reestablishing age-related legal access to alcohol and
other drugs (e.g., 2008 Amethyst Initiative to lower the
drinking age)
• drug decriminalization/legalization through legislation
I
• controlled drinking/drug use through behavior modifi-
cation-the most controversial technique
Numerous studies have been done on controlled drinking,
but definitions obscure the reported data. What constitutes
controlled drinking? Was the patient an alcoholic or a prob-
lem drinker before entering treatment? Has the patient accu-
rately reported the amount consumed? 40 Long-term
follow-up strongly suggests that true controlled drinking
does not work. 41 ·42 Some harm reduction proponents use
individual techniques that help advance the addict to full
(abstinent) recovery; others believe that harm reduction is
an all-encompassing philosophy of treatment and drug use.
There is a lack of consistency regarding how treatment out-
come is measured. ls it measured in days of abstinence,
amount of drug used, reduction in hospital visits, improve-
ment in marital and other relationships, or amount of money
saved by society? This lack of consensus further aggravates
the argument."
 9.6 CHAPTER9
The distinction between harm reduction and treatment
remains muddled and confusing. Harm reduction developed
as an alternative interdiction to the demand reduction strat-
egy of the "War on Drugs"; it was the third intervention
added to prevention and treatment in this strategy. Perhaps
because of the overlap of harm reduction and treatment
presented by drug replacement or substitution activities, the
confusion and the conflicts persist. Most treatment centers
effectively employ an abstinence-based philosophy of treat-
ment that also incorporates many harm reduction tech-
niques . The content of this chapter reflects that philosophy.
Chemical dependency is the number one health and social
problem in the United States and possibly the world , and it
is also the most treatable. Studies confirm that treatment
outcomes for drug and alcohol abuse result in long-term
abstinence along with tremendous health, social, emo-
tional, and/or spiritual benefits to the patient.
"Ever~thin9that I am and ever~thin9 that I have in me is
invested in what I'm doin9 toda~ in recover~- ever~thin9."
56-year-old recovering heroin addict
What is often overlooked when local, state, and federal
governments determine the amount of money allotted for
treatment is the undeniable fact that treatment saves
money-large sums of money (Figure 9-1).
TreatmentStudies
CaliforniaDrug and Alcohol
TreatmentAssessment
Studies conducted by the Rand Corporation and the Research
Triangle Institute support the findings of the California Drug
and Alcohol Treatment Assessment ( CALDATA).This classic
I
study was the most comprehensive and rigorous study on
treatment outcome conducted by the state of California and
duplicated by several other states. All of these studies moni-
tored the effect of treatment on several hundred thousand
addicts and alcoholics in a variety of programs .
The CALDATA study monitored 1,850 individuals for three
to five years following treatment. Continuous abstinence in
these patients approached 50% of all those treated. It further
demonstrated that 74% of those treated avoided criminal
activity and that the state realized an average savings of $7
for every $1 spent on treatment. For more-expensive pro-
grams, there was a savings of $4; and for the inexpensive
programs , the savings were $12. California spent $209 mil-
lion on treatment between October 1991 and September
1992 and saved an estimated $1.5 billion ; much of this was
due to crime reduction and reduced use of healthcare facili-
ties. The only downside was the patients ' loss of income
while undergoing treatment and their diminished financial
condition immediately afterward.
The study also looked at a number of variables that , when
examined, supported many concepts and practices in the
treatment field.
• Treatment was most effective when patients were
treated continuously for at least six to eight months .
• Shorter periods of treatment resulted in poorer out-
comes; longer treatment (up to about eight months)
resulted in better outcomes; past that point, outcomes
improved but at a slower rate.
• Group therapy was shown to be much more effective
than individual therapy.
• Drug of choice seemed to affect outcomes. For example ,
those who listed alcohol as their primary drug of choice
had treatment outcomes twice as effective as those
who listed heroin . Cocaine users' outcomes fell between
the two.
• Better treatment outcomes were linked to program mod-
ifications that were culturally consistent with a specific
target population . Programs that targeted women and
offered child care services had much better outcomes than
generic treatment programs. Programs that offered trans-
portation services had better outcomes than those offering
only child care. Every additional innovation that was tar-
get-group specific improved the outcome of treatment. 44 •45
DrugAbuseTreatmentOutcomeStudy
To study treatment effectiveness, the Drug Abuse Treatment
Outcome Study (DATOS) tracked 10,010 drug abusers who
entered treatment from 1991 to 1993 in 100 treatment facili-
ties in 11 cities. The study compared pre- and post-treatment
drug use, criminal activity, employment, and thoughts of
suicide. 46 The four common types of drug-abuse treatment
studied were:
• outpatient methadone programs
• long-term (several months) residential programs
• short-term (up to 30 days) inpatient programs
• outpatient drug-free programs
Researchers found that post-treatment use of all drugs was
reduced 50% to 70%. The level of drug use after treatment
was about the same for all four programs. Short- and long-
term residential programs had the greatest effect. Low
retention rates were most prevalent in clients with more-
complicated problems .41Most of the patients surveyed said
they did not receive the services they believed they needed.
The study also found that the number of services offered
decreased over time. 48
TreatmentEpisodeData Sets
To provide descriptive information about the flow of admis-
sions to substance-abuse treatment providers, the Treatment
Episode Data Sets (TEDS) survey, part of the Drug and
Alcohol Services Information System (OASIS), collects data
from all 50 states , the District of Columbia, and Puerto Rico.
The information is available through publications or online
(see www.samhsa.gov/data/DASIS.aspx).

Untreated
addiction
Incarceration
Probation I S15,ooo-s20,ooo
Residential
treatmen
t: long-term $6,800-$15,000
Resident
ial treatment short-term
Methadon
e maintenance
Intensive
outpatient
Outpatient
treatment
$10,000 $20,000
Annualsocialcostof treatmentoptions
National Surveyof SubstanceAbuse
TreatmentServices
The National Survey of Substance Abuse Treatment Services
(N-SSATS) is an annual survey of all drug treatment facili-
ties in the United States , public and private. Unlike the
TEDS survey, which focuses on the clients who enter treat-
ment, the N-SSATS examines the facilities themselves and
their assessment services, continuing care, transitional ser-
vices, community outreach, and other services. It is available
in publication form or online at www.oas.samhsa.gov/
DASIS/2k5nssats.cfm.
Treatment ResearchInstitute,
Universityof Pennsylvania
Economic Bene.fits of Drug Treatment: A Critical Review of
the Evidence for Policy Makers validates the cost-effective-
ness of substance-abuse treatment. This meta-analysis of
more than 1,000 addiction treatment outcome studies con-
ducted over nearly two decades documented cost savings
ranging from 33 ¢ to $39 for every $1 spent in all studies
analyzed. Meta-analysis is a systematic evaluation of a num-
ber of individual studies for the purpose of integrating the
findings. None of the studies evaluated in this meta-analysis
could find any evidence of loss from money invested in
drug-abuse treatment. The study cited decreased crime
(including incarceration and victimization costs) and post-
treatment reduction in healthcare costs as the primary eco-
nomic benefit. 27 This study found that substance-abuse
treatment reduced health service utilization and costs not
only due to addicts receiving treatment but also due to a
reduction in the use of health services and costs by the
addict's family members.
Treatment and Prisons
These statistics are according to a 2010 U.S. Department of
Justice report:
• 2,284,913 Americans were in federal, state, and local
prisons, and 93,000 were in juvenile detention facili-
ties-this constitutes the largest incarcerated population
in the world.
• More than 5 million were on parole or probation. 282
Treatment 9. 7
$20,000-$30,000
The cost of treatment for an addict
utilizing outpatient treatment is less
than one-tenth the cost of incarceration.
Estimates by authors
$30,000 $40,000
• About 57% of federal inmates and 20% of state inmates
were serving a sentence for a drug offense; 11.5% (about
1.6 million) were arrested for a drug-abuse violation, and
1.2 million were arrested for possession.
• 40% to 65% of arrestees tested positive for alcohol or
drugs. 344
• Of those on probation, 24% violated a drug law, and
17% had a DUI (driving under the influence) convic-
tion; the average time served increased from 22 months
to 27 months. 49
The percentage of arrestees testing positive for drugs (not
including alcohol) is many times higher than the percentage
of drug use in the general population. Despite the high
percentage of inmates with drug problems, treatment slots
are available for only about 10% of those who have serious
drug habits, although 94% of federal prisons , 56% of
state prisons, and 33% of jails provide some on-site
substance-abuse treatment to inmates .9 ,49 Various studies of
inmates with drug problems found that a comparatively low
percentage had contact with the treatment community. There
are more programs in state and private prisons than in
county jails. 50
I
By 2005, 6.9 million adults were involved with the criminal
justice system; 5 million were under probation or parole
supervision, and the rest were incarcerated. 50 The Bureau of
Justice Statistics estimated that about 70% of state and 57%
of federal prisoners used drugs regularly prior to incarcera-
tion. 52 In 2002, 52% of incarcerated women and 44% of
incarcerated men met the criteria for alcohol or drug depen-
dence. 53 A survey of juvenile detainees found that 56% of
boys and 40% of girls tested positive for drug use at the time
of their arrest. 49
Earlier studies of prisoners and those involved with the CJS
have shown that drug-abuse treatment reduces recidivism
dramatically when the treatment is linked to community
services rather than exclusively to in-jail services. 54 The cost
of incarcerating a felon is bet ween $25,000 and $40,000 per
year (not including assistance for the felon's family, compen-
sation for human and property damage , and a dozen other
liabilities); and the cost of outpatient treatment is between
$1,800 and $4 ,000 per year. The savings are significant. 60
D<>pi1<1heplethoraoftbudemon<tr:1ting a high!ncidence 7. Medications u,
•n imporunt element of tru<rnrnt
ofC)Spanicipa ntswithdrugoral coholproblemsmdth e for manypatient>,•s~Wlywhen combined with
effectiv,....,.oftitt<rn<nt. the BureauolJustic, S<.uistic,, counseling•ndothubehovioraltherapies.M,lhodon<
reported that Fewa th • n 17% oF incncrn,t<d offend ,,.. buprer.orphi n, , noltruon, . ocamprosat<, di,ulfinm
withdru g problem sreceived t rtttment wh ile inpri!iOll topir>m:ue . nicotine r,cplacemenl products (patch"
About50%nec<ivedtI<C atmentwhileundu•nycorrectioI111 gum,orlozeng<0),bupropion,•ndvurnidinecanbem
supuvi>ion(jail.probation,OTparole) .,. eff ·\,.romponrntoltr<e a<rnent'pa··' . com -
preh,nsivebeh•vior>lt=<rn<ntprogr.tm
·1nG./i(omiadwin,9tl,,,artlj..,.,6<> , ...,b..Jt..:.,,.,..pruom 8 . Anindividual'streotmen t • ndS<Tvicesp lonmusthe
bor.,,boJt..,,.,..,""iwrsitr<>a..i~tual"!,«ffmdailK.r"'" .... , .. dront inuallyandmodifiedwhennec .. uryto
u,d'"8tr"'Dll<nt,lot.d",to"d"wJ.f.,..i"'5-Yrt80%to enoure that it meets the penonSclungingneeds .A
&5'11;o{ou,pruo,wuli,t,dadr"[iprol,l,m4!ama;o,r,"""' patient may r«jUir< ,,.ry ingcombiruotion, of service,
fo,tllriroff,.,,_ltl,;.l.,,l,o.,ourpnoo6<>b..cbuard.· md1Itttmen1componentso,.,, ., ,ur'·.rntment
Coll
"""'"'"""""-- mdrecowry.
9 . Manydrug-addicted individualshoveoth<Tmrntoldis-
ordeB. Patientsp=ntingwi thon econd ition,hould
h,a,...,,dlortheotha{s) . TI<Catmen
t,h ouldadclr-<>,
both (or•ll), indudingtheuS<ofmed ic•tionswhrn
• ppropriat<
10. Medk ally aosioted d<toxilication is only th< fim
stageofaddictiontreotmen t •ndbyiuelfdoe,; little
Principlesof Effective Treatment tochongelong-tffllldrugu....Patientsshouldbe
~:~:~'!.';;onto continue drug tI<Catment following
Th<N>tioruol lnstitut<onDrugAbuS< (NlDA)<0tobli>hedlJ
principlesofdfrcti,.,tru<rnentinl'nn<ir!<>ofDnogAddi<tion 11.Tre•<rnrntneednotbevoluntorytobe,ffectP,'e
T.-can,, ou,ARn<arrh-&u,dGui<l<(><CondEdition) ." Tl>ese
Sanction,orrnticementsfrom!.mily,<mplO}'<",orlh<
applytomytratmentfacility,progr= . ortherapy criminoljust ice,yst<mcan,ignifican tlyincreaseboth
l. Addictioni sarom plexbut t rtttabledi!in><that treatmentrntry•ndret ti1ra1<s
affectsbrai nfunctionand behavior.Drugsof•bu5< ll . Drugu...duringtreatmentmustbemonitoredcontinu-
• ltathebr.tin'ss<ructur<emdfuoction,=m ltinginp<T • ornly . aolapsesduri ng treotmentdooccur.Monitoring
'stentchange, canbe a powerfu l incentivelorpatirntsandcanh,lp
l . Nos ingl,treotmenti••pproJ>TU.t<forallindividuols themwithstandurgestou,edrugs.ltal50provid<San
Motch'n g1Itttm<nlS<t( ngs ,·n1uvenfons,•nd ·c,. eorlyindic>tionof•murntodruguS<
'°.~:u: hi';:1ivid~)\;nkulu prob l,ms•nd n«dsi, lJ. Trea<rnrnt progr.oms should provide ...... ment for
1 HIVIAIDS,hepatiti,BandC, tuherruto.is . andother
J . Treatment must be rndily IIVllll•ble. PotrntU.l appli - infectiousdiS<a,esaoweUHri•krrductionroun,eling
cantsca nbelos tiltra<rnentisnot immed U.t<ly•voil•ble
orrudily•cc«<ibl<.Th<earliu1Itttmen1isofferrd.the ::~1::i':r" ot~~r:torn:~:ri::;.~:::~s~~i::~
grnl<rthelik,lihoodolpo,itiv,outcome, •bu«lr<at mrnt canfac ilitot<odhuencetoothumed i-
4 . Effective tr<>.tmrnt ut<nds to multiple nttds of the
individual.notjuothisorherdrugu....A>oocU.tedm«l -
ical.p<ychological,socW,vocalion•l,andleg:,Jprobl<m, Thecosto£fullyimplementi1>J!mostofthe,eronttptsis
high. Many local, sat<, and feder.tl governments and htalth -
must he add~ . Tru<rnent must be •ppropriat< to the
cane , st<m>are uruob' ,r reluctontto comm 'tthe necessary

Re~:~~
individu.ofs•ge,g<ndu .<thnicity, andc ul1ure

5. t t rtttment Forr-"'.\~«tuot~ .:.•im~

::riod lund,toprovide•fullr.tng,ofS<rvic<0

~le~::::::~
. As•=ul1
a few of theS< m:ommrndatiom are imp lemented in any
. only

half• decade aft<r the princip l<S

in dividu•lsnttdotl ... stthr«monthsintI<C a<rnentto
significantlyreduceOTstoptheirdrugu«.Reco,,.ryi,
•long -tmnproc<SSfrequentlyr,qulringmultipl<IIttl ·
mrntep i<Oda
Principlesof Drug-AbuseTreatment
6.Counseling(individuoland/orgroup)andothu
behavioralthaapie s oreth emost commonformsof for CJSPopulations
t reatment.Th<S<indudemotivotiontochang, . provid -
ing incrntiv<> lor •hstir.rnc,, building,kill, to resist MorethanJ.Oy<>.~ofr<><>rchby t h<N>tionollnstitut<on
drug U><, replacing drug -using :u:tiviti<>, improving DrugAbuS<ontrn<rnrntforindh-idu•isim'Olvedwiththe
prob lem,o.olving,kill,,•ndfaciliutingbettuint<rp,r - crimiruol justkesy,1emhaoyi, lded••imib.r«tof\Jprin -
,oru, lre b.tiomhil"' cipl <0. <Stobli.bed inJulyl006
 Treatment 9.9

DrugUseAmong
Arrestees
M
70%
-5
60%
-E estimated
500/o
t
M
400/o
Female

! 30%
estimated

*
a
20%
Jails and prisons test for illicit drugs but not for
alcohol. In addition to alcohol, the most common
drugs found in arrestees are marijuana and
1.:, cocaine.
f! 10%
Arrestee Drug Abuse Monito ring Program, 200 6
g; 0
1990 1992 1994 1996 1998 2000 2002
Yea
r

1. Drug addiction is a brain disease that affects behavior.
2. Recovery from drug addiction re quires effective treat-
ment followed by management of th e problem over time.
3. Treatment must last long enough to produce stable
behaviora l changes.
4. Assessment is the first step in treatment.
5. Tailoring services to fit the needs of the individua l is an
important part of effective treatment.
6. Drug use during treatment must be carefully moni-
tored with drug testing.
7. Treatment should target factors that are associated
with crimina l behavior, such as att itudes and beliefs
that support a crimina l lifestyle and behavior ("crimi n al
thi nking").
8. CJS superv ision should incorporate treatment p lanning
for drug-abusing offenders, and treatment providers
must be aware of correctiona l supervision requirements.
9. Continuity of care is essential for drug abusers reenter-
ing the community.
10. A balance of rewards and sanctions encourages pos i-
tional need for the CJS to protect the general public from
potentia l crimes committed by those under its purview and
the lack of funds to implement new treatment resources
specifically directed toward benefiting the individual rather
than the general public.
Goals of EffectiveTreatment
Most treatment experts agree that the two most important
goals for treatment outcome are motivating clients toward
abstinence and then reconstructing their lives once their
focus is redirected away from substance abuse. Integrating
harm reduct ion into these goals indicates a willingness to
accept incrementa l behav ioral changes that reduce the harm
that addiction causes.
To accomplish these and other goals, several elements must
be addressed with the understanding that addiction treat-
ment is a lifelong process for the addict. Treatment merely
motivates, initiates, and provides some tools that help addicts
achieve uninterrupted abstinence throughout their lives.

tive social behavior and treatment participation.
11. Offenders with co-occurring drug-abuse and menta l
health problems often require an integrated treatment
approach.
12. Medications are an important part of treatment for
many drug-abusing offenders.
13. Treatment planning for drug-abusing offenders who are
living in or reentering the community should include
strategies to prevent and treat serious, chronic medi-
cal conditions such as HIV/AIDS, hepatitis Band C, and
tuberculos is.52
Drug-abuse treatment for CJS popu lations continues to
expand, fueled by the successes of drug courts and state-
mandated sentencing alternatives. A specific set of treatment
principles targeted for CJS participants is beneficial and cul-
turally relevant, as the unique needs of this popu lation con-
tinue to be identified. A major obstacle to full implementation
of these CJS drug-abuse treatment princip les is the tradi-
I
"/ wantTon~to hovea betterlife. I wontTon~to 90 bockto his
other life. I was a responsible, 900d. person, a 900d. member of
societ~. That'sthe personI wont. If I chooseto 90 bockdown
that roodto alcohol, I knowexact/~wherethat leads, but I
don 't want that in m~ life an~more . It caused. too much pain."
Tony, a 4S-yea r-old recover ing alcoho lic
PrimaryGoals
Components consist of educa-
M otivatio n Tow ard Abstine nce
tion, counseling, and participation in a 12-step or self-help
program. This might include harm reduction approaches
like replacement therapy (methadone or buprenorphine
maintenance) where an addict is provided with an alternate
medically controlled drug to promote abstinence from his or
her street drug of choice, as well as a measure of protection
from the medica l complication of illicit-drug use. This
approach eliminates the need to engage in an illegal lifestyle.
 9.10 CHAPTER9
Creating a Drug-Free Lifestyle This covers all aspects of an
addict's life, addressing social/environmental issu es, like
homelessness, relationships, family, and friends, and devel-
oping drug -free life interactions. Addicts are connected to
drug-free activities and events and learn relapse prevention
skills such as stress reduction, cue resistance, coping,
decision-making, and conflict resolution.
SupportingGoals
Enriching Job or Career Functioning Often neglected in treat-
ment, job and career constitute a major ponion of one 's life.
This goal is accomplished through vocational services,
management of personal finances, and maintenance of a
drug-free workplace .
Optimizing Medical Functioning In addition to the treatment of
withdrawal and other acute medical problems associated
with addiction, many addicts have undiagnosed or pre-
existing medical problems that have been neglected because
of their drug use . A comprehensive treatment program must
include the ability to assess and treat such conditions.
Unmanaged medical problems like chronic pain often lead
to relapse.
Optimizing Psychiatric and Emotional Functioning Many studies
suggest that greater than 50% of all substance abusers also
have a coexisting psychiatric condition. Identifying and
treating psychiatric problems are essential elements of the
modern treatment program (see Chapter 10).
Addressing Relevant Spiritual Issues Although the inclusion of
spirituality or religious beliefs in addiction treatment is
controversial , the most effective long-term treatments are
the spiritually based 12-step programs like Alcoholics
Anonymous (AA) and similar programs. Many treatment
programs base their interventions on the 12-step traditions ,
so it is essential that programs determine their clients ' level
of involvement with AA or other self-help groups and pro-
vide appropriate referrals. 58 •59 A large number of empirical
studies demonstrate a 60% to 80% correlation of better
addiction treatment outcome to participation in 12-step and
other spiritual practices. 60 -6 1-62 -63
I
of
"I don't have hopes livin9forever.I neverhave. I mean,
to be m~ a9e is a complete shock to me, so it's not about that;
of
the issueis about the qua/it~ life."
40 -year-old recovering heroin addict
Most people select a treatment program based on cost ,
familiarity, location, and convenience of access. The cur-
rent era of managed healthcare has made accurate diagnoses
and pretreatment assessments essential to validate the least
intrusive yet most appropriate level of treatment that will
promote better health and recovery. For a program to qualify
for insurance or publicly funded reimbursement , acceptable
evidence-based assessment tools are now mandated .
Diagnosis
Various diagnostic tools are used to help verify, support, and
clarify the potential diagnosis of chemical addiction .64·65 The
following are the most common.
The American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) delineates
substance use from substance-induced disorders. "Substance
Use" is divided into "Substance Abuse " and "Substance
Dependence, " which relies on the pattern and the duration
of drug use and descriptions of negative impacts on social or
occupational functioning . Tolerance or withdrawal symp-
toms confirm a diagnosis of dependence. 20
The DSM-5 redesignated "Substance Use Disorders" as
"Substance-Related and Addictive Disorders." This new
heading includes specific drug disorders (e.g., alcohol use
disorder and cocaine use disorder) and distinguishes
between those substances that cause only tolerance , tissue
dependence, and withdrawal (e.g., Thorazine ® and Elavil®)
and those that also cause compulsive and addictive use (e.g.,
alcohol, cocaine, and Vicodin ®). Also added is "Miscellaneous
Discontinuation Syndromes, " describing medications such
as antidepressants (e.g., Zoloft, ® Prolixin, ® and Thorazine ®)
that may cause withdrawal symptoms when used . Gambling
disorder is the only behavioral addiction in the DSM-5; other
groups of repetitive and/or compulsive behaviors such as
Internet use, sex, exercise, and shopping have been named
for further consideration.
Specific withdrawal syndromes, intoxication symptoms,
induced disorders, and other unspecified related disorders
described for each substance are included in the DSM-5.
Drug craving has been added as diagnostic criterion for
addictions; severity of abuse or dependence is quantified as
mild, moderate, or severe .20
Many effective tools have been developed to assess the sever-
ity of withdrawal symptoms .
• The Selective Severity Assessment (SSA) evaluates 11
physiologic signs (e.g., pulse, temperature , and tremors)
to confirm the severity of an addict's addiction.
• The National Council on Alcoholism Criteria for
Diagnosis of Alcoholism (NCA CRIT) and its Modified
Criteria (MODCRIT) assess 35 items through a structured
interview to establish two bases upon which to make the
diagnosis of alcoholism: physical and clinical parameters
and behavioral, psychological, and attitudinal impact.
• The Addiction Severity Index (AS!) represents the most
comprehensive and lengthy criteria for the diagnosis of
chemical dependency-200 items cover six areas affected
by substance use and abuse. There is also ASI-Lite (a
shortened version of the AS!, with 22 fewer questions)
and T-ASI, which is modified for the assessment of teen
drug use .
• The Michigan Alcoholism Screening Test (MAST) is a
simple diagnostic aid that uses 25 yes/no questions that
focus on the negative life effects alcohol causes to the user

© 201 1, Dave Granlund
(see Chapter 5) . There is also the Brief Michigan Alcohol
Screening Test (B-MAST),with just 10 questions, as well
as various other modifications: the MAST/ADscreens for
alcohol and drugs; the M-SAPS, a substance-abuse prob-
lem scale; and the SMAST-G, a short version of MAST
used for geriatric assessment.
• The CAGE questionnaire is the simplest assessment tool
for problem drinking and consists of just four questions:
• Have you felt the need to cut down on your drinking?
• Do you feel annoyed by people complaining about
your drinking?
• Do you ever feel guilty about your drinking?
• Do you ever drink an eye-opener in the morning to
relieve the shakes?
Two or more affirmative responses suggest that the client
is a problem drinker. 68
• AUDIT is a 10-item screen: frequency, daily amount, inci-
dence of six or more drinks , inability to stop , inability
to fulfill normal expectations, eye-opener , guilt/remorse,
blackouts/brownouts, suffered or injured someone while
drinking , and others ' concern about one's drinking. A
score of 8 or more indicates hazardous drinking.
• CRAFFT comprises driving a car while high , use to relax,
use alone , forget things while high, family and/or friends
ask you to cut down, and have gotten into trouble while
on alcohol or drugs .
• RAPS4 (Rapid Alcohol Assessment Screen) has four
items: guilt, blackouts , failing normal expectations, and
eye-opener.
• SAAST (Self-Administered Alcoholism Screening Test)
asks 35 yes/no questions.
• T-ACE covers tolerance, annoyed, cut down, and eye-
opener.
• TWEAK comprises tolerance (just begin to feel drug
effects after three or more drinks or hits , able to hold
Treatment 9.11
six or more drinks or hits) ; 2; worried ; 2; eye-opener
; l ; amnesia; l ; "kut" down; 1. A score of 3 or more
indicates a problem.
• DAST (Drug Abuse Screening Test) is a live-minute ,
20-item scale that can be used for screening, treatment
planning , and post-treatment outcome evaluation. It
assesses the consequences of drug use and has been vali-
dated against the DSM-III and DSM-IV diagnostic criteria.
• PESQ (Personal Experience Questionnaire), targeted
for adolescents , has 18 questions, takes 25 minut es, and
screens for both drugs and alcohol. It examines problem
onset, psychological and social functioning, problem
severity, and frequency of use, and it can detect "faking."
• 4P's Plus was developed by Dr. Ira Chasnoff of the
Children's Research Triangle in Chicago. It is being prof-
fered as a universal prescreening tool for pregnant women
to identify potential alcohol/nicotine, substance-abuse, and
domestic-violence problems. The P questions evaluate:
• parental history of alcohol or drug problems
• partner 's use of alcohol or drugs
• past personal history of alcohol use
• use of either tobacco or alcohol during the month
preceding pregnancy (also validated for 28 days after
delivery)
Any use of tobacco or alcohol 30 days before pregnancy
or within 28 days after delivery indicates the need for
further assessment or intervention .
• ASSIST (Alcohol , Smoking, and Substance Involvement
Screening Test) is an eight-question survey on the use
of nine specific drugs. It was developed and validated
by the World Health Organization (WHO) and published
in 2002.
e NMASSIST (Modified Alcohol, Smoking , and Substance
Involvement Screening Test) is the result of NIDA's2009
modification of the WHO ASSIST tool. It is an initial
prescreen to determine lifetime use of the specific sub-
stances listed or any other drugs.
e ASAMPPC-2R (American Society of Addiction Medicine
I
Patient Placement Criteria Revised) is also designed to
help identify co-occurring disorders , motivation , envi-
ronmental risks, and the most appropriate levels of treat-
ment. It is not really an assessment diagnostic tool in and
of itself and is used with other assessment tools such as
the DSM-5. The ASAMPPC-2R evaluates six dimensions
of problem areas and illness severity:
• acute intoxication/withdrawa l potential
• biomedical conditions and complications
• emotional, behavioral, or cognitive conditions and
complications
• readin ess to change
• relapse, continued use, or continued problem potential
• recovery environment
These dimension assessments are then used to match
patients to four levels of care:
• outpatient treatment
 9.12 CHAPTER 9
• intensive outpatient/partial hospitalization
• residential/inpatient treatment
• medically managed intensive inpatient treatment
As patients progress through their recovery treatment,
assessments should be redone to move them to the level of
care that matches their current need.
Though time-consuming, the ASAM PPC-2R provides the
most accurate and acceptable evaluation for insurance and
third-party payees. It also provides an effective way to match
substance abusers to the most appropriate yet least intrusive
level of treatment that will promote better health and recovery.
TreatmentOptions
"Letthe experimentbe fairlqtried;let an institutionbe founded;
let the meansof curebe provided;let the principleson which
it is to be foundedbe extensivelqpromulgatedand, I doubt
not, all intelligentpeoplewillbe satisfiedof its feasibilitf.
let the principleof total abstinencebe rigorouslq adoptedand
enforced;... let appropriatemedicationbe afforded;... let the
mindbe soothed;... letgood nutritionbe regularlq administered.
This course,rigorouslq adoptedand pursued,willrestorenine
out of 10 in all cases."
Dr. Samuel Woodward, 1833 69
Dr. Samuel Woodward, a nineteenth-century expert on men-
tal health, believed that society should support recovery
because addiction is a complex interaction among social,
biological, and toxic factors. Given these multiple influ-
ences, treatment has evolved along various paths, all of
which enjoy some success. Because every person is unique,
as is his or her level of addiction, no one treatment has
proven to be universally effective. Often, effective treatment
requires a variety of techniques in a number of settings.
"Ifsomeoneaskedme, 'Wherewouldqougo to get off drugs?
Wherewouldqou feelcomfortable?' Mq answerwouldbe
'If I had everqthingI needed,a lifetimeof supplies,being
I
shipwrecked on an island,wouldbe fine."'
22 -year-old recovering methamphetamine abuser
Treatment options for alcohol and/or other chemical addic-
tion range from:
• "cold turkey" or "white knuckle" dry-outs to medically
managed detoxification
• expensive medical or residential approaches to free self-
help peer groups, 12-step programs, or social model
group therapy
• outpatient treatment, to halfway houses, to residential
programs
• long-term residential treatment (two years or more) to
seven-day hospital detoxification with aftercare
• methadone maintenance, replacement therapies, or
other harm reduction techniques to acupuncture, aver-
sion therapies, and a dozen other treatment modalities.
"I believedtherewasonlqAAand NA [NarcoticsAnonqmous]
for mq 'crank'useand I knew-I just knew-these wouldn't
work.Then aftera particularlq
nastqrun, whichI thoughtI kept
secretfrommq probationofficer,he gaveme a choiceof going
into treatmentor goingbackto prison.I wasstartledwhenhe
handedme a full-pagelistof differentplacesI couldgo. There
wasa medicalprogram.Therewasan NA programmadeup
of speedfreakslikemqselfTherewasa mentalhealthprogram
nearmq apartment.TherewereplacesI couldgo to livewhile
kicking.The onlqproblemwaswaitingfor an openslot."
35 -year-old recovering "crank " addict
Statistical measurements of the effectiveness of any one pro-
gram do not provide a complete picture of the overall suc-
cess of treatment in general. Addicts drop out of a program
because they do not feel comfortable, the program is not
relevant to their problem, or because they are not ready for
treatment based on the stage of their addiction, but ulti-
mately they find a program that works. If an addict drops
out, the overall success rate of a program reflects that, so a
statistic might read, Thisprogramis effectivefor only 10%of all
addicts,which is technically true, but an addict may have
switched programs, entering recovery through another pro-
gram more suited to his or her needs. A more accurate mea-
surement would be: This type of programworksfor 10%of the
addictedpopulation,but thereare a dozen otherprogramsand if
eachone is effectivewith 10%of the population,thereare enough
programsto offer recoveryto most addicts.It also means that
society cannot put all treatment hopes in just one basket,
whether it is drug replacement therapy, motivational inter-
viewing, a therapeutic community, or a 12-step program.
Typesof Facilities
Medical Model Detoxification Programs These can be inpatient,
residential, or outpatient. The treatment is supervised and/
or managed by medical professionals. Medications are
administered in conjunction with traditional recovery-
oriented counseling and educational approaches. These are
usually the most expensive programs, but they have the
advantage of providing a more comprehensive assessment
and treatment of an addict's overall physical and mental
health than other kinds of treatment. Inpatient medical
model programs cost $3,000 to $25,000 or more, depending
on the length of stay (three to 28 days) and the amenities
provided. Outpatient medical model programs range from
$1,500 to $5,000, depending on the length of treatment (one
to six months).
Residential/Inpatient Treatment This is usually from one to 28
days and can be either medically monitored (ASAM Level
III) or medically managed (ASAM Level IV). Clients are
housed in the facility for the duration of treatment, and pro-
grams include intensive counseling, drug education, and
other recovery activities. 70
Partial Hospitalization and Day Treatment These are outpatient
medical model programs in which clients participate in ther-
apeutic activities for four to six hours per day while living
at home. ASAM placement criteria require that clients par-

At the end of World War I there werefew facilities availablefor
addicts. In 1929 the U.S. government allocated.fundsfor two
"narcoticsfarms" to house and rehabilitateaddicts who had been
convicted of violatingfederal drug laws or those who wished to
commit themselves voluntarily. The Lexington, Kentucky, Narcotics
Farm opened in 1935; the secondfacility, in Fort Worth, Texas,
opened in November 1938. The Lexingtonfacility shown in this
picture had about 1,000 inmates. Treatmentcould last up to a year or
more. A study of effectivenessshowed that 90% to 96% of addicts
returned to active addiction, most within six months of discharge.
Courtesyof the U.S.Departmentof Healthand Human ServicesProgram Support
Center (White, 1998)
ticipate in a minimum of 20 hours per week in a structured
program to meet this level of treatment. 70 These programs
provide medical services for detoxification and for medically
assisted recovery with medications that treat withdrawal
symptoms, modify craving, and help prevent relapse.
Counseling and drug education are part of these programs.
Outpatient Level II.l
Intensive Outpatient Level 11.1 Programs
programs (9 to 15 hours per week) and Outpatient Level
1.0 (1.5 to 8 hours per week) are modifications of this model
for those who assess with lower intensities of addiction
problems.
Methadone Maintenance and other Replacement Therapies These
are also considered outpatient medical model programs.
Methadone maintenance costs $4,000 to $6,000 per year,
per patient 239 •240(or about $97 per week for just the medica-
tion71). Buprenorphine in the form of Suboxone "' is used as
an alternative form of replacement therapy for opioid addic-
tion. In 2010 Suboxone "' at a daily dose of 16 milligrams
(mg) cost about $400 to $450 each month , or about $5,000
per year. When the medical and clinical costs of providing
this form of therapy are added to the cost of the medication,
it becomes more expensive than methadone maintenance.
Office-Based Medical Detoxification and Maintenance Treatment
For opiate abusers treatment can now be provided by quali-
Treatment 9.13
fied private medical practitioners. The Drug Addiction
Treatment Act of 2000 legalized the prescribing to opiate
addicts of Schedule Ill, IV, and V controlled substances by
physicians specially certified by the Drug Enforcement
Administration (DEA). Prior to the law, dispensing con-
trolled substances for the treatment of addiction was
restricted to registered clinics. This restriction compromised
confidentiality of treatment because anyone seen at such a
facility could be assumed to be an addict . It also exposed
patients to other drug users and often required excessive
travel for some patients. Although a physician must undergo
specific training to become certified to treat addicts in the
office, there is some concern that medical treatment detached
from immediate on-site counseling, education, and social
and other services for addicts will be ineffective in promot-
ing recovery. This treatment is also known as office-based
opiate addiction treatment (O-BOAT).
Social Model Detoxification Programs These are nonmedical
(no or minimal medical staff presence) and can be either
residential or outpatient . These programs are from seven
to 28 days and are aimed at providing a safe and sober envi-
ronment for addicts to rebalance the body and brain chemis-
try disrupted by drug abuse before entering a full recovery
program.
Social Model Recovery Programs Also called outpatient drug-
free programs , these use a wide variety of approaches to
move a client toward recovery. Because social model pro-
grams are nonmedical, clients must be abstinent from drugs
for 72 hours before admission. Approaches include cogni-
tive-behavioral therapy (CBT), insight-oriented psychother-
apy, problem-solving groups, and 12-step programs. This
model includes outpatient programs ranging from weekly
education and early intervention (ASAM Level 0.5), to
weekly counseling (Level I), to intensive outpatient pro-
grams (Level II) consisting of a minimum of three sessions
per week of three to four hours' duration. The total length of
outpatient therapy can vary from one to several months.
Clients may stay in these programs for months ."
I
Therapeutic Communities Known as TCs, these are one- to
three-year self-contained residential programs that provide
full rehabilitative and social services under the direction of
the facility.73 These include daily counseling, drug educa-
tion , vocational and educational rehabilitation, and case
management, including referrals to social and health ser-
vices. Many counselors, administrators, and role models in
TCs are in recovery. The goals of this type of program are:
• habilitation or rehabilitation of the individual
• changing thinking, feelings, and negative patterns of
behavior
• developing a drug-free lifestyle 74
The major stages of treatment in a TC are:
1. induction and early treatment , which occurs over the
first 30 days and includes learning TC policies and pro-
cedures, understanding addiction, and committing to the
recovery process
 9.14 CHAPTER 9
2. primary treatment
3. reentry into the community at large73
Because of funding limitations and program availability ,
variations of the long-term TC concept include short-term
communities (three to six months), modified therapeutic
communities (six to nine months), adolescent therapeutic
communities for juveniles, and jail-based TCs. 75 There are
also day treatment TCs that are less intensive than residen-
tial TCs but more intensive than most outpatient drug treat-
ment program. The keys to success are maintaining a
community approach and the principle of self-help.
Because many addicts are reluctant to commit to being iso-
lated from society for long periods of time, many programs
divide the treatment into three- to six-month phases, which
allows an addict to commit to each phase of treatment rather
than to the full one- to three-year program .
Halfway Houses Halfway houses permit addicts to keep
their jobs and outside contacts while participating in a
residential treatment program . Addicts receive educational
and therapeutic interactions after work hours and live within
the relative safety of the facility, where drugs and alcohol are
prohibited and external triggers (cues) are minimized.
Weekends or nonworking days are reserved for more-
intensive program work.
These
Religious Movements and Faith-Based Treatment Initiatives
offer halfway house or inpatient treatment programs to
treat addiction; they include Teen Challenge and Espiritismo.
These programs are controversial: critics maintain that join-
ing a religious movement is exchanging one compulsion for
another; advocates believe that a spiritual awaken ing is nec-
essary for true recovery and that these programs provide the
opportunity for that revelation to occur .76
Sober-Living and Transitional-Living Programs These are for cli-
ents who have completed a long-term residentia l program.
Groups of recovering addicts live in apartments or coop-
eratives under strict house rules to maintain a clean-and-
I
sober living environment that is supportive of each person 's
recovery effort. Minimal-to-moderate treatment structure is
provided, and programs merely monitor compliance to pro-
tocols that allow an addict to reenter the broader society
with a drug-free lifestyle.
Harm Reduction Programs These consist of pharmacotherapy
maintenance approaches (also called replacement therapy or
agonist maintenance treatment), particularly methadone or
buprenorphine maintenance clinics. Another , less successful
harm reduction program attempts to control drinking or
drug use through behaviora l training programs . There are
also education programs that focus on minimizing problems
from drug use; partial detox clinics that help addicts lower
their drug tolerance to minimize damage to the user; sober-
ing stations that provide a safe place for addicts and alcoho l-
ics to sleep off their inebriation or hangover; and designated
driver programs _77
Admissions
From early 1990 to 2010, TEDS documents 1.6 to 1.9 mil-
lion people treated annually in various U.S. programs and
facilities for substance-abuse problems .78 It is estimated that
another 17.4 million went untreated for alcoho l abuse and
6.4 million went untreated for illicit-drug use during each of
those years. 79 These numbers illustrate that millions of
Americans have serious enough drug and alcohol problems
each year to need treatment .
In 2010 (based on the most recent report released in 2012):
• 67 .9% of all clients were male; 4.9% of female clients
were pregnant.
• 59 .8% were White (non-Hispanic), 20.9% Black, and
13.7% Hispanic.
• 62.8% entered ambulatory treatment , 19.3% detoxifica-
tion , and 17% residential treatment .
• 37 .8% of clients were referred to treatment through the
criminal justice system.
• 32% were self- or individual referred to treatment .
• 9.1% were injection drug users (IDUs) at the time of
admission .
• 11.6% were younger than 20 years old.
• 63.9% were between 20 and 44 years old .
• 23.1% were between 45 and 64 years old .
• 0 .6% were older than 65 .78
The Nationa l Survey of Substance Abuse Treatment Services
listed 13,648 providers of alcohol- and substance-abuse
treatment in the United States . Private nonprofit organiza-
tions represented 57.9% of this total; 28 .6% were private-for-
profit organizations; 6.5% were local, county, or community
government; 3.2% state government; 2.4% federal govern-
ment; and 1.4% tribal government. 9 Time will tell how the
Addiction Equity Act of 2008 will affect these percentages
going forward.
Addiction is a dysfunction of the mind caused by actual
biochemical changes in the central nervous system. We are
born with most of the brain cells we will ever have (includ-
ing the reservoir of immature stem cells). Brain cells are
unlike other tissues such as skin cells, which are completely
replaced every eight days or so. 80 The brain cell disease of
addiction is a chronic progressive process that can be treated
and arrested but not reversed to any great extent nor cured.
Most recovery professiona ls recognize that an addict's brain
cells have been permanently changed, making recovery a
lifelong process. Addicts (those who have lost control of
the ir drug use) must refrain from ever abusing and, in most
cases, even using small amounts of any psychoactive drug if
they want to avoid relapsing.
 Treatment 9.15

Admissions
to DrugTreatment
by PrimarySubstance
of Abuse,2000-2010
PRIMARY
SUBSTANCE 2000 Percentage 2004 Percentage 2008 Percentage 2010 Percentage
Alcohol 811,313 46.3% 732,835 40.3% 784,262 41.4% 744,087 41.2%
alcoholonly 453,438 404,459 437,204 411,388
alcohol
w/secondary
drug 357,835 328,773 347,058 332,699
Opiates 298,301 17.0% 322,950 17.7% 378,586 20.0% 413,427 22.8%
heroin 269,967 261,610 246,871 256,256
otheropioids,
methadone 28,444 61,340 111,251 157,171
Cocaine 238,159 13.6% 249,957 13.6% 213,971 12.9% 148,151 8.2%
smokedcocaine 174,202 179,949 152,819 104,564
nonsmoked
cocaine 63,957 69,529 61,151 43,587
Marijuana/hash
ish 249,531 14.3% 287,581 15.8% 321,648 17.0% 335,833 18.6%
Stimulants
(amphetam
ine,methamphetamine) 81,176 4.6% 146,631 8.1% 122,999 6.5% 113,625 6.3%
Sedat
ive-hypnot
ics/tranquilizers 10,268 0.6% 12,387 0.5% 15,650 0.7% 4,117 0.2%
Hallucinogens 3,120 0.2% 2,298 0.1% 1,709 0.1% 1,675 0.1%
PCP 2,835 0.2% 3,242 0.2% 3,853 0.2% 4,501 0.2%
Inhalants 1,287 0.1% 1,196 0.1% 1,224 0.1% 1,447 0.1%
Over-the-co
untermedications 763 0.04% 827 0.05% 1,030 0.1% 2,250 0.1%
Other 12,332 0.7% 8,329 0.5% 6,950 0.4% 14,541 0.8%
None 41,325 2.6% 50,285 2.8% 41,758 2.2% 21,374 1.2%

TOTAL
ADMISSIONS 1,750,426 100% 1,818,357 100% 1,893,640 100% 1,805,031 100%

TEDS, 20 12

"FridaqI wasfeelin9900d. I evenwentto a meetin9.I'd been
in thisprosramfor two qears.I thou9htI couldhaveone drink
to relaxwithsomefriendsI raninto. I had aboutfiveScotches
and endedup usin9cokeall ni9htlon9in a hotelwithtwo
prostitutes.I wentthrou9habout $700 and wasbroke,and
then I stole$150 frommq roommate.I wasrippedoff a couple
of timesbuqin9stuff, and at the end of it I wastweakedand I
Coerced treatment via criminal justice sanctions can actu-
ally help addicts realize that they have hit bottom . In 2009
the National Institute on Alcohol Abuse and Alcoholism
(NIAAA) launched the online interactive site Rethinking
Drinking (http://rethinkingdrinking.niaaa.nih.gov), a non-
threatening tool for individuals to self-assess their alcohol
use anonymously. 81 •82

I
stillwantedmore."
24-year-old recovering crack cocaine user
Hitting Bottom
Addiction is a progressive illness that leads to severe life
impairment and dysfunction when left to proceed without
Recognitionand Acceptance disruption .

Treatment begins with the addict's recognition and accep-
tance of his or her addiction . This acceptance often requires
the addict to be the subject of an intervention or face
potential criminal consequences for not complying with
treatment . Some addicts simply "hit bottom" when life
with alcohol or drug abuse becomes unmanageable.
Assessment using one of the validated SUD diagnostic tools
will help support and confirm the need for treatment.
Addicts and alcoholics rarely accept the diagnosis of addic-
tion from others even if a health professional makes the
assessment. Only after an addict accepts the addiction can he
or she embrace a lifelong continuum of recovery
"It reallqtookmq soul. I reallqfeelit tookmq soul.Asa
humanbein9,it's importantto havea soul,and I thinkI
wasjust a hollowshell.It took mq familq;it tookmq kids;
it tookmq self-esteem,whichis probablqthe mostimportant
facetof all becausewithoutthat everqthin9 elsewasjust
temporarqanqwaq."
Recovering heroin abuser
The earlier addiction is recognized, accepted, and treated,
the more likely the addict will live a healthy, rewarding
life. It does not take a life-threatening event to hit bottom;
it can simply be a loss of hope .
 9.16 CHAPTER9
Protocolfor
ClientIntake
Nonemergency Emergency
t assessment done by a physician who is treating a patient for
.,.:· ·• --B·++A
___L:------::
t t ' t, .
-
This is the protocolstructurefor a typical clinic (outpatient medical
model program, requiringa physician). It illustrates the complexity of
treating a compulsivedrug user,particularly if other problems, such
as medical complications, mental problems (dual diagnosis), or HIV
disease, are involved.
"/ 9ot up and I lookedat mqpipe.And then I said, 'No,' and
I put it downand I put it in the trash- I didn't breakit-
and I rockedmqselfand I said, 'No dope, no dope, no dope,'
and I rockedmqselfuntil I couldnot rockmqselfanqmore."
Recovering crack addict
I
Every individual's perception of hitting bottom is different.
For some , losing their job is bottoming out ; for others , it is
the loss of important relationships or their children. A per-
son does not have to hit bottom to accept that he or she has
a chemical dependency problem and decide to participate
in treatment. It is much healthier to enter and embrace treat-
ment before suffering great losses in life.
Denial
Overcoming denial is essential to taking the first step to
treatment; it is also the most difficult. Denial is a universal
defense mechanism practiced by addicts as well as their
families, friends, and associates. Denial prevents or delays
the recognition and the acceptance of a chemical depen-
dency or compulsive behavioral problem . Denial is a
refusal to acknowledge the negative impact that drug use
has on one's life. It also assigns reasons for negative conse-
quences to other causes rather than to drug use or compul-
sive behaviors.
The medical profession has a tendency to deny or overlook
addiction , which compounds the problem. Many profes-
sionals are unwilling to make the diagnosis , or they fail to
recognize the signs and symptoms. How often or how thor-
oughly does a physician question a patient's history of alco-
hol or other drug use? How often is a caffeine intake
anxiety and insomnia? Uninsured clients, those with a his-
tory of mental illness , and those who had been previously
treated for substance abuse or mental illness were even more
unlikely to be correctly diagnosed by their physician. 83
A study of physician awareness in Boston found that about
45% of 1,440 patients with substance-abuse problems said
that their physician was unaware of their illness.83 A survey
conducted by the National Center on Addictions and
Substance Abuse at Columbia University found that more
than 50% of the physicians surveyed reported receiving no
training in identifying addiction, and 75% of physicians and
50% of pharmacists had no training since professional school
to identify prescription drug abuse or diversion of prescrip-
tion drugs. 84 Implementation of the Addiction Equity Act
mandated all medical schools to provide some education on
addiction medicine. As of 2014 some 20 medical fellowship
programs have been established in this new medical specialty,
and the American Board of Addiction Medicine now certifies
physicians as addictiono logists to treat addiction.
"/ wokeup afterpassin9out in a friend's home.Theq had
takenmq moneqawaqfromme and had postedsomebodqat
the door,and mq mothercameand said, '/ willnot watch
qourchildrenforqouwhileqou90 out and partq.If qoudo
somethin9aboutqourproblem,I'II takecareof qourkid;fora
week.'That wasthe rrst
timeanqbodqhad saidto me, You
havea problem,"and that wasthe prsttimeanqbodqsaid,
'Stop.Youcan't do thisanqmore."'
37-year-o ld recovering speed user
BreakingThroughDenial
Denial plus the toxic effects that psychoactive drugs have on
judgment and memory increase the likelihood that an addict
is the last to recognize and accept her or his addiction.
Usually, those closest to the addict-the family or spouse-
are in the best position to recognize addiction early on and
help the addict break through denial. In addition to close
relatives, others able to recognize addiction include friends,
co-work ers, employers, ministers, medical professionals,
and law enforcement. Even when recognized by others,
addiction is the only illness that requires a self-diagnosis
for treatment to be effective. Normally, when a physician
tells patients that they have high blood pressure, they accept
that diagnosis without question and make appropriate
changes to improve their health. When addicts are first con-
fronted with their addiction, denial kicks in and they con-
tinue to abuse drugs.
There are several ways to break through denial.
• Legal intervention. The threat of loss of freedom, prop-
erty, relationships, and professional licenses forces users

CZ002lk\iversa!
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e ment. The percentage of self-referrals for marijuana is only
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F1RsTSTEP loWIRD
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Bass rehab.
IN THE BLEACHERS © 2002 Steve Moore.
Reprinted bypermission of UniversalUclick.
Allrightsreserved.
to accept that they have a problem with drugs. Legal
requirements may mandate treatment; incarceration
limits drug use and promotes abstinence .
• Workplace intervention . Poor performance and the
threat of the loss of one's livelihood can break through
denial. Strong employee assistance programs (EAPs)
work with at-risk employees, often requiring a "last
chance agreement " to participate successfully in treat-
ment or resign from the job.
• Physical health problems . Deteriorating health and doc-
tors ' warnings can make a user consider drug use as a
possible cause or complicating factor. Lung cancer , high
blood pressure , or heart , liver, kidney, and other diseases
caused by drug toxicity can be powerful forces with
which to confront a patient 's denial of addiction.
• Pregnancy. Concern over fetal development and a neo-
nate 's health is a strong motivator to accept the need for
sobriety.
• Mental health problems. Emotional and mental traumas
like depression, anger, and confusion that affect day-to-
day functioning also act as warning signs.
• Financial difficulties. If there are no funds to pay bills,
buy food , or cover the rent because of escalating drug
costs, the user is forced to recognize the financial conse-
quences of addiction .85 •198
Table 9-2 shows the source of referral for people who have
entered substance-abuse treatment. Overall about one-third
are self-referred and another one-third are referred by the
criminal justice system , usually through court-ordered treat-
Treatment 9. 17
half that of referrals for other drugs. 86
"Mq dad's an alcoholic.I've triedso manqthingsjust to get
him into treatment,but no matterhow much I trq, he just
doesn'tlisten.So I'm not gonnalet him takeme down frommq
recoverq.I just told him, qou know, 'Forgetit. And if qou want
to be with me, qou'regoingto haveto be clean.'And he loves
onlqtwo thingsand that's me and mq brother.And if we take
one of thoseawaq, he mightwantto quit."
15-year-old recovering polydrug abuser
Intervention
Interventions are employed to challenge denial by con-
fronting an addict and helping him or her recognize a
dependence on drugs. This strategy has been documented
since the late 1800s as a way to effectively bring addicts into
treatment and keep them there. The current style of formal
intervention was developed by Dr. Vernon Johnson in the
1960s and refined by a number of treatment professionals .
"Intervention is a processbq whichthe harmful,progressive
, and
destructiveeffectsof chemicaldependencqare interruptedand
the chemicallqdependentpersonis helpedto stop usingmood-
alteringchemicalsand to developnew, healthierwaqsof coping
with his or herneedsand problems.It impliesthat the person
neednot be an emotionalor phqsicalwreck(or hit bottom)
beforesuch helpcan begiven."
Vernon E. Johnson, founder, Johnson Institute 243
Today there are specialists who help organize and implement
interventions. A formal intervention may be necessary if
informal interventions have failed or if a professional
believes that the wall of denial is too great. Most interven-
tions consist of the following elements.
Love An intervention must start and end with an expres-
sion of love and genuine concern for the well-being of the
addicted person . Multiple participants are recruited from
I
various aspects of the addict 's life-all of whom share a sense
of true affection for the user but recognize the progressive
impairment of the addiction and are bold enough to commit
to participating in the intervention . The intervention team
consists of multiple family members, close friends and co-
workers, other recovering addicts, a clergy or community
leader , and a lead facilitator.
FacilitatorA professional intervention specialist or a knowl-
edgeable chemical dependency treatment professional
organizes the intervention , educates the participants about
addiction and treatment options, trains and assists team
members in the preparation of their statements, and sup-
ports or confirms the diagnosis of addiction . The team meets
and prepares its intervention without revealing its activities
to the user.
Intervention Statements Each team member prepares a state-
ment that he or she will make to the addicted person at the
intervention. Each stat ement consists of four parts:
 9.18 CHAPTER9

bySource
Admissions ofReferral
intheUnited
States
SOURCE
OF ALL Alcoholw~h Metham-
REFERRAL ADMISSIONS AlcoholOnly OtherDrug Heroin Cocaine Marijuana phetamine
TOTAL
ADMISSIONS 1,820,737 411,388 332,699 256,256 148,151 335,833 112,473
Criminaljustice/DUI 36.9% 42.5% 35.7% 16.3% 33.6% 53.6% 51.8%
Individual
(self) 33.1% 29.5% 31.7% 55.00/o 31.8% 16.00/o 24.4%
Substance-abuse
provider 9.9% 7.9% 10.9% 15.8% 12.8% 5.7% 5.7%
Otherhealthcare
provider 6.4% 8.2% 7.6% 4.8% 6.2% 4.1% 3.4%
Schoo
l (educationa
l) 1.2% 0.6% 0.7% 0.2% 4.1% 0.3%
Employer/EAP 0.5% 0.7% 0.5% 0.1% 0.6% 0.7% 0.2%
Othercommunity
referral 12.1% 10.6% 12.9% 7.9% 14.8% 16.00/o 14.1%

SAMHSA,2012

• a declaration of how much they love, care for, and respect
the user
• specific incidents they have personally witnessed or
experienced related to the addiction and the pain they
have personally experienced because of the incidents
• personal know ledge that the incidents occurred not
because of the user's intent but because of the drug's
effects on the user's behavior
• reassurance of their love, concern, and respect for the
user, with a strong request that he or she recognize and
accept the illness and enter treatment immediately
Anticipated Defenses and Outcomes The facilitator prepares
the team to deal with expected defense mechanisms like
denial, rationalization, minimization, anger, and accusations.
The team makes all the logistical preparations (reserving a
program or hospital admission, packing clothing and toilet-
ries, and covering work and home duties) so that the user
will have no excuse to delay entering treatment immediately
should the intervention be successful. Team members must
make treatment arrangements based on the addicted person's
specific needs, his or her resources to afford treatment, the
specific components and deficiencies of available treatments,
the intervention to process their experiences . This also pro-
vides the opportunity for team members (especially family
members) to explore their own support or treatment needs
for issues such as codependency, enabling, or adult children
of addicts syndrome.
Despite the inherent risk of anger or rejection that may result
from an unsuccessful intervention, the potential benefits far
outweigh the risks. At a very minimum, the pathological
effects of secrecy that pervade an addiction have been
revealed to all those who are most affected by them, allowing
an opportunity for successful treatment or supportive
services for all who participate.
"/ know it sounds strange, but the best thing that everhappened
to me was that I became an addict. That's becausem~
addiction forced me into treatment and the recover~process,
and through recover~I found what was missingin m~ life."
Nurse with 20 years of recovery time

I
and the ultimate client goal of the potential programs. The
team must also prepare for contingencies and alternative
treatments should the addict refuse to accept the first recom-
mendation . Offering options prevents the user from delaying
entry because he or she wants a different program.
Intervention Timing, location, and surprise are crucial com-
ponents of the actual intervention. A neutral, nonthreaten-
ing, and private location must be secured. It should occur at
a time when the user is most likely to be sober and not under
the influence of a drug . The evidence presented in state-
ments should include current incidents. A reliable plan
should be developed to get the addicted person to the inter-
vention location without any suspicion of what is about to
occur . Finally, the facilitator should prepare the order of the
statements that have been rehearsed by the team prior to the
intervention.
Contingency Regardless of the outcome, it is important for
the intervention team members to continue to meet after
The chronic, progressive, and relapsing nature of addiction
is a depressing and degrading process. Results of a Beck's
Depression Inventory evaluation of patients entering treat-
ment at the Haight Ashbury Detox Clinic demonstrated that
34% to 38% were experiencing major depression. Admission
interviews also demonstrated that 30% to 34% made at least
one suicide gesture prior to seeking help for their addiction.
Fortunately, recovery is a spiritually uplifting and motivating
process through which individuals gain a sense of purpose,
community, and meaning in their lives.
Recovery is gradual, and a client undergoes several changes
regardless of the particular therapy used. Success depends
on the addict's becoming and remaining abstinent through
all phases of treatment. The four phases of recovery-
detoxification, initial abstinence, long-term abstinence
(sobriety), and continuous recovery-are used in programs
that have the resources and the ability to work with recover-
ing clients over an extended period of time.

Detoxification
If a client is still using, eliminating the drug from his or her
body is the first step. A user's bioc hemistry is so un balanced
that only abstinence gives the body time to metabolize the
drug and to normalize the brain's neurochemical balance.
Detoxification also helps normalize clients ' thin king pro-
cesses, so they can participate fully in the ir own recovery
It takes about a week to completely excrete a drug like
cocaine and another four weeks to 10 months until the
body chemistry settles down. It can take certa in other
drugs, including marijuana, benzod iazepines, and PCP,
longer to be excreted from the body than cocaine or heroin.
Some treatment programs assist in the detox phase, but most
requ ire severa l days of abstinence pr ior to admiss ion to
ensure that the patient is no longer at risk of suffering
dangerous withdrawa l symptoms, such as seizures, part icu-
larly when alcohol or sedatives are involved. Social or non-
medically supervised programs require clients to go
through either a medical detoxification or be 72 hours
clean-and-sober on their own before being admitted for
recovery treatment. This is to minimize the potential for a
withdrawal emergency requiring medica l attention after the
client has entered socia l model treatment .
"M~mother sworeoff the9in and the Valium®for m~weddin9.
She wastoo 900d to herword.She startedwithdrawin9 and
havin9convulsionsat m~receptionand almostdiedin the
ambulance.It put somewhatofa damperon the hone~moon."
23-year-old bride
Initial detoxification often includes a process called "white
knuckling" in which addicts or abusers stop taking the drug
on their own and suffer through physical and mental with-
drawal symptoms . Detoxification is also done on a normal
outpatient basis, on an intense outpatient basis, at a residen-
tial facility that is medically supervised, or at a medically
managed inpatient facility that can provide treatment in the
emergency room of a hospital if the client is in crisis. 87
Medically or chemically assisted detoxification is aimed at
minimizing withdrawal symptoms that can cause life-
endanger ing effects or an immediate relapse .
For those facilities that assist in detoxification, assessing the
severity of addiction is crucial to determining the need for
medical detoxification . The level of intoxication, the poten-
tial for severe withdrawal symptoms, the presence of other
medical or psychological problems, the patient's response to
treatment recommendat ions, the potential for relapse, and
the environment for recovery-all must be determined.
Of the dozen or so scales used to measure the severity of
addiction to determine the appropriate intensity of treat-
ment, the most valuable are the Clinical Institute Withdrawal
Assessment of Alcohol Scale, revised (CIWA-Ar), which
measures alcohol and sedative drug withdrawal, and the
Clinical Opiate Withdrawal Scale (COWS), used to mea-
sure the severity of opioid withdrawal symptoms. 88 •89
Another very practical withdrawal assessment too l is the
Modified Selective Severity Assessment (MSSA) Detoxi-
Treatment 9.19
fication Scoring; this assesses the severity of opioid, benzo-
diazepine, and alcoho l withdrawal symptoms and is
especially useful because a considerable number of polydrug
abusers have simultaneous tissue dependence to all three
drugs that cause fatal withdraw syndromes . Withdrawa l
assessment too ls have also been developed for amphetamine,
cocaine, cannabinoid, and benzodiazepine dependence.
Severe physical dependence on depressants, major medical
or psychiatric complications, and pregnancy-all are condi-
tions appropriate to initiating detoxification in a hospital-
based program.
"Somethin9told me I had to stop, so I did. And I stoppedb~
m~selffor sevenda~sstrai9ht.I didn't knowwhat I was9oin9
throu9h.I washavin9nashes,I heardpeopletalkin9to me,
and I wassweatin9.I had the shakesrealbad, so I calledthe
hospital.The~9aveme poisoncontrol,and the~transferred
me to the Hai9htAshbur~Clinic."
23-year-old recovering cocaine addict
Medication Therapyfor Detoxification
A variety of specific medications are used during the detoxi-
fication phase to ease the symptoms of withdrawal and
minimize the initial drug cravings. Some of the same medi-
cations are also used during the initial abstinence, long-term
abstinence, and recovery phases . (More detail on potential
treatmentmedicationscan befound later in this chapter.)
• Clonidine (Catapres ®) dampens the withdrawal symp-
toms of opioids, alcohol, and nicotine addiction .
• Phenobarbital or chlordiazepoxide (Librium ®) is used
to prevent withdrawal seizures and other symptoms asso-
ciated with alcohol and sedative-hypnotic dependence .
• Methadone, a long-acting opio id, is one of four feder-
ally approved medications for opioid addiction treatment
(for detoxification and maintenance) . The other three are
buprenorphine, LAAM, and naltrexone .
• Buprenorphine (Subutex ® and Suboxone ®) can be
used for short-term opioid detox ification or long-term
I
maintenance.
• Naltrexone (ReVia®) or in its injectable form, Vivitrol®
blocks the effects of opioids. It is also used during alcoho l
detoxificat ion. The drug blocks the response to heroin if
the addict to slips while in treatment; it also blocks crav-
ings for alcohol and opiates, making it useful in relapse
prevention. Some clinicians also use it to block cravings in
stimulant abuse, gambling, and other addictive disorders .
• Psychiatric medications, including antipsychotics such
as haloperido l (Haldol®), antidepressants such as desip-
ramine and imipramine (Tofranil ®), and selective sero-
tonin reuptake inhibitor (SSRI) antidepressants such as
sertraline (Zoloft ®) and fluoxetine (Prozac ®), are used in
the initia l detox ification of cocaine , amphetam ine, and
other stimu lant addictions.
• Anticonvulsant medications such as topiramate (Topa-
max®) and gabapentin (Neurontin ®) control cravings to
prevent alcohol or stimulant-abuse relapse .
 9.20 CHAPTER 9
• Bromocriptine (Parlodel ®), amantadine (Symmetrel®),
and L-DOPA treat the craving associated with cocaine
and stimulant drug dependence.
• Acamprosate is prescribed for use during initial detoxi-
fication to decrease alcohol cravings. It is more effective
when used in combination with naltrexone and is used
during psychosocial interventions. 90
• Bupropion (Zyban,® Wellbutrin ®) is used to treat nico-
tine and stimulant withdrawal or craving.
• Varenicline (Chantix®) and bupropion (Zyban®) lessen
withdrawal and curb craving of nicotine addiction.
• Nicotine patches (Nicoderm ® and ProStep®) treat the
withdrawal symptoms of tobacco; nicotine-laced gum ,
(N icorette ®), sprays , inhalers , lozenges , and even e-cig-
arettes helps lessen craving or are used as replacement
harm reduction therapies.
• Amino acids are used individually or in combination
to alleviate withdrawal and craving symptoms based
on the theory that the brain uses these amino acids to
make neurotransmitters that were depleted by the drug
addiction. It is believed that the imbalance or depletion
of neurotransmitters causes many withdrawal symptoms
and intense craving. Common amino acids used for this
purpose are tyrosine, tyramine , taurine, tryptophan,
d,1-phenylalanine , lecithin , and glutamine.
Psychosocial
Therapy
Medical intervention alone is rarely effective during the
detoxification phase. Most programs forgo medical treat-
ment if the addict is not in any physiological or psychologi-
cal danger from drug withdrawal. Intensive counseling and
group work have proven to be the most effective ways to
engage addicts in the recovery process and should be the
main focus of all phases of treatment.
Psychosocial client interactions during detoxification are
usually intense (daily encounters in an outpatient program)
and highly structured for a four- to 12-week duration. The
aim of this treatment phase is to break down residual
denial and engage the client in the full recovery process .
I
This is accomplished through mandated participation in
educational sessions , task-oriented group work , therapy
sessions , peer recovery groups, 12-step programs, and
individual counseling.
Treatment focuses on educating the addict about the dis-
ease concept of addiction, the harmful effects of the disease,
and the intensity of detoxification symptoms. Clients also
receive information about their treatment and any medica-
tions used in detoxification, work with their primary coun-
selor to develop their recovery or treatment plan, and initiate
activities to accomplish their goals during the detoxification
phase. Some programs also use structured evidence-based
treatment manuals that have a developed curriculum for
each phase of treatment and provide individual daily lesson
plans, exercises, and homework assignments . Structured ,
evidence-based treatment approaches address firmly held
denial about addictive disorders even for those who have
already entered and engaged in treatment .
"/ knew I could do it m~self I tried those pro9ramsin AA.
I stopped usin9dru9s a milliontimesand I neverneeded
one of those pro9rams."
Heroin addict dying fro m AIDS
Initial Abstinence
Once an addict has been detoxified, his or her body chemis -
try must be allowed to regain balance. Continued absti-
nence during this phase is best promoted by addressing both
the continuous craving for drugs and the aspects of the
addict 's life that may present a risk of relapse .
Continuous craving is caused by depletion of brain neu-
rotransmitters brought about by the drug use in a type of
drug hunger known as "endogenous" craving. Anticraving
medications , such as those used during the detoxification
phase, can be continued during the initial abstinence phase
when more-traditional approaches-voluntary isolation
from environmental triggers or cues (e.g., bars, co-users, and
drug paraphernalia), counseling, and 12-step meetings-are
ineffective in controlling the episodic drug hunger. The per-
sistent change in brain chemistry and circuitry brought
about by drug addiction creates a vulnerability to relapse
long after drug-taking has ceased. 9 1
Medical approaches used during detoxification (e.g.,
Antabuse® for alcoholism and naltrexone for opioids and
alcohol) and various amino acids help rebalance the brain
chemistry, continue to suppress and/or reverse the pleasur-
able effects of drugs, or decrease the drug craving-all of
which encourages the addict to stay clean. 92 -93
Research into a cocaine vaccine and a true alcohol antagonist
may lead to treatments for these addictions in the same man-
ner that naltrexone is often effective in preventing cravings
and relapse in users of opioids and alcohol.
In addition to endogenous craving , post - acute withdrawal
symptoms (PAWS) and environmentally cued or triggered
craving are two other symptoms that begin during and con-
tinue through later stages of treatment and pose a powerful
threat to continued sobriety.
Long-TermAbstinence
The pivotal component of this phase occurs when an addict
finally admits and accepts that his or her addiction is lifelong
and surrenders to a long-term , one-day-at -a-time treatment
process. Continued participation in group, family, and
12-step programs is the key to maintaining long-term absti-
nence. The addict must accept that addiction is chronic,
progressive , incurable, and potentially fatal and that
relapse is always possible .
if
"/ know that/ have another relapsein me. I don't know I have
another recover~in me."
Seven -year member of Alcoholics Anonymous
 Treatment 9.21

It is also vital for recovering addicts to accept that their con-
dition is chemical dependency or drug compulsivity-not
alcoholism or drug addiction. Individuals who manifest an
addiction to a particular drug, such as cocaine, are well
advised to abstain from the use of all abusable psychoactive
substances, especially alcohol. A seemingly benign flirta-
tion with marijuana will probably lead to other drug hungers
and relapse. It is a common clinical observation that com-
pulsive drug abusers often switch intoxicants only to find
the symptoms of addiction resurfacing through another
addictive agent. Drug switching complicates and is coun-
terproductive to recovery-oriented treatment. A study of
men and women in treatment found that 80% had a problem
with two or more substances during their lifetimes, either
concurrently or sequentially. 94 Abstention from smoking or
chewing tobacco can help in the recovery process. 95 Years
of experience and clinical practice also indicate a need to be
wary of compulsive behaviors (e.g., gambling, overeating,
sexual addiction, and compulsive shopping) if one is in
recovery from drug or alcohol addiction.
formula with which most recovering addicts have found
success in achieving their treatment goals. 96
"I found in sobrietqthat I lovepeople. I found in sobrietqthat
I have real feelings.I found in sobrietqthat I have realemotions.
I found in sobrietqthat there'sa worldof people out there in
societqthat's willing,that's been there all along for me, to assist
me. I just neverknew it."
56-year-old recovering heroin addict
RelapsePrevention
Relapse after treatment or after a sustained period of remis-
sion is a characteristic of all chronic persistent medical dis-
orders (e.g., diabetes, asthma, and hypertension); but when
it occurs with addiction, it is often met with a heavy stigma
that causes shame, guilt, and feelings of hopelessness.

Recovery
"Can we cure addiction? Absolutelqnot! Addiction causes
unrecoverablechanges,alterations,and death to braincells.
Brain cells are not readilqregeneratedlikeother cells, so the
changescaused bq drug abuse are permanent.What we can do
is arrestthe illness,teach new livingtechniques,rewirethe brain
to bqpassthose addicted cells, and help an addict in recoverq
livea worthwhilelife. Although addiction cannot be cured, it
can be effectivelqpreventedand treated."
Darryl Inaba, Pharm.D ., Addictions Recovery Center, Medford, OR

Treatment and a continued focus on abstinence are not

enough to ensure recovery and a positive lifestyle. Unless
recovering addicts restructure their lives, replacing the
artificial highs provided by the drugs they used with the
natural highs that come from activities that provide them
with satisfaction and enjoyment, they may achieve sobriety

I
but not recovery. This integral phase of treatment has been
validated experimentally by Dr. George Vaillant, professor of
psychiatry at Harvard University. In classic studies con-
ducted in the 1980s, he identified four components neces-
sary to change an ingrained habit of alcohol dependence. 96
This list substitutes the generic term drug for Dr. Vaillant's
specific reference to alcohol :
• offering the client a nonchemical substitute dependency
for the drug, such as exercise These positron emission tomography (PET) scans of a normal person'.s
• reminding the client ritually that even one episode of brain and a heavy cocaineuser'.sbrain show how long recoverycan
drug use can lead to pain and relapse take and why it is so difficult. The yellow signifies normal brain
function. In a nonuseryellow and even red are abundant. In the
• repairing the social, emotional, and medical damage cocaineabuser 10 days after quitting, there is significantly less yellow
done and thereforeless normal brainfunction. At 100 days there is some
• restoring self-esteem additional normal activity, but it is not nearly as active as it should
be. It can take a year for the brain of a long-term cocaineabuser to
Continued and lifelong participation in the fellowship of approachnormalfunction.
12-step programs along with a concerted effort to seek out Courtesyof NoraVolkow(Volkow,Hitzemann,Wang,et al., 1992)
natural, healthy, nondrug rewarding experiences is the
 9.22 CHAPTER 9

Environmentalcues that
trigger drug craving can
include paraphernalia,
the drugs themselves,
drug use locations,and
money.
© 201 l CNSProductions,
Inc.

For this reason relapse must be accepted but not excused in
recovery. Clients should not be made to feel shame after
a relapse and should be welcomed back into treatment,
where the relapse must be aggressively processed by
the client and the counselor or therapist so that the causes
can be identified and strategies developed to avoid future
slips and relapses. Harm reduction education and alterna-
tives should be part of this process. It is easier to address a
slip after the first use than trying to arrest continued use
after a slip.
Treatment of addiction is incomplete unless a full relapse
compared with healthy, nonusing subjects), an area of the
brain that is vital for memories and emotions. 98
The most common cognitive deficits are impairments of
learning, use and meaning of words, attention span, percep-
tion, information processing, memory efficiency, temporal or
time processing (difficulty with delayed gratification and
goal setting), cognitive inflexibility, problem solving, abstract
thinking, and judgment . These effects can last for several
months after initiating abstinence from drug or alcohol
abuse. 99 Patients often appear normal during the early
phase of recovery treatment but are actually experiencing
an inability to fully understand and process the treatment

I
prevention plan is developed that identifies and addresses
cognitive deficits, PAWS, cravings (endogenous and envi-
ronmental triggers), and relapse prevention strategies.
Cognitive Deficits
Common complications during the initial abstinence phase
of treatment include debilitated thought processes and the
persistence of withdrawal symptoms long after the addict
has been detoxified. Research indicates that 30% to 80% of
substance abusers suffer from mild to severe cognitive
impairments perhaps due to the neurotoxic effects of drug
addiction. 97 The deficits of cognition often impair addicts'
ability to understand what is necessary to prevent or mini-
mize their cravings and remain in recovery.
The deficits can be also be caused by chemical and structural
changes in the central nervous system. In 2005 scientists
found that heavy methamphetamine abusers suffered an
average 11.3% loss of their brain's gray matter. The greatest
deficit was seen in the hippocampus (an average of 7.8% loss
curriculum . A patient can repeat what he or she hears, but
the information and the therapy do not sink in. It may take
weeks or months after detoxification for reasoning, mem-
ory, and thinking to return to a point where the individual
can begin to fully engage in treatment . Educational strate-
gies during treatment must be tailored to the person's ability
to process the information being provided.
Post-Acute Withdrawal Symptoms
PAWS is a group of emotional and physical symptoms that
appear after major withdrawal symptoms (including cogni-
tive deficits) have abated. The syndrome can persist for six
to 18 months or up to 10 years and may contribute to inter-
rupted abstinence or relapse. It is believed that PAWS results
from a combination of brain neuron damage caused by
drug use and the psychological stress of living drug- and
alcohol-free after many years of a drug-using lifestyle. The
syndrome usually begins within seven to 14 days of absti-

nence and peaks in intensity over three to six months.
Symptoms often occur at regular intervals and without
apparent outside stressors. The patterns can occur every two
weeks, monthly, during holidays, or annually on recovery
birthdays. Re-occurrence of PAWS seems to be associated
with patterns of past drug use or stressful events .
Six major types of symptoms are most often associated with
PAWS:
• Sleep disturbances-difficulty falling or staying asleep,
restlessness, and vivid and disturbing nightmares.
• Memory problems-short-term memory is the most
impaired, often making it difficult to learn new skills or
process new information .
• Inability to think clearly-difficulty with concentration,
rigid and repetitive thinking, and impairment of abstract
reasoning; thoughts become chaotic during stressful
situations; decreased problem-solving skills, even with
simple problems; overall intelligence is not affected, and
the thinking impairment is episodic.
• Anxiety and hypersensitivity to stress-chronic stress
with an inability to differentiate between low-stress and
high-stress situations; inappropriate reaction to situa-
tions and difficulty managing stress; all other symptoms
of PAWS syndrome become worse during high-stress
situations.
• Inappropriate emotional reactions and mood swings-
overreaction to emotions, which results in increased
stress that leads to an emotional shutdown or numbness
and the inability to feel any emotions .
• Physical coordination difficulties-hand/eye coordina-
tion issues; and problems with balance, dizziness, and
slow reflexes.
Most recovering addicts also experience inadequacy,
incompetence, embarrassment, lowered self-esteem, and
great shame while experiencing PAWS. These negative
mood states make a recovering addict extremely vulnerable
to relapse . 100
Education, individual and group counseling, participation in
peer support activities, and isolation from potential sources
of alcohol or drug use are strategies used to prevent use and
relapse when a recovering substance abuser is experiencing
PAWS. Some medications are currently being used to treat
PAWS symptoms as well as to prevent the occurrence of the
symptoms. These include acamprosate, carbamazepine,
trazodone, and naltrexone.
"More o~en than not, it is imperativethat a man's brain be
clearedbeforehe is approached, as he has then a better chance
of understandingand acceptingwhat we have to offer."
Alcoholics Anonymous Big Book, 1939
Cravings:Endogenous(internal) Triggers
and Environmental(external) Triggers
Drug triggers (cues) can precipitate drug cravings that often
lead to slips and relapse . These triggers are classified into
Treatment 9.23
two broad categories: endogenous triggers, also referred to as
internal or intrapersonal influences, and environmental trig-
gers, also referred to as external or interpersonal influences .
Endogenous(internal or intrapersonal)Triggers
Endogenous triggers having the greatest impact on drug
craving and relapse are negative emotional and physical
states or internally motivated attempts to regain control in
order to use. These emotional states include exhaustion,
dishonesty, impatience, argumentativeness, depression, frus-
tration, self-pity, cockiness, complacency, expecting too
much from others, letting up on discipline, use of any mood-
altering drugs, and overconfidence .249 They can be caused by
pre-existing conditions (e.g., chronic depression, traumas)
or by imbalances in brain chemistry brought about by
chronic drug abuse .
Long ago addicts discovered that negative mood states also
imbalance neurotransmitters, which can lead to drug crav-
ings and relapse . Handy acronyms for the most common of
these negative mood states-like HALT (hungry, angry,
lonely, tired), RIID (restless, irritable, isolated, discontent),
and BAAD (bored, anxious, angry, depressed)-are used to
remind addicts of the craving triggers that lead to relapse.
A homeostatic theory for drug addiction to explain the influ-
ence of endogenous and exogenous influences was first pro-
posed by C. K. Himmelsbach in 1941. 10 1 Homeostasis in
brain chemistry is the normal balance and functioning of
neurotransmitters. Under Himmelsbach's theory, abuse of
addictive drugs disrupts a brain's normal functioning and
chemical balance, or homeostasis, resulting in a depletion
of certain neurotransmitters . This altered brain chemical
state, known as allostasis (imbalance), must then be main-
tained for the individual to remain functional. If use of the
addictive drug or drugs is not maintained, the individual's
brain will experience severe withdrawal symptoms and
cravings that serve to reinforce the need to resume drug
use. This powerful type of drug hunger (endogenous, or
interpersonal craving) usually results in an immediate and
severe relapse to addiction because the body 's most powerful
I
survival mechanism is the drive to restore brain functioning,
albeit the abnormal functioning of allostasis.
Traditional treatments for endogenous cravings consist of
counseling, education, discussions with recovery spon-
sors, stress reduction therapies, biofeedback, and partici-
pation in 12-step meetings. More-recent treatments include
medications and nutrients like amino acid precursors that
are targeted to restore neurotransmitter homeostasis. These
substances can lessen initial negative feelings of early sobri-
ety, continue to suppress and/or reverse the pleasurable
effects of drugs, and even decrease the drug craving-all of
which helps encourage the addict to stay clean. 92 •93 -102
Environmental(externalor interpersonal)Triggers
Environmental triggers often precipitate drug cravings .
Also known as external influences or interpersonal factors,
this type of craving is caused by relationship conflicts, social
pressures, lack of support systems, negative life events,
 9.24 CHAPTER 9
sensory stimuli, and "slippery" people, places, and things
(e.g., money, neighborhoods, past using panners, a beer dis-
play in a grocery store) .38 •103 Sensory stimuli (odor, sight,
noise, or anything related to a person 's past drug use) can
also trigger memories that evoke cravings.
"When /'m smellingmarijuanahere in the buildingwhere I live
and I smell the 'primo' (which is crackcocainelaced with
marijuana),the cravingsdo come back, And what I do is I call
m~ sponsor, I go to an NA and AAmeeting,and I most/~ talk
tom~ sponsorand I tell her what I'm feeling,and I pra~ to
God to give me the strengthnot to go out to bu~ me an~ kind
of drugs to use."
38 -year-old recovering polydrug abuser
Drug craving caused by an environmental cue results in
true psychological responses that are manifested by actual
physiological changes of increased heart rate, pulse rate,
and blood pressure; sweating; dilation of the pupils; specific
electrical changes in the skin and electroencephalogram
scans; increased peristalsis activity; and an immediate drop
of 2 degrees or more in body temperature.
RelapsePreventionStrategies
Relapse prevention is the focus of almost all treatment
programs . There are a number of strategies employed in the
process.
• Addicts must understand the nature of relapse and learn
to recognize their personal triggers, which can be any-
thing from drug odors, seeing friends who use, having
money in their pocket, or hearing a song about drugs.
• Addicts must develop behaviors to avoid external trig-
gers. These include staying away from old neighbor-
hoods, dealers, and bars or gatherings where drugs are
readily available; avoiding certain friends; and carrying
only a limited amount of cash.
• Addicts must be prepared with an automatic reflex
strategy that will prevent them from using when their
I
craving is activated by internal or external cues . These
include engaging their support system, going to a 12-step
meeting, using coping skills for negative emotional states
and cognitive distortions, remembering the damage
cause by their addiction, reminding themselves of their
reasons for wanting to stay clean, remembering their last
binge, creating a balanced lifestyle, and, in some cases,
using anticraving medications. 104
Cue Extinction
Deconditioning techniques, stress reduction exercises,
expressing one's feelings, working out, long walks, and cold
showers-all are ways that addicts dissipate the craving
response when it arises . Dr. Anna Rose Childress's Desen-
sitization Program retrains brain cells to avoid reacting
when confronted by environmental cues . The procedure
involves exposing an addict to progressively stronger envi-
ronmental cues over 40 to 50 sessions in a controlled setting;
this gradually decreases the addict's response to the cues
until there are no physiological signs of a craving response
even after the addict is exposed to heavy triggers. Every time
an addict refrains from using while craving a drug serves
to lessen the response to the next trigger experience .
Desensitization to drug triggers is also known as cue
extinction . 106 · 107
"/ did it m~self Ever~da~ I would take out m~ Librium®pills
and look at them, touch them, and even smell them. Then I
would put them back in the bottle becauseI knew I couldn't ever
use them again. A~er a while I lost interestin them altogether."
44 -year-old female recovering benzodiazepine addict
PsychosocialSupport
Initial abstinence is also the phase during which addicts
start to put their lives back in order, working on all the
things they neglected while indulging their addiction. This is
the point at which a comprehensive analysis of an addict's
medical health, psychiatric status, social problems, and envi-
ronmental needs must be conducted so that a plan can be
developed to address all the issues presented .
It is important for addicts to build a support system that
will continue to provide advice, help, and information
when they return home and go back to work. The pressures
and the environmental triggers that led to addiction remain,
necessitating panicipation in support groups and 12-step
programs along with involvement in group therapy and con-
tinued recovery counseling. These activities have the most
positive treatment outcomes during the initial abstinence
phase.
Natural Highs
"Gettinghigh on life is a skill,and just likean~ other skill-
athletic, artistic,musical.or professional- the more ~ou
practiceit, the more ~ou can improve."
George Obermeier, drug educator
Because psychoactive drugs cause sensations or feelings that
have natural counterparts in the body, human beings can
create virtually all of those same sensations and feelings
from natural activities. Athletic competition releases the
same neurotransmitters as cocaine and methamphetamine .
Experiencing a second wind or the runner's high from jog-
ging comes from opiate receptor activation by endorphins.
Traveling and experiencing new environments activates the
novelty center, the same area of the brain that marijuana
affects. Being in touch with the natural or drug-free highs
available to the brain is an essential part of living.
Outcome and Follow-Up
Tracking client outcomes and preparing follow-up evalua-
tions have become a major activity for treatment programs.
Government and other funding sources require documenta-
tion to justify spending levels, and in some cases the strin-

gent criteria elim inate a program's ability to be flexible or to
provide an indiv idual client with an alternative treatment
that may be more effective.
Because addiction is by nature a chronic and relapsing con-
dit ion caused by many things, outcome measures should
evaluate every phase of the recovery process, including
long-term follow-up.
Indicators most often used to determine successful addiction
treatment include:
• prevalence of drug slips and relapses (duration of con-
tinuous sobriety)
• retention in treatment
• completion of a treatment plan and its phases
• family funct ion ing
• social and environmenta l adjustments
• vocat ional or educational functioning, including per-
sonal finance management
• crimina l activity or legal invo lvement.
All types of addiction treatment have demonstrated posi-
tive client outcomes when evaluated by rigorous scientific
methods.2'•44 •45
There are two main integrated components of addiction
treatment: psychosocial therapy and medical (especially
medication) therapy, Medical treatments are not effective
unless they are integrated with psychosocial therapies .
A deeper understanding of the neurobiological process of
addiction prompted the development of new med ication
treatments and an unprecedented interest in the new medi-
cal specialty of addict ion medicine called add ictionology.
There are two general types of counseling therapies: indi-
vidua l and group. Most treatment facilities use a comb ina-
tion of both methods .
IndividualTherapy
Individual therapy is usually conducted by a credent ialed
chemical dependency counselor who deals with clients on a
one-on-one basis, exploring the reasons for their continued
use of psychoactive substances and identifying all areas of
intervention needs with the aim of changing behavior .
Sometimes a client is referred for specialized therapies such
as psychotherapy, medical care, or family counseling. The
therapist helps addicts gain perspective on their drug use
and explains how to use the too ls that will keep them absti-
nent. The most common indiv idual th erapies are cognitive-
behavioral therapy, reality therapy, aversion therapy,
psychodynamic therapy, art therapy, assertiveness train-
Treatment 9.25
ing, motivational interviewing or enhancement, and social
skills training. 108
Once an individua l treatment plan is developed with a client,
treatment may span a month to several years. Although the
majority of treatment is based on group and peer interaction,
ind ividual treatment may be more effective for particular
clients and specific drugs (e.g., heroin and sedatives) .
Dialoguebetween a drug counselorand a heroin
addict in a counselingsessionat the HaightAshbury
Detox Clinicin San Francisco:
Addict: "When I'm going through withdrawal, its a physical
thing, and then after I'm clean, I have the mental problemof
having to say no every time I get money in my hands:'Should
I or shouldn't I? No, I shouldn't. Go ahead, one more time
won't hurt.' After I've passed withdrawal, and I pass by areas
where I used to hang out, and I see other people nodding, in
my mind, I start feeling like I'm sick again. I want to stay
clean."
Counselor: "You can stay clean for a while. Is that what you
want? You want to stay cleanfor a while or for the rest of
your life?"
Addict: "I want to stay clean permanently,"
Counselor: "Permanentlydrug-free?"
Addict: "But I can do it without attending those {Narcotics
Anonymous] meetings."
Counselor: "All by yourself?"
Addict: "I mean with the medication that I take."
Counselor: "But the medications are going to last you only 21
days. They'll help you for a little while with the withdrawal
of getting off heroin, but what are you going to do when the
urges come up?"
Addict: "I guess I'll deal with that when the time comes."
Counselor: "So you're just going to wait for it? You'regoing to
wait for the urges to come on and start using then?"
I
Addict: "Nah, I can deal with it."
Counselor: "You'rebeing highly uncooperative. As a matter of
fact, we're going to stop the medications today because we
know you're still using heroinand we can't haveyou using on
the program."
Addict: "I need those medications."
Counselor: "What for? Its just another drug. What you're doing
is using it like another drug. I'd like for you to come back to
get into that group meeting we have at three o'clock.Also I
want you to go to an NA meeting every day, I want you to go
to thesemeetingsand participate. Talkevery opportunityyou
can. I also want you to bring back the signed participation
card that provesyou attended. I want you to do that. Thats
just part of the requirementof being in the program. See, I'm
going to assume that you want to stop using drugs."
Addict: "Why can't I just get the detoxificationdrugs?"
 9.26 CHAPTER 9
"Becausewe're not just a medicationprogram. It~ a
Counselor:
counselingandfull-recoveryprogramtoo."
Because individual treatment is less threatening for many,
it is often used in the short term to introduce addicts to the
treatment process.
Motivational Interviewingand Motivational
EnhancementTherapy
One of the most frequently used counseling techniques in
substance-abuse treatment is motivational interviewing cou-
pled with a stages-of-change model. The technique uses a
nonconfrontational style to involve clients in their own
recovery process and helps them change ambivalence
about drug use into motivation to make changes that lead
to abstinence and recovery. As happens in 12-step recovery
groups, where people look to their own higher power for
direction and strength, clients succeed at making major
changes when their motivation is internal rather than exter-
nal. The counselor guides a client through the stages of
change by helping them reach decisions for themselves
rather than by forcing or overdirecting them. This technique
helps a client "release the potential for change that exists in
every person." The objective is to have clients advocate for
their own positive lifestyle changes.
These are the general principles of motivational interviewing:
• Express empathy-seeing the world through the clients'
eyes and developing empathy is a way to develop a rap-
port with them; reflective listening and acceptance help
the counselor understand the clients .
• Roll with resistance-resistance is not to be challenged
or argued with but rather used to help explore the cli-
ents' ideas; using that momentum rather than fighting it
decreases resistance.
• Develop discrepancy-the counselor helps clients rec-
ognize discrepancies between where they are and where
they want to be and explains why their current actions
will not lead them to their goals.
• Support self-efficacy-by empowering clients to choose
I
their own options, the counselor encourages them to
make changes_l09
Motivational interviewing techniques are used within the
framework of the stages-of-change model. This requires the
counselor to match motivational tasks to each client's stage
of change.
• Precontemplation is the stage during which clients do
not admit they have a problem and are not thinking
about change, although others may perceive behaviors
that need changing. The counselor's task is to raise doubt
and increase a client's perception of the risks and the
problems associated with his or her current behavior.
• Contemplation is the stage when clients begin thinking
that there may be a problem and deciding if they should
change . The counselor can tip the balance by evoking
reasons to change, outlining the risks of not changing,
and strengthening a client's self-efficacy to change cur-
rent behavior .
• Determination (or preparation) is the stage at which
the client decides to do something to change his or her
behavior; it is a conscious decision. The counselor can
help the client determine the best course of action to take
in seeking change.
• Action is the stage of actively doing something: the client
chooses a strategy for change and pursues it, taking steps
to put that decision into action. The counselor helps the
client take those steps toward change.
• Maintenance and relapse prevention involve incorpo-
rating all the change strategies for the long haul.
The counselor helps the client renew the process of con-
templation and determination and provides support when
an occasional slip occurs so that the patient does not
become stuck or demoralized because ofrelapse. 109 .111
GroupTherapy
The main types of group therapy are: facilitated, peer, 12-step
(spiritual and recovery), educational, targeted, and topic
specific. The primary focus of group therapy involves cli-
ents helping each other break the isolation that chemical
dependency induces so that they know they are not alone.
Addicts gain experience and understanding from one another
about their addiction and learn different ways to combat
craving to help prevent further drug impairment or relapse.
As peers they are also able to confront one another on issues
that may lead to relapse or continued use.
'The 9roupkeepsme honestwith mqself I 9et to lookat a lot
of thin9sand behaviorsthat are9oin9on with me, and I trq to
keepin the now. I keepthinkin9about staqin9cleantodaq,
and the 9roupkeepsme focusedon mq9oal of each daq trqin9
to staq clean."
Recovering crack cocaine user
FacilitatedGroups
Facilitated group therapy usually consists of six or more
clients who meet with one or more therapists or counsel-
ors on a daily, weekly, or monthly basis . Therapists facili-
tate the group, presenting topics for discussion, encouraging
participants to disclose major life issues, prompting others
to provide feedback, and processing every issue with their
clinical insight. The facilitator also helps establish a group
culture wherein sharing, trust, and openness become natural
to the participants.
Stimulant-abusepeer group that usesconfrontational
techniquesand a facilitator:
William: "I have two sets offriends: people I use with and people
who don't use at all; we've got togetherand had dinner and
soforth."
Facilitator: "That~ real safe for you, William. Listen to me,
William. They don't know what to lookfor. They don't know
what to expect,and you can manipulatethem real easy."

Maria: "The same thing happenedto me. You still think you can
sit around with alcoholics,with people who drink, like you
think you can hang aroundwith dope dealers?"
William: "So the only people I can associatewith are people in
recovery?"
Maria: "I had to give up my sister."
William: "Okay, admit it. Everybody out there doesn't have a
problem."
Maria: "Butyou do."
William: "Thats true."
Facilitator: "Let me ask you a question. Canyou see your ears?"
William: "No."
Facilitator: "So that means we can see something you can't see,
right? Okay. So far, this group, with your issues, we're
batting a thousand,yes or no?"
William: "Yes."
Peer Groups
In peer group therapy, the therapist plays a less active role in
the group dynamics. The therapist observes the interaction
and is available to mitigate any conflicts or clarify ques-
tions but does not direct or lead the process.
Drug-abuserecoverypeer group:
John: "I didn'twant to come here this morning and befaced with,
'Well, you gotta think whether you really want to be here.'
Its like I'm ready and I'm scared."
Counselor: "Whats scaringyou?"
John: "Ifeel like I'm failing myself"
Bob: "When did you fail before?"
John: "When have I failed before?Oh, I would say the last time
was when I got busted buying crack.Just going out there is
failing-knowing I shouldn'tbe doing that."
Bob: "Yougotta put that out there. Yougotta deal with that."
John: "The thing is, I'm scaredof when I'm going to snap again."
Treatment 9.27
© 1999 Mike Baldwin.Printed
by permission UniversalUclick.
All rightsreserved.
Self-Help Groupsand AlcoholicsAnonymous
(12-step groups)
The concept of abstinence-based self-help groups goes back
almost 200 years in America to fraternal temperance societ-
ies and reform clubs, where recovering alcoholics main-
tained their abstinence through discussion, prayer, and
social activities. One of the earliest groups was the
Washingtonian Revival, started in 1840 by six members of
a drinking club in Baltimore, Maryland. They started a
weekly temperance meeting; and instead of debates, drink-
ing games, and speeches, their main activity was sharing
their experiences, starting with confessions of a debasing
lifestyle caused by their excessive drinking. New members,
still in the throes of their addiction, were encouraged to tell
their story and sign a pledge of abstinence. Word of this
working-class movement spread rapidly, and chapters
formed across the country. At the peak of the Washingtonian
movement, more than 600,000 pledges were signed. The
Washingtonian program of recovery closely mirrors that of
Alcoholics Anonymous, which was created 90 years later .
Although the Washingtonians lasted only seven years, their
I
example encouraged other fraternal temperance societies
and reform clubs, including the Order of the Good
Samaritans, the Order of Good Templars, Osgood's Reformed
Drinkers Club, and the Oxford Group. Over the next 50
years, many types of organizations were formed, such as
those with a religious basis like rescue missions and the
Salvation Army.112 There was also continuing debate over
whether Prohibition was the real answer to alcoholism.
It was the evolution and the refinement of these groups-
coupled with the end of Prohibition, the closing of many
drying-out institutions and treatment hospitals, and the
beginning of the Great Depression-that eventually led in
the 1930s to Alcoholics Anonymous, the most widespread
recovery movement in history. AA is a peer group concept
based on 12 steps of recovery. A professional therapist or
facilitator does not interact with members at meetings.
Each group is independent, and members rely on one anoth-
er's knowledge and successes to help curb alcohol and other
 9.28 CHAPTER 9
drug use. The parent group provides literature and sugges-
tions for the general structure and format of meetings. The
core book, Alcoholics Anonymous (usually referred to as
The Big Book), was written by Bill Wilson (a recovering alco-
holic), Dr. Bob Smith (a physician), and the founders of AA,
with contributions from 100 recovering alcoholics sharing
their stories. 113
"When I went to mq first meetin9,a 30-qear-old beauticianwas
tellin9her storq about how her drinkin9started, the pain she
sufferedbecauseof it, and what happened to chan9e her. I was
a 49-qear-old male with mq own business,and qet her storq
was mq storq. Her reactionto alcohol was the same as mine.
Her helplessnessa~er the first drink was mine. Her denial was
mine. Her divorcewas mine. Her reactionsto life's problems
weremine. The familiarit~and the sheerpowerof her storq have
kept me in the sroup for fiveand a half qears. In AAtheq saq,
'We have onlq our stories,and all we can do is tell what worked
for us to staq sober."'
54-year-old recovering alcoholic
Other 12-step groups include Narcotics Anonymous (NA),
Crystal Meth Anonymous, Cocaine Anonymous (CA),
Marijuana Anonymous (MA), Gamblers Anonymous (GA),
Overeaters Anonymous (OA), Sexaholics Anonymous (SA),
and Debtors Anonymous (DA). Al-Anon (for families of
alcoholics), Adult Children of Alcoholics (ACoA), and
Alateen (for teenagers with alcoholic relatives) also use the
12-step process to help those immediately affected by the
behavior of addicts and alcoholics in their lives. All 12-step
programs are free. They pay their minimal costs through vol-
untary donations. The only requirement for membership in
these groups is a desire to stop the addiction .
"We'renot here to help qou stop qouraddiction. We're here to
help qou if qou want to stop qouraddiction."
Sign at AA meeting
The 12-step process engages addicts at their level of addic-
tion; breaks the isolation, guilt, and pain; and shows them
that they are not alone. The process also fully supports the
I
idea that addiction is a lifelong disease (or an allergy, as orig-
inally defined in Alcoholics Anonymous) that must be dealt
with for the remainder of a person 's life. It promotes a pro-
gram of honesty, open-mindedness, and willingness (HOW)
to change . Those are the key elements in sustaining lifelong
abstinence from drugs, alcohol, and other addictive behav-
iors. It breaks down denial and supplies a structure through
which people can continue to work on their addiction.
The 12-step programs are based on the concept of solving
problems through personal spiritual change, a concept
articulated by the Oxford Group , a popular spiritual move-
ment of the 1920s and 1930s that harkened back to the
Washingtonian groups of the 1840s. 114 ,115 ,116
Spiritualityand Recovery
Spirituality- and faith-based treatment interventions have
a long and positive tradition in the recovery community
but continue to generate controversy in a culture that pro-
motes freedom of religion yet separation of church and state.
Many empirical studies and research reviews document a
60% to 80% correlation between religion or spirituality
and better health in diverse medical areas of prevention,
treatment, and recovery for a wide range of mental and phys-
ical conditions . Studies find better health outcomes and
improved quality of life in individuals who are spiritually
engaged in terms of physical health, affective mental states,
sustained recovery from drug and alcohol abuse, coping
skills, immune system improvement, lowered blood pres-
sure, better cardiac status, fewer problems caused by cere-
bral vascular disease, reduced suicidal ideation, and a more
hopeful outlook on life. 117 ,118 , 119
Although a traditional program (emphasizing conventional
medical and psychosocial treatments) may incorporate the
12-step philosophy or other spiritual content, spiritual pro-
grams rely on belief and faith to help restore health and
maintain abstinence from drugs or alcohol. Nonscientific
language and religious passages can be more acceptable
than the complex clinical and psychological language of
recovery, but scripture can also be condemning and judg-
mental, which presents problems for chemically depen-
dent people because they are already experiencing undue
shame and guilt. There is also the risk that an addict will
take a "spiritual bypass"-misusing faith to avoid taking
responsibility for past behaviors and to avoid making diffi-
cult psychological changes. There are often limitations on
who can participate in faith-based programs due to limited
and exclusive perceptions of spirituality. 120 ,124
"Peoplemisunderstandspiritualitq.Theq mistakeit for reli9ion.
Spiritualitqis a person'spersonalrelationshipwith their hi9her
poweras theq define it. Reli9ionis the waq theq practicetheir
spiritualitq.Mq hi9herpoweris God as I learnedof Him in
mq qouth. Forothers their hi9herpowercould be an ideal, a
philosophq,the 9oodness within themselves,a sreat persontheq
met in their lives,the stars, or the membersof the 12-step9roup
itself It's somethin9sreater than themselvesthat theq can turn
to for help to reconstructtheir lives."
5 1-year-old former priest who gives talks on spirituality and his
recovery from alcoholism
Although most 12-step groups understand and accept spiri-
tuality, some users cannot accept the idea of a higher power.
For those people The Big Book advises to take what you want
and leave the rest.
The 12 Steps of AlcoholicsAnonymous
Step I: We admitted we were powerless over alcohol
[cocaine, cigarettes , food, gambling] and that our lives
had become unmanageable .
Step 2:Came to believe that a power greater than ourselves
could restore us to sanity.
Step 3: Made a decision to tum our will and our lives over to
the care of God as we understood Him.
Step 4: Made a searching and fearless moral inventory of
ourselves .

For every addiction,thereis a recoverygroup.
Step 5:Admitted to God, to ourselves, and to another human
being the exact nature of our wrongs .
Step 6: Were entirely ready to have God remove all these
defects of character.
Step 7: Humbly asked Him to remove our shortcomings.
Step B: Made a list of all persons we had harmed and became
willing to make amends to them all.
Step 9: Made direct amends to such people wherever possi-
ble, except when to do so would injure them or others .
Step 10:Continued to take persona l inventory and when we
were wrong, promptly admitted it.
Step II: Sought through prayer and meditation to improve
our conscious contact with God as we understood Him,
praying only for knowledge of His will for us and the
power to carry that out.
Step 12:Having had a spiritual awakening as the result of
these steps, we tried to carry this message to alcoholics
and to practice these principles in all our affairs.
A University of California, Los Angeles (UCLA) study of
12-step program attendance conducted by Dr. Robert
Fiorentine found that participation in meetings after com-
pleting treatment increased the six-month abstinence rate
almost twofold over those who did not attend meetings
upon completion of treatment (Figure 9-4) .32 The same
study found that adding counseling sessions (at least four
group sessions and one individual session more per month)
reduced drug use by 40%.
Several studies demonstrate that through its 12-step prac-
tices, M has a profound and positive impact on maintaining
abstinence and improving both life functioning and appre-
ciation. These studies suggest that M works by increasing
social networks in support of abstinence and by increasing
self-efficacy or self-confidence in maintaining sobriety
Spirituality, another key factor of AAf; success, is a difficult
concept to study scientifically Newly developed research
tools can measure different aspects of spirituality and con-
firm its role in the recovery process .62
In 2008 Marc Galanter and Herbert D. Kleber summarized
their meta-analys is of several outcome studies of self-help-
group (SHG) participation. Here are some of their findings:
• Sustained attendance is associated with a higher likeli-
hood of abstinence and better substance use treatment
outcomes.
Treatment 9.29
rl.,.,u
~8l:on
..
ymou
~
• Delay in participation and dropout from SHGs foreshad-
ows poorer outcomes .
• Participation in SHGs can reduce healthcare utilization
and costs.
• Less religious individuals appear to benefit from SHGs as
much as individuals who are more religious.
• Individuals who are court mandated to participate in
SHGs benefit as much from them as do non-mandated
patients. 61
"I'mnot the samepersonthat I waswhenI enteredthis
fellowship.
Throughmq recoverq and the 12 steps,I havefound
meaningand purposein mq life. It feelsespeciallq
good with
mq kidsbecausetheqknowthat I'm herefor them.There'sno
catch-upanqmore.I keepmqpromises. The challengeof a sober
parentis keepingpromises."
Recovering heroin addict
The 12 steps work for any addictive behavior because the
roots of addiction lie first in the character and the current
lifestyle of the user and, second, in the use of psychoactive
substances or the practice of the behavioral addiction.
Secular versions of the 12-step peer group process do not
believe that a higher power is necessary for recovery One
group, Rational Recovery, believes that if you learn to like
yourself for who you are, you will not need to drink or use
other drugs. They believe that all addictions come from the
same roots. Their approach is based on rational, emotive
I
therapy developed by Dr. Albert Ellis. Another group,
Secular Organization for Sobriety, or Save Our Selves
(SOS), makes no distinction among the various chemica l
addictions. Its goal is sobriety, one day at a time, like AAf;
and NA's goal.
Women for Sobriety (WFS) has a spiritual basis but believes
that M principles work better for men. WFS emphasizes the
power of positive emotions. Men for Sobriety (MFS) focuses
on participants' recognizing their comp lex role in society
and the need to recover from alcoholism through self-
discovery, leading to a sense of self-value and self-worth. 125
EducationalGroups
These groups focus primarily on providing information
about the addictive process in recovery. Trained counselors
provide the education and often bring in other experts to
present individual lesson plans to help addicts gain knowl-
edge about their condition .
 9.30 CHAPTER 9

90 86.40/o Topic-SpecificGroups
Participation
in DrugAbuse While targeted groups are aimed at cultures, topic-specific
80
Treatment and12-Step groups are aimed at such issues as AIDS recovery, early
70
Program Improves recovery, relapse prevention, recovery maintenance, rela-
Treatment Outcomes tionships , and codependency. The advantage of these groups
60 is that they allow the participants to focus on key issues
that are a threat to their continued recovery .
so No weekly 48.40/o
12-step Most studies indicate that group therapies are more likely
attendance to promote better outcomes and sustain abstinence than
40
individual therapies. Specifically, alcohol and cocaine
30.80/o addictions are more responsive to the group process than to
30
individual counseling. From both an administrative and a
20
consumer standpoint, group processes are also more cost-
effective.
10
10 Common ErrorsMade in Group
Treatment by BeginningCounselors
Treatment Treatment Treatment
drop-out completed completedand
or Substance-AbuseWorkers
weekly 12-step Adapted from Geoffrey L. Greif, D.S.W, associate dean and
attendance professor,University of Maryland
1. Failure to have a realistic view of group treatment
Preconceived expectations about the effectiveness of
Weekly attendance at 12-step meetings after treatment almost doubles
group therapy may cause a new therapist to become
patients' abstinence rate (48.4%vs. 86.4%).
impatient with the group 's progress; the reality is that
each group progresses at a different rate, from extremely
slow to explosive.
Possible solution: Supervision teaches the therapist to
Homework is often assigned to help addicts understand the adopt a longer-term perspective . In addition , a thorough
information, along with access to workbooks , manuals, and understanding of the behaviors caused by the specific
other teaching resources. These groups teach relapse preven- drug, the way the other groups in the agency function,
tion, coping skills, and support therapy Research conducted and the cultural backgrounds and gender-related behav-
during the development of the Matrix Model for stimulant- iors of the members make for more-realistic expectations.
abuse problems indicates that a manual-based educational
process may be more successful than a formal counseling 2. Self-disclosure issues and the failure to drop the "mask"
process in promoting and sustaining recovery. 126 Resistance of professionalism
to manual-driven education and process groups is often cen- New leaders are often challenged by the group mem-
tered on their inflexibility regarding serious clinical issues bers, who test the therapist 's understanding and/or
that may arise but are not covered by the curriculum or that personal experience with substance abuse.

I
may be out of sequence with the particular lesson plan for
that session. Although such manuals are most effective when
the clinician does not waiver from the curriculum, this
objection has been effectively addressed by adding 30 to 60
minutes to each session so that vital issues not related to a
specific lesson plan can also be processed.
TargetedGroups
These groups can be part of a formal program or a non-
facilitated peer group and are directed at specific popula-
tions of users. Such targeted groups include those for men ,
women, gays and lesbians, physicians, and those with a
dual diagnosis. People often feel more comfortable begin-
ning a group process with those of similar backgrounds or
culture; some then move on to participate in groups with
more-diverse populations. The key to the success of any
group is its ability to develop a culture that provides relevant ,
meaningful, acceptable, and insightful knowledge for every
participant.
Possiblesolution: A response to any challenge by group
members should be prepared in advance because too
much disclosure of the therapist's personal experience
can be as bad as too little disclosure . Leaders must
accept the humanity of their clients as well as the disclo-
sure of their own.
3. Agency culture issues and personal style
Different methods of running groups can confuse clients
and make them feel trapped between styles; group
culture vs. facility culture can cause dissonance.
Possiblesolution: Guided by his or her supervisor and
more-experienced therapists, the therapist must make
his or her approach consistent with agency style.
4. Failure to understand the stages of therapy
Groups pass through specific stages during the recovery
process, and failure to see the progression can hamper
the group's process .

Cornered by Baldwin
c:ornered@com1c.com ____ _ 1~
7-15 C2002 Mike Baldwln I OISLDy UnlversalPress Syndleate www.cornered.com
S
\-\'-?t'OCl-\O~V~lAC.
AtlJO MOIJS
I to have the group reevaluate its progress and recommit
"Firststep is the hardest.You'vegot to
admitthat you don't have a problem."
C>2002 Mike Baldwin. Printed by permission UniversalUclick.All rights reserved
.
Possiblesolution: There must be a thorough understand-
ing of the various stages of recovery and how to respond
with appropriate and timely exercises and comments.
5. Failure to recognize counter-transference issues
Often an inexperienced group leader or therapist will let
personal feelings about the group affect his or her per-
formance, particularly if there are differences in age,
gender, ethnic background , or lifestyle.
Possible solution: The novice therapist must be aware of
and accept such feelings as a normal part of the therapist/
client relationship and avoid acting on those feelings in
a nontherapeutic manner.
6. Failure to clarify group rules
When the group rules (e.g., ignoring confidentiality,
coming to the group high, arriving late, meeting outside
of group , and making personal attacks on other mem-
bers) are not clearly communicated by the leader, the
process is jeopardized.
Possible solution: Posting the rules at every session or
distributing a handout that clearly explains the proce-
dures , followed by a discussion of the rules , gives the
group a solid base of understanding.
7. Failure to use the entire group effectively by focusing
on individual problem-solving
By trying to please individual members of the group by
giving insightful and helpful suggestions to solve per-
Treatment 9.31
sonal problems unrelated to recovery issues, the thera-
pist can weaken the group.
Possible solution: Focus the group on providing advice,
information , help, and support to address recovery-
related issues rather than individual unrelated problems.
This gives meaning, purpose, and power to the group.
8. Failure to plan in advance
When the leader decides to wing it because he or she did
not plan for the session, less is accomplished.
Possible solution: The therapist should have a primary
plan for each session as well as a backup plan so that the
group always has direction. A structured curriculum
with a set number of sequential lesson plans that can
also serve as benchmarks for the group's progress toward
recovery can also be helpful.
9. Failure to integrate new members into the group
Integrating a new member into the established flow can
slow the group down. Conversely; if new members are
instantly integrated, they do not have time to develop
naturally and feel part of the group.
Possible solution: The therapist can use the opportunity
to the group.
10. Failure to understand interactions in the group as a
metaphor for drug-related issues occurring in the
group member's family of origin
A new therapist may believe that reactions among group
members that are based on a client's familial relation-
ships are true reactions. They might not realize the
source of the reactions and lose an opportunity to use
that information to help the client.
Possiblesolution: The therapist needs to take the time to
establish strong bonds with group members so that
issues and insights raised by group interactions can be
used to help the clients.
I
"I aot put into treatmentand9ot out of treatment.qou know.
I just BS'ed mq wholewa~throu9htreatment.I told them
what theqwantedto hearand9ot out and just relapseda9ain
becausemq dad said, 'Here,qou wantto smokesomeweed?
You wantto drinka beer?'It's kindahardto saqno when~our
dad'ssittin9thereaskin9qou. It makesqou feellikeit'saka~."
15-year-old recovering polydrug abuser
About one-fourth of the U.S. population is a member of a
family that is affected by an addictive disorder in a first-
degree relative; up to 90% of active addicts live at home with
family or with a significant other. 127 Addiction is a family
disease; abuse of drugs and alcohol greatly impacts every
member of an addict's family regardless of whether they
abuse psychoactive substances. 129 Analysis of employed
 9.32 CHAPTER 9
addicts and alcoholics shows that their families use the
employer's health insurance more than the families of non-
addicts . This is indicative of the great emotional, physical,
and social strain that addicts place on their families .
"Addictsdon't havefamilies;theqhavehosta9es.
" substance-abuse problem.
John DeDomenico, family therapist, Haight Ashbury Detox Clinic
"Despitethis well-established
relationship
, the familqis often
i9noredand neelectedin the treatmentofaddictivedisease.
This resultsin familqmembers'seekin9counselin9on theirown
throu9htraditionalfamilqand mentalhealthservicesor throu9h
self-helpfamilqtreatmentsqstemslikeTou9hlove,® Al-Anon,
Alateen,and Nar-Anon.If a recoverin9 addict is understress
becauseofunresolved familqproblemsora troubledfamilq
member,remainin9 abstinentmaqbecomedifficult.A familqis
ruledbq its sickestmember."
Moss Hart, dramatist
Goalsof FamilyTreatment
There are four goals of family treatment:
1. Acceptance by all family members, as well as by the
addict, that addiction is a treatable disease and not a
sign of moral weakness .
2. Establishing and maintaining a drug-free family sys-
tem . This often includes treatment of a spouse 's drug
problem or those of the addict 's children .
3. Developing a system for family communication and
interaction that reinforces the addict 's recovery process
by integrating family therapy into addiction treatment.
4. Processing the family's readjustment after cessation of
drug and alcohol abuse .
"I burnteverqbridt]ewithprettqmucheverqbodq in mq whole
life.The familqsessionsherearehelpin9a littlebit. Mq step-
dad doesn'twantanqthin9to do with me, but mq momcomes
in; we'reworkin9,we'relistenin9,qouknow.We're not just
I
fi9htin9anqmore . She'snot qellin9at the top ofher lun9s.
I'm not tellin9hertor•• off anqmore.We'reactuallqworkin9
to9ether.It feels900d. I mi9htbe ableto 9et a life."
18-year-old male recovering polydrug abuser
DifferentFamilyApproaches
Family therapists employ a wide variety of tools and tech-
niques to accomplish these goals once all family members
have been motivated to participate. The following are some
of the more common models.
FamilySystems Approach
This model explores and recognizes how a family regulates
its internal and external environments, making note of
how these interactional patterns change over time. Major
focus areas of this approach are daily routines , family rituals
(e.g., holidays), and short-term problem-solving strategies.
A drug or drinking problem is seen as an integral part of
the functioning of all members of the family, not just the
person with the problem . Some family systems therapists
use 12-step groups as part of their therapy, and many feel
that correcting family relationships corrects much of the
FamilyBehavioralApproach
This approach is based on the theory that interactional behav-
iors are learned and perpetuated by reinforcing the behavior.
The therapist works with the family to recognize those family
behaviors associated with drug use, to categorize the interac-
tions as either negative or positive in reinforcing the drug use,
and then to provide specific interventions to support and
reinforce those behaviors that promote a drug-free family
system. Specific strategies include couples sessions, home-
work, self-monitoring exercises, communication training,
and the development of negotiating and problem-solving
skills. Some couples enter into a documented behavior
change agreement.13° Some who use the behavioral approach
work more extensively with the nonabusing spouse.
FamilyFunctioningApproach
This approach classifies the family system into one of four
types and uses the therapeutic intervention that is best suited
to the functioning of that family system.
1. Functional family systems are those in which the fam-
ily of the addict has maintained healthy interactions.
Interventions in this system are targeted directly at the
addict. Other family members receive limited education
and advice to support the addict's recovery.
2. Neurotic or enmeshed family systems usually require
intensive family treatment aimed at restructuring family
interactions.
3. Disintegrated family systems call for separate yet inte-
grated treatment of addicts and their families. The fam-
ily may attend Al-Anon while an alcoholic is engaged in
an intensive medical detoxification program. Though the
addict is separated in treatment , this approach must be
integrated at some point into the common goal of main-
taining a drug-free lifestyle.
4. Absent family systems are those in which family mem-
bers are not available for treatment . Addicts estranged
from members of their family of origin often develop a
family of choice with people with whom they spend the
most time. Identifying and clarifying the roles of these
extended family members is important, and clinicians
encourage their participation in treatment .
Recent research showed that adolescents whose parents
engaged in family-centered interventions succeeded in
arresting or lessening their alcohol, tobacco, or marijuana
use and their problem behaviors as compared with adoles-
cents whose parents did not participate in treatment/preven-
tion interventions. 131
Social NetworkApproach
This approach focuses primarily on the treatment of the
addict and also establishes a concurrent and integrated
 Treatment 9.33

support network for family members to assist with the prob-

lems caused by the addiction. Through participation in mul- Cornered by Mike Baldwin
tiple family support or therapy groups , the family breaks 1-13 C2006 Mike Baldwin I OisL by Uriversal Press Syncflcate wwwcomered ccrn
cornered@comlc .com \_
their isolation and develops skills that help them support i~
the recovery effort of their addicted member.

Toughlove®Approach
Though controversial, this movement has grown on the
West Coast . The ToughLove ®approach addresses the biggest
obstacle: denial in both the addict and his or her family.
When an addict refuses to accept or deal with dysfunctional
drug-using behavior , family members seek treatment and
support from others experiencing similar problems. The
family learns to establish limits for their interaction with
the addict , which sometimes includes kicking the addict out
of the home and severing all contact until the addict agrees
to treatment.

Other Behaviors

"Eventhou9hit wasmq dad that drank'ti/he 9ot sicl

doin9the intervention
washarderforme than (orhim.
I knewhe deniedhisdrinkin9
. I didn't realizethat I did, too,
eventhou9hI didn'tdrinkmqselfand that I had almostas "Hello, my name is Roberto,and I will
manqproblemsas he did." be your enablerthis evening."
31-year-old adult child of an alcoholic
© 2006 Mike Baldwin. Pnntedby permissionUniversalUdick All nghtsreseived.

The stress of living with an alcoholic or a drug abuser causes

dysfunctional behaviors in nonusing family members. The
most prevalent conditions are codependency, enabling, and Enabling
manifesting symptoms caused by being children of addicts
If a family is dependent on the addiction of a family member,
or adult children of addicts.
there is a strong tendency to avoid any confrontation of the
Codependency addictive behavior and a subconscious effort to actively per-
petuate the addiction. This position is often upheld by the
Just as addicts are dependent on a substance, codependents
person who benefits most from that addiction-the chief
are mutually dependent on the addicts to fulfill some need
enabler. Although enablers may be disgusted with the addict
of their own . For example, a wife may be dependent on her
and the addictive behavior, they continue to pay off drug or
husband 's maintaining his addiction so that she can retain
gambling debts, pay rent, provide money, and continue to
her power over the relationship. So Jong as he is addicted,

I
emotionally support the practicing addict. Enabling is also
she believes she has an excuse for her own shortcomings
the result of misguided efforts to assist an addict. For exam-
and problems . This dysfunction fosters the addiction.
ple, the eldest child of addicted parents will take over all the
Codependency can also be extremely subtle, such as a
parental duties of caring for siblings in the erroneous belief
spouse 's offering a drink to his or her mate as a reward for
that he or she is helping the parents get better by assuming
a week of abstinence . In this kind of hous ehold, the chances
these responsibilities . Enabling actually results in deeper
of recovery are greatly reduced unless the codependents
addiction because it allows the addict to avoid facing the
are willing to accept their role in the addictive process
addiction for a much longer period of time. Like codepen-
and submit to treatment themselves. 132 · 133
dents, enablers must accept the role they play in this cycle
and seek therapy to be more effective in the addict's recovery.
"I wascleanfor 16 months.Mq husbandhad beencleanfor
onlqsixweeks.And I triedto showhimthat bein9clean-and- Childrenof Addictsand
soberdoes workbecausemq husband,he'snot an alcoholic,
AdultChildrenof Addicts
he basicallqjust smokescrack.And I thinkhe sawwhat the
proaramwasdoin9forme and that I wasn't9oin9to backout About 11 million children of alcoholics are und er the age of
or relap
se or buqdru9sfor him. [In the past] he wouldsit and 18 and about 3 million of those will eventually develop
thinkI would9et up and feelsorrq forhim and90, 'Okaq, alc,oholism, other drug problems , and serious coping prob-
honeq, qou're cravin9;let's9et hi9hto9ether
."' lems. 134These statistics also show that about three-fourths of
the children of alcoholics never develop an addiction and are
38-year-old recovering polydrug abuser
able to successfully manage their lives.
 9.34 CHAPTER9
Many children of addicts take on predictable maladaptive
behavioral roles within the family that "co" (codependent)
or enable the addict(s) in the family. These behaviors often
continue into their adult personalities. In addict families,
the roles taken on by the children are usually one or more of
the following.
• Model child. These children are high achievers and
are overly responsible. They become chief enablers
of addicted parents by taking over parental roles and
responsibilities.
• Problem child. These children get blamed for everything;
they have problems at school, exhibit negative behavior,
and often develop drug or alcohol problems as a way to
act out. Their behavior demands whatever attention is
available from parents and siblings.
• Lost child. These children are withdrawn , "spaced-
out, " and disconnected from their emotions and the life
around them. Often avoiding any emotionally confront-
ing issues, they are unable to form close friendships or
intimate bonds with others.
• Mascot child or family clown. These children trivial-
ize things by minimizing serious issues as an avoidance
strategy. They are well liked and easy to befriend but are
usually superficial in all relationships, including those
with their own family members.
Although children of addicts or alcoholics may not abuse
drugs, their behavior and emotional reactions can be as
dysfunctional as those of an addict. They learn early on that
they cannot control their parent's addiction, so they often
attempt to control every other aspect of their lives, leading to
strained and inappropriate relationships later in life.
Adult children of addicts or alcoholics:
• are isolated and afraid of people and authority figures
• are approval seekers who lose their identity in the
process
• are frightened by angry people and personal criticism
• become or marry alcoholics or find another compulsive
I
person to fulfill abandonment needs
• are more likely to give in to others rather than stand up
for themselves
• become addicted to excitement and stimulation
• confuse love and pity, and tend to love people who need
rescuing
• repress feelings from traumatic childhoods and Jose the
ability to feel or express feelings
• judge themselves harshly and have low self-esteem
• react rather than act 135-136
Adult Children of Alcoholics (ACoA) is a 12-step program
that helps people work through the emotional baggage that
followed them into adulthood. 137 ACoA and other similar
groups try to help members:
• understand the disease of addiction and alcoholism
because understanding leads to forgiveness
• put themselves at the top of their priority list
• detach with love
• feel, accept , and express feelings and build self-esteem
• learn to love themselves, making it possible for them to
love others in healthy ways
There is a growing sensitivity to the role of early childhood
and other environmental trauma in the development of
addiction. The new science of epigenetics furthers this cor-
relation. Trauma has been shown to change the structure
and the chemistry of the brain , resulting in a susceptibility
to addiction and other mental health disorders ; 90% of
substance-abuse and mental health patients report at least
one traumatic event in their life. uo
Trauma-informed care permeates the entire treatment
environment, including staff to create a stress-neutral envi-
ronment for clients so that they are less likely to experience
trauma that could lead to slips and relapses. This approach
differs from the confrontational, rigidly structured programs
that depend on solid boundary interactions to move addicts
toward accepting their addiction.
Trauma-focused care is a counseling approach that assumes
that clients have suffered deep and significant trauma in
their lives. Clinicians are trained to be less confrontational in
their therapeutic approaches. Many counselors , especially
those who are in recovery themselves, still believe that early-
recovering clients are so steeped in denial that confrontation
of their maladaptive addictive behaviors is necessary. Both
of these trauma-centered methods endeavor to end the
anachronistic practices that can retraumatize a client.
Another contemporary treatment innovation is the employ-
ment of a personal assistant or monitor for addicts to ensure
their continued and active participation in their recovery
program. A recovery coach is also known as a recovery
mentor , sober companion , sober escort, sober mentor,
recovery support specialist, family recovery coach, tele-
phone or virtual recovery coach, and legal support special-
ist recovery coach . This concept has created new professional
positions in addiction treatment. Credentialing bodies for
these designations have been created in states , requiring
formal certification to work in such a capacity.
Recovery coaches help addicts obtain abstinence or reduce
harm associated with addictive behaviors. They assist clients
in making decisions and help clarify the role that addiction
or recovery plays in their lives. Sober mentors also help their
addicts access treatment , education, family, social, voca-
tional, legal, and any other resources that may be needed.
These professionals require accountability to help keep

addicts focused on their recovery plans. Some coaches have
become specialists in specific drug or behavioral addictions
or for legal, family; or vocational issues.
A recovery coach or mentor should never make a diagnosis
of addiction or offer any primary treatment services.
Drug abuse and addiction along with behavioral addictions
have a negative impact on the addict's physical, emotional,
familial, social , and spiritual well-being . Addicts and alco-
holics suffer from higher rates of AIDS, viral hepatitis (A, B,
and C), heart disease, mental illness, emotional disorders,
and other physical and psychiatric illnesses. All of these
issues represent serious health and quality-of-life problems
for addicts. The traditional role of treatment has been to help
identify these various needs and then case-manage addicts
toward appropriate treatment or service providers.
Many treatment professionals believe that treatment that
effectively addresses all of these components through a com-
prehensive , integrated, and "wrap-around " service delivery
design within the same program results in higher positive
outcomes. Treatment campuses offering a variety of inte-
grated services, county mental health and substance-abuse
services departments merging into a single behavioral health
department , and the "any door " or "every door is the right
door " substance-abuse treatment access initiatives-all are
examples of this movement toward a single, comprehensive
addiction treatment system. The recently growing faith-
based or spiritual substance-abuse treatment initiatives are
also part of this movement . The U.S. Department of Health
and Human Services created the HHS Center for Faith-Based
and Community Initiatives to support nonprofit religious
and secular organizations with prevention and abuse and
addiction treatment.
Treating every issue that may threaten continuous recovery
or impair an addict 's quality of life increases the addict 's par-
ticipation , retention, and potential for ongoing recovery.
Additionally, many alternative and complementary treat-
ments improve treatment outcomes.
In today's environment of accepting only evidence-based
interventions, many of these practiced-based treatments
have been neglected, and most may lack only the fiscal or
scientific resources to become recognized as effective evi-
dence-based practices. Still, many of the following interven-
tions are gaining acceptance as evidence-based treatments .
• Arts therapies are designed to provide insight and relief
for deep-seated emotional traumas. Therapies include
creative arts, music, drama, psychodrama, and dance_l38
• Hypnosis helps the mind reopen and become receptive
to ideas and suggestions for recovery.139
Treatment 9.35
• Guided imagery uses the client's own imagination to
reopen the mind.
• Eye movement desensitization relaxation (EMDR)
involves the therapist 's audibly directing the client's
lateral rapid eye movements while processing stress
and trauma memories. Practitioners believe that the eye
movements create new memory networks. Controversy
exists regarding its efficacy.140
• Emotional Freedom Techniques such as tapping ,
Brainspotting, and EMDR, are counseling techniques
that incorporate aspects of acupuncture, Thought Field
Therapy, energy medicine, and neuro-linguistic pro-
gramming. Though it has not been shown to have any
therapeutic benefit other than a placebo effect121 or that
obtained from the counseling that was provided along
with the tapping and other procedures ,122 proponents
claim that these techniques are effective in treating
addiction craving, stress, PTSD, and other emotional
conditions .123
• Virtual-reality graded exposure therapy desensitizes
the addict to environmental cues by inducing crav-
ing through increasing levels of virtual drug cue stim-
uli and then employing cognitive therapies to prevent
responses. 14 1
• Acupuncture (especially auriculotherapy) has a 2,500-
year history of treatment for a variety of medical condi-
tions. The technique employs the placement of needles
using pulse diagnosis in one or a combination of some
12,000 points located along 12 to 16 body meridians to
unblock "chi, " or one's vital energy force. The needles
are then stimulated manually; electrically, or with heat.
The use of acupuncture to relieve drug withdrawal symp-
toms and reduce craving increased once it was found to
reduce opium withdrawal symptoms in the 1970s. 142 It
is hypothesized that acupuncture works by stimulating
the peripheral nerves, which then send messages to the
brain to release natural (endogenous) endorphins that
promote a feeling of well-being. 143 Acupuncture has also
been shown to alter levels of other neurotransmitters ,
I
specifically serotonin and norepinephrine , as well as the
hormones prolactin, oxytocin, thyroxin, corticosteroid ,
and insulin. 144•145 In addition to use for opioid detoxifica-
tion, acupuncture has been used to reduce craving for
alcohol and stimulants with varying results 141 and is not
effective when used as the sole treatment or modality. It
can also be used with detox medication. 146 Acupuncture
is not a replacement therapy for other modalities , and
it adds an additional therapeutic cost to the treatment
process. Effects last for a short time, often requiring
frequent treatments to relieve symptoms during detoxi-
fication and initial abstinence. Auriculo acupuncture
focuses on the many acupuncture points located on the
surface of the outer ear.
• Nutrition/amino acid precursor loading and mega-dose
vitamin therapy may help prevent cravings and addic-
tion relapses. This belief is based on a high volume of
anecdotal reports and Internet chatter about the use of
 9.36 CHAPTER 9

nutritional and orthomolecular interventions. Based on
discoveries of addiction-related neurotransmitter imbal-
ances (allostasis), there is some evidence that using
amino acid and protein supplements can rebalance the
neurotransmitters depleted by addiction quickly enough
to prevent cravings. 147 SAAVE (Special Amino Acids
and Vitamin Enteral), TrophAmine, ® ReNew,® and
Rescue ® are some of the many proprietary products
containing a combination of vitamins and amino acids
targeted to restore the balance of brain neurotransmitters
(homeostasis).
Individual amino acids for specific neurotransmitters
are also used:
• DL-phenylalanine for endorphins/enkephalins,
epinephrine, and dopamine
• L-tyrosine, tyramine, or taurine for norepinephrine
and dopamine
• L-tryptophan or 5-hydroxytryptophan (5-HTP) for
serotonin
• gamma-amino butyric acid (GABA) for GABA
• L-glutamine for GABA
• lecithin for acetylcholine
Empirical research has yet to fully validate the supposi-
tion that amino acid and vitamin supplements result in
increased levels of brain neurotransmitters. 141
• Herbal therapy involves the use of various herbs to treat
specific substance addictions . A vast number of histori-
cal and anecdotal reports can be found in journals and
on the Internet. An evaluation of clinical trials and neu-
rochemical mechanisms describing the action of tradi-
tional herbal remedies and acupuncture for treating
various drug addictions concluded that these treatments
can complement pharmacotherapies for drug withdrawal
and possibly relapse prevention with less expense and
perhaps fewer side effects, albeit with some notable
exceptions. 148
Herbal remedies for specific addictions include
• Ginseng (Pana.x quinquefolius, P ginseng) is used for
opiate and stimulant addictions .
• Passionflower (Passiflora incamata) is used for anxi-
ety and opiate addictions (with clonidine).
• Heantos (#1 for withdrawal symptoms, #2 for sleep,
and #3 to prevent recidivism, taken daily for six
months)-a Vietnamese tonic comprising 13 herbs, is
used to treat heroin addiction over three to five days .
• Homeopathy dilutes traditional medications or remedies
to treat addictions . This is thought to reduce withdrawal
symptoms and cravings in addiction by jump-starting or
mobilizing the body's own rebalancing mechanisms. 149
• Nootropic or "smart" drugs allegedly enhance mental
nor-
functions such as memory and rebalance the brain to
promote recovery (e.g ., piracetam, hydergine, and Ginko
biloba for cocaine addiction).
• Brainwave biofeedback, or neurofeedback, is another
option . Addiction has been correlated with abnormal
alpha and theta brain wave activity Addicts learn various
relaxation techniques to help them generate rhythmic
alpha or slow theta waves to help deal with cravings and
withdrawal stress. 150
• Somatic psychology and dance therapy uses posture,
movement, and breathing to better integrate mind and
body to manage drug cravings and prevent relapse. Dance
therapy is also a form of somatic psychology that incor-
porates breathing and posture into dance movements .151
• Mindfulness meditation is a Buddhist practice that
uses the breath to bring the mind to a state of present
awareness . Nonjudgmental, passive acknowledgment of
one 's thoughts and environment are part of the practice.
Meditation has been shown to decrease stress, improve
mood, and boost immune function-all helpful in main-
taining drug abstinence and recovery from addiction. 152
• Qigong is a movement and meditation practice intended
to unblock energy channels in the body responsible for
illness and negative body symptoms. It is also the seem-
the ingly paranormal practice whereby a qigong master proj-

I
following.
• Kudzu (Pueraria lobata; Radix puerariae) is used alone
or combined with St. John's wort for alcoholism .
• Ashwagandha (Withania somnifera) is a sedative used
to treat opioid withdrawal. It is used in Ayurvedic
medicine, an alternative medical practice based on
5,000 years of traditional Indian medical practices. 141
• Aristeguietia discolor is a Peruvian herb used to treat
opioid withdrawal.
• Kava (Piper methysticum) is used for anxiety, insom-
nia, and opiate and methamphetamine addictions.
• Valerian root (Valeriana officinalis) is used for anxiety,
sleep, and alcohol and stimulant addictions .
• Milk thistle (Silybum marianum) is used for liver con-
ditions and nicotine and alcohol addictions.
• Saint-John 's-wort (Hypericum peiforatum) is used for
depression and alcohol and stimulant addictions.
ects his own energies into others to assist in the healing
process of those being treated. Although considered curi-
ous by some standards, there is research documenting the
fact that laboratory mice and rats suffering from tumors
or morphine withdrawal have been positively influenced
by qigong therapy.141.m. 1s4
• Hatha yoga uses body positions and breathing practices
to prepare the body for mindfulness meditation, which
aids in preventing drug cravings and relapse .m
• Equine or pet or animal therapy involves animal-assisted
psychotherapy, which leads to an increase in a client's
sense of responsibility, communication skills, trust , self-
esteem, confidence, patience, and cooperation and pro-
vides a positive alternative to using substances to alter
states of consciousness. For these reasons, incorporating
this type of therapy into addiction treatment curricula is
on the rise even though there are no definitive studies on
the efficacy of these programs. 156

• Aromatherapy therapy uses essential oils extracted from
herbs and plants for inhalation or absorption through the
skin to relieve stress and instill feelings of calm and well-
being. It is said to support emotional balance in recover-
ing addicts . More than 40 essential oils are used to treat
various medical conditions; and though aromatherapy is
often mentioned in various complementary or alterna-
tive holistic treatments for addiction, very little empirical
research exists to either verify or invalidate its efficacy.
• Sensory deprivation, or restricted environmental stim-
ulation therapy (REST), intentionally removes stimuli
affecting one or all five of the human senses . The patient
is placed in a "chamber" (a bed in a darkened room with
sound reduction for 24 hours) or in a flotation tank (a
small chamber filled with an Epsom salts solution at
body temperature; the patient floats on his or her back
in the dark with sound reduction for one hour). Sensory
deprivation therapy is said to promote meditation and
relaxation, preparing patients for better receptivity to
other types of therapy; it has shown promise in the treat-
ment of nicotine, alcohol, and other drug addictions .
A University of Arizona study found that 43% of patients
who participated in "chamber" REST in addition to their
outpatient substance-abuse treatment were able to main-
tain abstinence for four years compared with addicts in
the control group, all of whom were unable to maintain
more than eight months of recovery. 157 A Washington
State University study found that a short-duration (two-
hour) REST session combined with anti-alcohol educa-
tion reduced consumption of alcohol by 56% in the first
two weeks after treatment . Reduced consumption was
maintained for three and six months post-treatment as
verified by follow-up surveys. 158 For smoking cessation,
25% of patients exposed to REST achieved abstinence for
one to five years after completing treatment; 50%
achieved long-term abstinence when REST was com-
bined with other effective smoking-cessation therapies;
and an impressive 80% remained in long-term abstinence
when weekly support groups were attended after the
REST procedure. 159 Patients with hypertension, heart or
kidney disease, or serious medical conditions and those
with claustrophobia and certain psychological disorders
should not participate in REST procedures.
PolydrugAbuse
Experiences at treatment centers across the United States
show that although addicts may identify their drug of choice,
they are more often than not polysubstance abusers who are
using a wide range of substances either concurrently or
intermittently. The profile of an alcoholic, for example, often
includes the use of sedatives, methamphetamine, cocaine,
marijuana, and opioids in addition to the abuse of alcohol.
Treatment programs must be aggressive about identifying
the client's total drug profile. Heroin addicts often minimize
Treatment 9.37
or lie about their use of alcohol, though their drinking may
be at a more problematic level than their use of heroin.
Many substance abusers also practice a behavioral addic-
tion like gambling, compulsive eating, or Internet addic-
tion simultaneously with their drug use or sequentially
during their recovery.
"I have cleaned up off of dope though I've been a drug addict
for 23 ~ears.And I have no desirewhatsoeverto do drugs, but
alcohol is still there and I drinkout of boredom."
42 -year-old recovering heroin addict with AIDS
A study of twins found high levels of comorbidity for abuse/
dependence for six different substances (marijuana, cocaine,
hallucinogens, sedatives , stimulants, and opiates) and only
low levels for single substances. Each twin's environment-
rather than heredity-was more influential in the specific
drug of choice . 160 Addiction must be addressed as chemical
dependency rather than a drug-specific problem. Treatment
is effective when it promotes recovery, prevents relapse, and
prevents a switch to alternative drug addictions.
'The cravingswerejust continuous. It was just like if I was
off
coming speed, I wanted heroin. If I was comingoff heroin, I
wanted to snort cocaine;and if I was comingoff that, I wanted
to sta~ numb. I wanted to just go from one drug to another."
38 -year old recovering polydrug abuser
Although the roots of different drug addictions are similar ,
each drug still has unique effects and problems that should
be specifically addressed.
Stimulants
(cocaineand amphetamines)
Amphetamine abusers are more likely to be male, White,
and gay or bisexual. They are also more likely than cocaine
abusers to engage in unsafe sex, share needles, be HIV-
positive, have a psychiatric diagnosis, and take psychiatric
I
medications. 161 Both cocaine abusers and meth abusers have
similar adherence to treatment protocols and recovery rates,
suggesting that one stimulant-abuse program would proba-
bly be appropriate for both groups . Both drugs impair cogni-
tive ability, which necessitates a slower pace during early
treatment. Methamphetamine abusers have more trouble
with tasks requiring attention and the ability to organize
information. 162
The profile of the typical adolescent methamphetamine
abuser in the U.S. during the first decade of the second
millennia was a 17-year-old White male who lives with
both parents; he first tried meth at age 12 .6, is an under-
performer in school, and does not think the drug is harm-
ful to his health. An equal if not slightly greater number of
younger users (eighth- and tenth-graders) and those in some
parts of the West (especially Hawaii and Southern California)
are female . 163 Stimulant abuse crosses all ethnic and social
lines . The vast majority of known users in Hawaii are of
 9.38 CHAPTER 9
Asian or Pacific Islander decent. There is also a high inci-
dence of abuse among gay males in the San Francisco Bay
Area. Mexico is experiencing a rapid growth in abuse of
methamphetamine , and some counties in California are
seeing a significant population of Hispanic abusers .
Annual U.S. treatment admissions for cocaine abuse in the
first decade of the second millennia averaged about 256,000
but decreased from a high of 268,240 in 2005 to 148,151
in 2010. This was only 8.1% of the 1.821 million treated
for substance-abuse problems in 2010, the most recent
data available. Of those treated for cocaine addiction, 71.5%
were primarily abusing smokable or "crack " cocaine.
Additionally, 113,625 people were treated in 2010 for stimu-
lant abuse (primarily methamphetamine) , or about 6.2% of
all substance-abuse treatments. 78 -' 64
A wide range of drug-induced psychiatric symptoms often
accompanies stimulant abuse . Acute paranoia, schizophre-
nia, major depression, and bipolar disorder are often the ini-
tial presentations by a stimulant addict, particularly at the
end of a long run. These symptoms require psychiatric
intervention to prevent harm and to assess whether they
are caused by the drug itself and if the mental illnesses are
pre-existing and will pose a problem after detoxification and
initial abstinence .
Symptoms of cocaine or amphetamine abusers who are
detoxifying are prolonged craving, anergia (exhaustion),
anhedonia (lack of an ability to feel pleasure), and euthymia
(a feeling of elation that occurs three to five days after stop-
ping use) .165 Euthymia makes users believe that they were
never addicted and therefore do not need to be in treatment.
Anergia and anhedonia begin to overtake the euthymia about
two weeks after starting detoxification, and these feelings,
particularly the total lack of ability to feel pleasure , often
lead to relapse .166
Detoxification and Initial Abstinence
After detoxification and treatment for any psychotic and life-
threatening symptoms, such as extremely high blood pres-
sure , high body temperature , high and irregular heart rate ,
I
and seizures, the majority of stimulant abusers respond
positively to traditional drug-counseling approaches.
Evidence-based best practices have demonstrated that
cognitive-behavioral therapies and behavioral therapies like
the Matrix Model (methamphetamine treatment protocol)
along with 12-step-oriented individual counseling are useful
for cocaine- or stimulant-abuse treatment. 167
Stimulant addicts who do not initially respond to these
traditional approaches require a more intensive medical
approach to bridge the detoxification/withdrawal period
prior to their engagement in recovery . No medication has
yet received Food and Drug Administration (FDA) approval
for the treatment of cocaine or methamphetamine depen-
dence, although several are in FDA investigational new drug
development.
A variety of drugs treat the symptoms of stimulant detoxi-
fication and initial abstinence.
• Antidepressant agents, such as SSRI drugs like fluox-
etine (Prozac ®), paroxetine (Paxil ®), sertraline (Zoloft ®),
and citalopram (Celexa ®), are often used to treat low
serotonin levels brought about by the abuse of stimu-
lants . Other antidepressants that affect norepinephrine
and dopamine as well as serotonin-such as imipramine
(Tofranil ®) , desipramine (Norpramin ®), and newer ones
such as mirtazapine (Remeron ®), nefazodone (Serzone ®),
venlafaxine (Effexor®), bupropion (Wellbutrin ®), and
ritanserin (Tisterton ®)-are also being used to treat stim-
ulant drug addiction .
• Monoamine oxidase inhibitor type B (MAO-B) drugs are
used to treat depression by preventing the metabolism
of the brain 's stimulatory neurotransmitters . They are
used to boost the action of the low levels of dopamine,
adrenaline, and noradrenaline brought about by abuse
of stimulant drugs. Their use is limited due to the toxic
effects that occur with a variety of drug and food interac-
tions. This dangerous interaction with food is somewhat
less likely to occur with MAO-B compared with previous
MAO medications .
• Selegiline (Eldepryl ®) is being studied to treat cocaine
and amphetamine addiction.
• Antipsychotic medications are used to buffer the effects
of unbalanced dopamine during the toxic phase of
cocaine abuse known as "tweaking, " which can mimic a
psychosis. These drugs include risperidone (Risperdal ®),
olanzapine (Zyprexa ®), ziprasidone (Geodon ®), que-
tiapine (Seroquel ®), haloperidol (Haldol ®), and oth-
ers. These are also called neuroleptic medications . The
strong sedating effects of quetiapine have recently led to
its abuse .
• Sedatives are carefully prescribed for short-term treat-
ment of anxiety or sleep disturbances. These include
phenobarbital, chloral hydrate, buspirone (BuSpar®),
and, less often, flurazepam (Dalmane ®), chlordiazepox-
ide (Librium ®), and diazepam (Valium®) .
• Nutritional approaches aimed at enhancing the produc-
tion of neurotransmitters that were depleted by heavy
stimulant use help decrease craving and counteract many
of the withdrawal symptoms seen in stimulant addiction.
Tyrosine , phenylalanine, and tryptophan are proteins
used by brain cells to manufacture the dopamine, adren-
aline, and serotonin depleted by stimulant abuse . Studies
have not yet proven their effectiveness.
• Dopamine agonists like bromocriptine (Parlodel ®),
amantadine (Symmetrel ®), and levodopa (combined with
carbidopa in Sinemet ®) activate the dopamine receptors
in the brain to suppress withdrawal symptoms and ini-
tial craving for stimulants. Abuse of both cocaine and
amphetamines depletes brain dopamine levels, which
results in craving and other symptoms of withdrawal.
Disulfiram (Antabuse ®) has long been used to treat alco-
holism and has been found to block the metabolism of
dopamine to norepinephrine and is being used to treat
stimulant drug addiction as well.

• Anti-epileptic seizure drugs like topiramate (Topamax®),
carbamazepine (Tegretol®), tiagabine (Gabitril®), and
vigabatrin (Sabril®) increase the brain 's GABA activity
or decrease its glutamate; both decrease stimulant drug
effects and reduce craving.
• Naltrexone (Revia® and Depade®) is FDA approved to
treat opioid addiction and alcohol craving; it has been
found to decrease craving for stimulant drugs as well.168
• Others include modafinil (Provigil ®), a stimulant drug
used to treat narcolepsy and sleep disorders, and a wide
variety of medications used to treat attention-deficit
disorders , including amphetamine itself; these are used
to treat stimulant drug abuse analogous to methadone
replacement therapy in the treatment of opiate drug
addiction.
Long-TermAbstinence
Much research is currently focusing on the treatment of
craving, particularly stimulant craving . To counter endoge-
nous (internal) craving, believed to be caused by stimu-
lants' depletion of dopamine activity, many of the
medications mentioned here have been used to stimulate
dopamine release. Acupuncture also stimulates dopamine
release. Animal research suggests that the dopamine imbal-
ance may persist for several months to years after cessation
of cocaine or amphetamine use. 169
Environmentally triggered craving is particularly intense
in stimulant addiction. It is more likely than endogenous
craving to lead to relapse and must be treated with intense
counseling, group sessions , or desensitization techniques.
This type of craving may last a lifetime, but evidence indi-
cates that continued abstinence from stimulants weakens
the craving response_l7°
In one NIDA investigation of 1,600 cocaine-dependent
patients with moderate-to-severe problems, researchers
found that a minimum of three months of treatment was
needed to achieve long-term results ; eight months of treat-
ment was the most effective.
Cocaine aversion therapy is a recent and interesting strategy
to treat cocaine dependence. Disulfiram (Antabuse ®) is
used to induce aversive physical consequences if cocaine is
used (similar to the way it is used to treat alcohol depen-
dence). Disulfiram, the oldest FDA-approved addiction
treatment drug, induces aversive effects-increased heart
rate and blood pressure, anxiety, paranoia, and restless-
ness-when taken simultaneously with cocaine . This effect
has been shown to reduce cocaine use by those in cocaine
recovery treatment. Although many cocaine abusers also
abuse alcohol, the cocaine effect has been shown to be unre-
lated to its effect on alcohol metabolism . Researchers specu-
late that both disulfiram and cocaine increase dopamine
effects at a number of locations in the brain , resulting in a
synergistic action of negative symptoms. Early research also
indicates that the adverse effects occur more in men than in
women_ 111,112,1n, 1H
Treatment 9.39
"I wentinto a recovenihouseaftera hospitalproaram,where
for
I lived ei9htmonths. And I went into an outpatient
pro9ram,and I did threemonthsof intense, pve-hours-a-daq
9rouppsqchotherapqand individualcounselin9,and I staqed
for
in aftercare a qear,and I had randomurinalq sis twicea
week... .And all of thosethin9s,everqsin9leone of thosethin9s,
wasa pillarthat supportsthe foundationof mq recoverq ."
34-y ear-o ld recovering methamphetamine addict
Tobacco
Today more drug and alcohol treatment centers are includ-
ing nicotine addiction treatment as part of their program.
Many believe that full recovery from addiction is made more
difficult if the recovering client remains a smoker . The tradi-
tional view has been that giving up tobacco might hinder
recovery from more-dangerous drugs; however, recovery
rates improve among those who also give up smoking .175, 179
More than 80% of alcoholics and drug addicts smoke com-
pared with 25% of the general population.
The only guaranteed way to prevent a tobacco addiction is
never to smoke, chew, or use it in any form . Abstinence is
essential because many of the neurological and neurochemi-
cal alterations that cause nicotine addiction are permanent,
so even 10 years after cessation of smoking, a single cigarette
can trigger the nicotine craving, leading to a relapse.
The failure rate for most smoking-cessation therapies is
extremely high. About 70% of all smokers want to quit , and
46% try each year. 180 One well-conducted study found that
the six-month-or-longer tobacco abstinence rate after treat-
ment was only 8.5% in young adults 18 to 24 years and 5%
in older adults 35 to 65.128 In the past, treatment focused on
the immediate psychological components of the smoking
habit. That approach did not fully take into account the life-
time nature of nicotine addiction and therefore recovery. The
average smoker seriously tries to quit five to seven times
before succeeding. Applying short-term fixes (e.g., 21-day
smoking-cessation programs) to a long-term problem does
I
not eradicate the addiction .
In recognition of the very real alterations in brain chemistry
that trigger nicotine craving during withdrawal , the treat-
ment community is now focusing on pharmacological
treatments . The five-month success rate with the various
pharmacological treatments in one study were: nicotine
patch , 17.7%; nicotine inhaler, 22.8%; nicotine gum , 23. 7%;
bupropion SR (Zyban®), 30.5%; nicotine spray, 30.5%; and a
combination of two or more, 28.6%.180 Nicotine lozenges
had about the same success rate as nicotine gum in British
studies. 18 1 Varenicline (Chantix ®), approved for nicotine
addiction treatment in 2006, had a 44% initial success rate
in Europe and a 22% to 23% sustained (up to one year)
nicotine abstinence efficacy.182 ,183
Nicotine ReplacementTreatment
The main mechanism that causes craving is the drop in
blood levels of nicotine that then triggers withdrawal
 9.40 CHAPTER 9
symptoms (such as irritability, anxiety, drowsiness, and light-
headedness). Nicotine replacement systems address that drop
by slowly reducing the blood plasma nicotine levels to the
point where cessation does not trigger the severe withdrawal
symptoms that frequently cause the smoker to relapse .168 ,184
This pharmacological technique, called antipriming, uses
low, controlled dosages of a substance, which prevents
withdrawal but does not reinforce the addiction.
The six types of nicotine replacement systems are transder-
mal nicotine patches, nicotine gum, nicotine sprays, nico-
tine nasal inhalers, nicotine lozenges, and electronic
cigarettes. All of these systems protect a user's lungs from
exposure to the 4,000 damaging chemicals found in cigarette
smoke; this alone could save almost 200,000 lives per year in
the United States. Unless relapse prevention, counseling ,
and self-help groups are used in conjunction with nicotine
replacement therapy, the chances of a smoker 's returning
to old habits are high . 185
Nicotine Patches By 1999 all four FDA-approved nicotine
patches (Nicotrol,® Nicoderm CQ,®ProStep,® and Habitrol®)
were available as over-the-counter (OTC) or non-prescrip-
tion medications. These nicotine-infused adhesive patches
are applied to the skin and can be worn intermittently (day-
time only) or continuously. Most contain enough nicotine to
last 24 to 72 hours. The advantages of patches are the
steady rate of release of nicotine, the ease of compliance,
and the lack of toxic effects to tissues in the mouth, lungs,
and digestive track. The disadvantages are the cost, the
inability to alter the amount being absorbed, and the four to
six hours it takes for a patch to raise the nicotine level
enough to dull nicotine craving. If the user smokes while
wearing a patch, extremely high and dangerous plasma
levels of nicotine can result.
Nicotine Gum Nicotine gums, such as Nicorette,® slow the
rise in nicotine levels; the IO-second nicotine rush of an
inhaled cigarette is replaced by the 15- to 30-minute slow
rise that nicotine gum provides when absorbed through the
gums and other mucosa! tissues. A slower rise means that
the craving, triggered by the sudden drop in nicotine levels
I
after smoking, is eliminated. The 15- to 30-minute rise is
considerably faster than the four to six hours it takes for a
transdermal patch to work, so the user has more control over
the dose. The disadvantages are improper dosage (chewing
more than one piece at a time or not using it at all), irritated
mucosa! tissues, and maintaining an oral habit by putting
something in the mouth when the craving hits or to calm
agitation.
Nicotine Nasal Spray Nicotrol® nasal spray is self-adminis-
tered, giving more control to the user; it reaches the brain
in three to five minutes, providing quick relief of the nico-
tine craving. Disadvantages include irritation to the nasal
passages and reinforcement of nicotine addiction.
Nicotine Inhalers The Nicotrol ®inhaler gives the fastest relief
for nicotine craving without delivering any of the toxic
chemicals present in cigarette smoke. Misuse can produce
plasma levels similar to those produced by smoking, thereby
perpetuating the addictive process.
With 4 7 million Americans addicted to cigarettes,the potential
market for devices and drugs to control craving is huge. Some have
been approved,some have not. The latest battlegroundis the electronic
cigaretteor e-cigarette,a device to deliver a vaporized solution
containing nicotine through a heated elongatedtube resemblinga
cigarette.The FDA claims it is a drug/drug-deliverydevice and wants
it regulatedor banned. Others claim it is merely another hind of
nicotine delivery system.
© 2011 CNSProductions,
lnc.
Nicotine Lozenges Ariva® mint-favored tobacco lozenges con-
tain up to 60% powdered tobacco (1 mg nicotine), making
them more of a source of nicotine when one is in a
smoke-free environment (e.g., a long airplane flight) than a
smoking-cessation product. These were marketed without
FDA approval as a tobacco product before the American
Medical Association and other groups filed a petition with
the FDA to regulate the product along with nicotine water.
Electronic Cigarettes The vaporization of various nicotine
solutions via a battery-powered heating device is the newest
strategy for nicotine replacement. These devices have
exploded onto the market and as of 2014 have not been
researched, regulated, or controlled. Independent studies
suggest that e-cigarettes may be as effective or better than
other replacement products in promoting smoking cessa-
tion. "Vaping" also offers the behavioral advantage of satisfy-
ing the ritual of holding a cigarette and puffing on vapor
because the action replicates smoking an actual tobacco
cigarette. 176 •177 The health and environmental dangers of
these products have yet to be evaluated. 178
Treatingthe Symptoms
The purpose of symptomatic treatment is to reduce the anx-
iety, depression, and craving associated with nicotine with-
drawal that trigger relapse . Varenicline (Chantix ®) and
bupropion (Zyban®) are the only FDA-approved medica-
tions to treat nicotine withdrawal and craving, but a num-
ber of other medications are being used for these indications.
Benzodiazepines, buspirone, fluoxetine (Prozac ®) or other
antidepressants, mecamylamine, propranolol, naltrexone,
and naloxone have been used to help alleviate the symptoms
of nicotine withdrawal. Clonidine, ® often used to control
symptoms of heroin or alcohol withdrawal, has also been
used effectively to control withdrawal from nicotine. 168 ,186
Treatingthe Behaviors frequrntlytoprovidelong-tennuplacemtnttnatmtntfor
Mostbehavionlthaapie, (CBT,moti v..tioruol<nh m cement opioid dqxndene< . l'rognm, •lso use clonidin<--<SOm<•
timesrombinedwithpromethuine,h)..Jroxyzin e, b<ruodi -
the r.tpy, •nd brid th <r.tpy ) u«d fo, ,moking ""'°"-tion
.,<p ines, a nticholinugic,i, non -steroi cbl•nti -inO.mmatory
includeon e-on-<inecoumeling,groupther:,py . education•I
•pproache,,"'"<nionther•py,hypnotiom.mdocupuncture drugs,ormildopio id-lik<medications(e .g. Tr:a~ ol 0 )-t o
maragethe,ymptom,olopioidwithdnwal•ndd<toxif)'the
Theseha,.,•one-yn. r"'1CC<••n«ofl5%to30% .withth e
oddict.Addicabecomele,sfem'u l ofwithdnwal a ndape -
butn,ultsachi<vedwhrnrombinedwithphannacologi -
calint<n'<n tions.M •nyofthetechn ique,u .,din,timu lmt - rirn cele .. painduringwi1hdr.tv.,. l.wh ichencoung<>them
tos Loyintre atment.Lofexidinemdoth<Tmti -hyput<nsive
•bu«ucovery>t<diT<Ctly•pplic•bletom,okingce,<ation
medic •tiono,i mibr toclonidine•r< >l,o llOM fo,op ioid
• de«mitllingthe ,mokertornvironmrntolcue, thot d<toxification.Rapidopioidd<toxilication•ndane.,heoia-
triggac,...,.;ng n,i.,,dultnra pidopioiddetoxificationwith naloxone(or
• rractkingilt<Truitivem<thod•oFcalmingoneselfwhen
undastressorgoingthroughwithdnwal ~::;t::::~7,:,:;;:,c~:i:~;,.:;.::n~<i°~;.'o";:
• • voidingenvironmentsandsit u.otions whu,,mokingis 6cation.,nteg:iesForopioiddeperuknce. "'·' '"
r:,mp,mt
• findingoth<T""')"of getting the sma ll ru,h oTmild
euphorult hat nicotinepro,ide,
• educatingthem,oku•bouttheph}-.iologyofn ico tine
:'.,':ac";!•ddiction•ndthemedic•lcon«qurncnofusing

• informing the,mokuoftheatr.tordiruoryb<nefil5o l
quitting "'

Opioids InitialAbstinenceand Long-TermAbstinence

A long-lHti ng opioid antagonist, ,uch H noltnxone
Thtmajority(61.1%)ofU.S.trn.tmtnt•dmissionsforopi - (ReVia", Depade " •ndVivi tro l'), i,usciafterd<toxilica -
oid •buse in 2OlO list heroin H the prlmary drug of t' ntorn,uu a: ti ncebecause·1decra""rn · ~' th
•bn-256~outofi!J,i27opioid•dmi,.ion,. "-' .. drugand a lso blocksop ioiclsfromacti,,.ting br.tinc,ll,
Butthegrut'ncr<a«'nttt.a.tmrntadm' · r ' ,th , ·. Vivitrot,• a ninj<cuble30.dayatended -T<l,..,fo,mofn.al -
ot<>. ,ynthetics . •ndnon -prescribedm<tladonefroml8.326 trexone for •kohol oddict ion 1reotmrnt, now been
inl000tol57.l7lin2O10gfrucredence tothebelidthat •ppro ,,edtottt.a.topioid•ddiction n well . Depo-ruoltrexone,
th eU nitedS Lotesioe,q><riencing • >ittualepide micol minjecublepelletthatcmprovideodequ.otebloodlev,ls
divuted pre,cription opioid P"in medi cations of •bu« ."' oln.altrexone lorthru months to ttt.a.topioidor >lcohol
MostheroinabuO<T!loc caoioruollyu«pre,criptionopioiclsto dq,endrnc,,i,indev<lopm<nt. '"
prevmtwithd nwal or u• heroin,ubstitute.Tho,.ewholist
Lik<•lltr<Catmena,initialandiong-tennabstinence•honld
othadrug, .. theirprimarydrugof•bu«frequ<ntlyliot
beoupponedbypanicipationinindividu.olrounseling""o-
divutedpr<>eriptionopioicls••<h<irsecondaryorteni>ry
•ions,groupS< .. ions,or«lf-helpgroup••nchHNurotics
drugo l• buse
Anonymou, . Behavior.t i ther•pies like CBT, moti,c,t io""I
Alo ng 'thtratmen·' ,·c.ti,eadd' fen.treatment< rnhancem<nl. contingency ""'""gem<nl . p,ychodynamic
opioid•ddictionha,thehighestnteofr<ebp,ep.utiolly p,ychother:1py,•ndfamily1herapyhavebernu«deffective ly
btt • n0<ephysicalwithdnw.:tFromopioiclsismoT<.....,,.. to tr<at op ioid •ddiction ." ' During the fo~t four to eig ht
tlun withdnwlll from otimnl•nts or m.orijuorut. For this wttt.s '•.,,:nence, cb'lyattend•nce at trn.tmtnt .., ..
r<a,onmootopioid•bu..,,.deoirl ngreroveryc-tobe • ns ·, cruc· Ito ma'nu·n ·ng a dru~-• ,tat< lot<ron,
in• dttoxi6cotion OTmedical tn>tmtnt program. lleau,e wh<nth ecnv! ngbecom<Sthestrongut . Ass uc=sfultrut •
8J%ofodm i,. ion ,fo, injectiondrur-,abu«ttt.a.tmrnlw<r< m<ntcont'nues,r ,., .. ·ons>r<n<C<Mar)'.
opi>te >bUS<TS,addition.alhe>lthproblem,duetonecil e-
bome infection, rompl ic•t< th e n,covay proce,s _• Recovery
Opioid • ddiction is time-consuming and in,'OlV<S m:tn)'
Detoxification .. pectsof•person'slife.ThekeytoT<COvayi,learni ng
Methadone , u.AM (no longer ._ .. it.bl< in the United •new lifestylt. Addicts must exchange •lifeolnodding
Sutes ), mdbupunorphine•retheFD A....ppro,=lmedic• - olf,scnmbl ingtosupponan,xprnsive habit,andworry -
tion,foropio idd<tox ification . Thesedrug,canbesub"i • ing•boutinfect ion,from,haringneedleoto•lifeofenjoy -
tut«! for heroin or •notha opioid being abused •nd ingactivitiesthatdonotin,'Olveusing .l earninghow to
gnduolly upeud to minimi« withdn.wlll fOTdetoxifica- :::i!::ineulat ion ,hip,, md «ei ngpot<ntialin theiT
tion thenpy. The0< mtdications ar, being used mon
 9.42 CHAPTER 9
"I'm not used to havinga room. For the past two ~ears,I was
on the streets. I spent $200 a da~ on heroinand couldn't even
manageto find enough mone~to get a room at the end of
the night. That's prett~ sick. I've neveractual/~had a checking
account and such becauseI started usingand dealingheroin
when I was 12 and I alwa~shad to hide m~ finances."
42 -year-old recovering heroin addict
Other Opioid Treatment Modalities
Methadone, LAAM, and buprenorphine have FDA approval
for opioid detoxification as well as for opioid replacement
therapy.
Methadone The concept of opiate or opioid substitution has
spurred controversy ever since morphine addiction became a
problem in the nineteenth century. The large number of
morphine addicts after the Civil War caused the number of
opiate maintenance clinics to multiply. The practice of using
opiates to treat opiate addiction (morphine was used to treat
opium addiction in China, and heroin was used to treat mor-
phine addiction in Europe) ended in the United States
(though it continued in England and other countries) in the
1920s and was not revived until methadone maintenance
was developed in the late 1960s in New York City by Dr.
Vincent Dole and Dr. Marie Nyswander. 189 •190 This treatment
modality eventually spread to hundreds of methadone main-
tenance clinics nationwide in the 1970s and 1980s . By 2009,
1,200 methadone maintenance clinics provided treatment
for about 260,000 opioid addicts . 191
The rationale for methadone replacement therapy is that
methadone, a synthetic opiate less intense than heroin, is
longer lasting, which prevents the user from having heroin-
like withdrawal symptoms for 36 to 48 hours. Heroin, on
the other hand, causes withdrawal symptoms in a just few
hours, so the user experiences a roller coaster of highs and
lows and the pain of withdrawal on a daily basis .192 Balancing
the dose of methadone requires constant monitoring for
symptoms of withdrawal. Because methadone is more ame-
I
nable to oral ingestion, its use eliminates many of the medi-
cal problems caused by injection. Once the dose is stabilized,
methadone should no longer be sedating, allowing the
maintained addict to work and more fully participate in
counseling and other activities.
Methadone maintenance eliminates the highs and the lows
that promote addiction. The user does not have to hustle for
money to pay for a habit, search the streets for drugs and
needles, or be exposed to a high-risk lifestyle. With HIV and
hepatitis C infection rates in intravenous (IV) heroin users
as high as 80%, this method of harm reduction has real ben-
efits. These include forcing the addict to come to a desig-
nated location every day, where counseling, medical care,
and other services are available, thus reducing the harm that
addicts do to themselves and others. 194
There is controversy over methadone maintenance because
many chemical dependency treatment personnel believe
that drug abuse should not be treated with another addict-
ing drug over the long term. Many users seek treatment
after only a short period of addiction while their need is still
relatively low and the immediate use of methadone further
ingrains their opioid addiction. In fact, one study has shown
that a higher dose of methadone is more effective in reducing
illegal opioid and heroin use than a moderate dose, thus
imprinting the reliance on the opioid. 195 Many methadone
users have conflicted feelings about this harm reduction
technique.
"I got on methadone. It wasgreat. It let me hold down a job,
and I wasn't sick;but still, for me, that's not a programto be
on. It's likea millstonearound ~ourneck. You have to be there
ever~daf Sometimes ~ou take ~ourdose home. If ~ou want to
go on a vacation,~ouget permission.And later I started using
heroinwhile usingmethadone. And that becamea problem. I
actual/~had two habits."
45-year-old recovering heroin addict
Methadone is a strong opioid that causes withdrawal symp-
toms if stopped.
"When ~ou'rekickingmethadone, God, that's the worstone to
kick.Your bonesache. You can't hard/~get out of bed if ~ou're
on a big dosaee. And there are ver~few places where~OU can
cold-turke~off methadone-ver~ few places.The~ bringit to
jail if ~ouget locked up 'causeit would be crueland unusual
punishmentif the~ cut ~ou off of methadone."
45 -year-ol d recovering heroin addict
Methadone advocates cite numerous, in-depth studies con-
ducted over nearly 50 years that demonstrate the effective-
ness of methadone maintenance in delivering positive
outcomes for society as well as for the addict. In this treat-
ment model, stabilizing addicts and allowing them to
change their harmful lifestyle through opioid replacement
therapy is considered the priority. This model does not
exclude eventual tapering of medication with a goal of
complete abstinence. Methadone therapy is credited
with reducing crime, medical/emotional illness, and other
social problems by providing access to measured doses of
a legal drug.
LAAM Levomethadyl acetate (formerly named levo acetyl
alpha methadol) is an opioid agonist replacement therapy
that is longer acting than methadone. Orlam, ® the trade
name of this drug, remains active in the body for up to
three days. It was reported to be less euphoric and thus less
prone to abuse, with milder withdrawal symptoms than
methadone; but in 2001 its use was connected to severe
heart arrhythmias, so the FDA required a black box warning
in its package information insert. 196 The manufacturer of
Orlam, ® Roxanne Laboratories, voluntarily ceased produc-
tion of the medication in 2003; although LAAM is no longer
available in the United States for treatment, it is still used
for research purposes.
Buprenorphine In October 2002 the FDA approved high-dose
sublingual tablets of buprenorphine (Subutex, ® Suboxone, ®
and Zubsolv®) for use in the treatment of opioid addiction.

Buprenorphine, also referred to as "bupe ," is an opioid agonist-
antagonist , which means that at low doses it is a powerful
opioid-almost 50 times as powerful as heroin-but at
doses above 8 to 16 mg, it blocks the opioid receptors. It
must be first administered when the patient is in withdrawal.
Once a patient begins use, a maximum dose of 32 mg is
advised to avoid the potential of precipitating withdrawal
from its own dependence as it hits a ceiling dose of 40 mg
and then becomes its own antagonist. It enables an addict to
begin methadone and then switch to buprenorphine as a
transition to a true antagonist like naltrexone . The benefits
of "bupe " over methadone are a lower risk of overdose or
sedation , less severe withdrawal symptoms , the patient can
receive opioid addiction treatment at a physician 's office, and
the medication is available through a local pharmacy.
Subutex"' is used during the early part of detoxification;
Suboxone "' or Zubsolv ® is used thereafter and during the
maintenance phase of treatment. Suboxone "' combines nal-
oxon e with buprenorphine to prevent injection misuse of
the medication. Buprenorphine without naloxone (Subutex ®
and various generics) are off patent protection and therefore
more economical than Suboxone "' or Zubsolv.®For that rea-
son they are often used in residential or medical detoxifica-
tion , where patients are better monitored to prevent misuse
of their medications. Buprenorphine can be used for either
long-term detoxification or short-term maintenance, permit-
ting greater stabilization for patients detoxifying from
methadone maintenance. Methadone-maintained clients
have been effectively switched to buprenorphine after their
methadone dose is reduced to 30 mg or lower. There is some
evidence of buprenorphine abuse in the United States and
Europe because it is a powerful opioid . In India and Nepal,
bupr enorphine is the most abused opioid .
One of the most significant changes in opioid treatment is
the decision to allow physicians to treat patients with
buprenorphine in their offices rather than only at drug
treatment clinics. To provide office-based opiate addiction
treatment , the prescribing physician must complete special
training courses, treat no more than 30 patients at a
time , and refer patients to appropriate counseling and
support services, although there is no requirement for
follow-through. 197 Qualified physicians have an X appended
to their DEA registration numbers , identifying them as able
to write valid prescriptions for buprenorphine. After one
year approved buprenorphine addiction treatment prescrib-
ers may apply for a Drug Addiction Treatment Act 2000
(DATA) waver that allows them to treat up to 100 patients
with buprenorphine. Recently, access to buprenorphine
through private clinics offering differing levels of clinical
quality, structure, and patient accountability has caused
federal reluctance to allow the expansion of DATAwaivers
for individual practitioners. Many opioid treatment pro-
grams now offer buprenorphine therapy as an alternative
to methadone . A Wall Street Journal article published in
July 2012 reporting the number of prescriptions for
Suboxone "' written in 2011 (about 6.6 million) vs.
methadone (about 4.3 million) confirmed the growing
popularity of buprenorphine therapy.
Treatment 9.43
''We believethat increasedaccessto treatmentfor all substance
abusersis vitalto solvin9the problemsof addiction. The use
of buprenorphine alone-without the full ran9eof treatment
interventions that arenecessarqfor successfulrecovefl.f
, however,
is fri9htenin9
. Addicts needcounselin9,peerinteractions ,
education, nutritionalsupport,and help with lifestqlechan9es.
These thin9swillnot be availableif a phqsicianreliesonlqon a
medicalintervention."
Darryl Inaba, Pharm.D., Addictions Recovery Center, Medford , OR
Sedative-Hypnotics
(barbituratesand benzodiazepines)
The majority of tranquilizer and sedative abusers are older,
White (85% to 89%) , and female (59% to 60%). Most enter
treatment through self-referral. About 41% of primary tran-
quilizer treatm ent admissions and 33% of sedative admis-
sions reported concurrent use of alcohol; 18% reported
concurrent use of marijuana. 86 If not medically managed,
withdrawal from sedative-hypnotic addiction can result in
life-threatening seizures. Intensive medical assessment and
medically managed treatment are a necessity when treating
people who have become addicted to sedative-hypnotics
such as secobarbital ("reds"), Xanax® (alprazolam) , other
benzodiazepines, and muscle relaxants like Soma"' (cariso-
prodol) .1 99
Detoxification
"Comin9off of Xanax®is so intense.Yourwholebodq twitches;
qourmusclestwitch.You want to just pull qourhairout. You
are bitchqand snappq,and I'd9one as far as thinkin9that I'd
see somethin9that is reallqnot there.You thinkthat everqbodq
is a9ainstqou. I aot to the point that I wasso bad that I was
throwin9up trqin9to comeoff of it. I couldn'tsleep.. .sweats.
It is one of the most horrendousfeelin9s."
40-y ear-old reco vering presc ription drug abuser
I
Though no medications have been approved to specifically
treat sedative-hypnotic addiction , substitution therapy
(using a drug that is cross-tolerant with another drug) is
needed to detoxify from these substances. Although many
drugs in this class can be used to accomplish detoxification ,
outpatient programs often use phenobarbital because of its
long duration of action and more-specific antiseizure activ-
ity. A dose of phenobarbital sufficient to prevent withdrawa l
symptoms without causing major drowsiness or sedation is
established as a baseline to begin detoxification. Butabarbital
is also used as an alternative to phenobarbital in the detox
process. Phenytoin (Dilantin ®), carbamazepine (Tegretol"'),
or gabapentin (Neurontin ®) may be added to either medica-
tion therapy to further prevent seizures. 168
The initial detoxification from sedative-hypnotics requires
intensive and daily medical management , which also
provides an opportunity to get the addict into counseling
and the social services that are vital to recovery once
 9.44 CHAPTER 9
detoxification is completed. Inpatient medical detoxification
is optimal for those who have complications due to severe
medical or mental health problems or for those at serious
risk of major withdrawal seizure activity.
Initial Abstinence
Continued abstinence from sedatives requires intensive
participation in group, individual, and educational coun-
seling as well as specific self-help groups or NA. Many seda-
tive addicts, especially those addicted to benzodiazepines,
complain of bizarre and prolonged symptoms such as taste
or visual distortions lasting several months after detoxifica-
tion . Many also experience inappropriate rage or anger dur-
ing the early months of abstinence, which requires skilled
mental health intervention.
After detoxification some sedative-hypnotic addicts experi-
ence the reemergence of withdrawal-like symptoms even
though they have remained totally abstinent. This reaction
can occur from one to several months after detoxification
and may occasionally require medical intervention. Two
controversial explanations have been offered to account for
this phenomenon . One asserts that long-acting benzodiaze-
pines, such as diazepam (Valium®) and alprazolam (Xanax ®),
produce active metabolites that persist in the body. Another
explanation asserts that these are not true withdrawal symp-
toms but merely the reemergence of an original anxiety dis-
order that was controlled by the use of sedatives and suggests
that psychiatrists may need to initiate maintenance pharma-
cotherapy treatment to address the underlying psychiatric
problems. Because many antianxiety medications are abus-
able sedative-hypnotics, switching to nonbenzodiazepine
alternatives, particularly SSRis like Zoloft, ® is preferable.
BuSpar® (buspirone), a low-abuse-potential serotonergic
agent, can also be used . If benzodiazepines must be used to
treat anxiety in a chemically dependent person, skillful med-
ical management is needed to prevent inappropriate use or
relapse to sedative-hypnotic addiction .2<){)
Flumazenil (Mazicon ®) is an effective benzodiazepine antag-
onist currently available only in injectable form. Though it is
I
used mainly to treat benzodiazepine overdoses, there is a
growing interest in its use to reduce craving in alcohol and
stimulant abusers . Future developments may lead to effec-
tive oral and long-acting benzodiazepine or barbiturate
antagonists to help those addicted to sedative-hypnotics
continue initial abstinence similar to the way naltrexone is
used to treat opiate addiction.
Addiction to sedative-hypnotic substances is often associ-
ated with an underlying co-occurring mental health condi-
tion such as a sleep or anxiety disorder. These drugs are also
commonly abused with other substances and result in poly-
drug addiction . Treatment must include these potential
complications, rigorously assess for their involvement, and
provide treatment when necessary .168
Recovery
Continued participation in self-help groups like Benzo-
diazepines Anonymous, Pills Anonymous, and Narcotics
Anonymous is the most effective means of promoting con-
tinuous abstinence and recovery for sedative-hypnotic
addicts . Sedative-hypnotic addicts are vulnerable to environ-
mental cues that trigger drug hunger and relapse throughout
their lifetimes, so treatment must include cue or trigger
recognition, avoidance tools, and coping mechanisms.
Alcohol
Alcohol alone was the primary substance of abuse for
almost 22.6% of all treatment admissions in the United
States in 2010. Alcohol with a secondary drug was 18.8%
of all treatment admissions, making the total for alcohol
41.4%. 78 The average age of those with only an alcohol
problem was 39; the average age for those admitted for
alcohol and a secondary drug was 35. Marijuana was the
most frequently named secondary drug for those who
were treated for alcohol with other abused drugs, followed
by crack cocaine, powder cocaine, methamphetamine,
and heroin. 66
Denial
Denial on the part of the compulsive drinker is the most sig-
nificant barrier to entering treatment. One reason denial is
so common among those with an alcohol problem is the
length of time it can take for social or habitual drinking to
advance to abuse and addiction (10 years on average). 20 1
Alcoholics are often in denial because they have no memory
of the negative effects they experienced while in an alcoholic
blackout, so they don't believe that alcohol has really harmed
them. Alcohol abuse causes cognitive deficits that impair
judgment and reason, making users less likely to associate
any problem with their drinking .
Detoxification
Both acute intoxication and initial withdrawal from alcohol
can be medically dangerous and should be monitored in a
safe environment like a sobering station, where trained pro-
fessionals can respond quickly and appropriately to any
emergency. In alcohol-dependent persons, acute intoxica-
tion usually lasts for only 4 to 8 hours, and withdrawal
begins within 4 to 12 hours after cessation of use .
For a heavy drinker or an alcoholic, physical withdrawal
is very uncomfortable. Symptoms such as sweating, increased
heart rate, increased respiratory rate , and gastrointestinal
complaints can often be treated with aspirin, rest, liquids,
and any one of hundreds of hangover cures that have been
handed down from generation to generation. Minor alcohol
withdrawal most often occurs at home unless delirium
tremens (confusion, agitation, hallucinations, uncontrolla-
ble tremors, and paranoia) or seizure activity necessitates
admission to a hospital. Symptoms are likely to peak in
48 to 72 hours and are greatly diminished after five days.
Lesser symptoms, including mildly elevated blood pressure,
a mild tremor, disturbed sleep, and moodiness, also known
as post-acute withdrawal symptoms, can last for weeks
or months.

Up to 10% of untreated alcohol withdrawal and up to 3%
of medically treated episodes include severe, potentially
life-threatening symptoms such as seizures that require
medical management with a variety of sedating drugs, such
as barbiturates, benzodiazepines (e.g., chlordiazepoxide
[Librium ®]), paraldehyde, chloral hydrate, and the pheno-
thiazines. Because several of these drugs are addictive, they
are used sparingly and on a very short-term basis. Normally,
tapering is done over 5 to 7 days but can be extended to 11
to 14 days . If untreated , the delirium tremens and the
seizure activity can be fatal in up to 35% of those who
experience the condition. 167 -202
The Clinical Institute Withdrawal Assessment for Alcohol
(CIWA-Ar) revised scale is used to quantify physical signs
and patient complaints of withdrawal into a score that deter-
mines the type and the degree of medical treatment needed
to prevent a life-endangering seizure or other medical prob-
lems during alcohol detoxification. 203 For clients who abuse
alcohol, opioids, and benzodiazepines, withdrawal is both
extremely dangerous and hard to evaluate. The Modified
Selective Severity Assessment (MSSA) detoxification scoring
has been developed to assess the withdrawal and safely
detoxify the client .
Along with emergency medical care, withdrawal and detoxi-
fication must include emotional support and basic physical
care, such as rest and efforts to restore physiologic homeo-
stasis with fluids, thiamin, folic acid, multivitamins, miner-
als, amino acids, electrolytes, and fructose . Evidence-based
best practices indicate the effectiveness of motivational
enhancement, behavioral, cognitive-behavioral, 12-step-
facilitation, group, or psychodynamic interpersonal thera-
pies along with participation in self-help groups like AA for
all phases of alcohol dependence treatment. Many of the
problems begin to abate with detoxification, but if someone
has been a long-term drinker, irreversible damage such as
liver disease, enlarged heart, cancer, and nerve damage could
continue to compromise their health. 167-20 1•204
Initial Abstinence
A common treatment for initial abstinence is Antabuse ®
(disulfiram), a drug that makes people ill if they drink
alcohol after taking it. This drug is used for six months or
longer to help alcoholics get through initial abstinence
when they are most likely to relapse. Medication non-
compliance is the main drawback of disulfiram treatment.
Disulfiram has recently been found to also decrease stimu-
lant and alcohol cravings . The most important element of
recovery is attendance at AA meetings or other support
groups in addition to individual therapy. One course of
action is called a 90/90 contract, where the user attends 90
M meetings in 90 days.
In 1996 naltrexone (ReVia®) was FDA approved for the
treatment of alcohol addiction during the first three months
of recovery; it decreased the rate of relapse by 50% to 70%
when combined with a comprehensive treatment program.
Naltrexone is hard on the liver, it blocks the effects of opioid
pain medications during an emergency, and it must be used
Treatment 9.45
under strict supervision. Because patient compliance is a
major issue with naltrexone treatment, injectable long-
acting forms of naltrexone (e.g. Vivitrol®) have been devel-
oped to help prevent cravings and relapse in alcohol use
disorder treatment. Acamprosate (Campral®) has had
modest success in lowering craving and keeping clients
abstinent. 205 Rigorous studies of its effectiveness to prevent
drinking compared with naltrexone, disulfiram, and
placebo, however, found acamprosate no more effective
than a placebo in reducing alcohol use .206
Topiramate (Topamax ®) is one of a number of drugs that
block dopamine, preventing alcohol from stimulating the
reward/control pathway. 20 7 Blocking dopamine also helps
with weight loss and binge-eating disorder. 208
Recent research showed that cannabinoids play a role in
modulating the reinforcing effects of alcohol and other
abused drugs by affecting the nucleus accumbens and
should be avoided as a treatment for any addictive disorder .
Once the alcohol clears from a client's system, it is important
for the clinician to evaluate the client for any psychiatric
problems (especially depression and anxiety) that have
developed or were pre-existing. Attempts at suicide should
also be addressed because the lifetime risk of suicide in
alcoholics is 10%.
'That last time I relapsed,beforethis, I wassittingon
a couchin m~ livingroom,with no thoughtsof drinking.
I had beengoingto meetingsand I justgot up and said,
"/'m goingto go get somethingto drink,"and wentto
the liquorstoreand that startedme on a run.Just like
that -just cameout of nowhere."
38 -year-old female recovering alcoholic
Long-TermAbstinenceand Recovery
In treatment one often encounters a "dry drunk. " This is a
person who is not actually drinking but who has retained the
behavior and the mind-set of an alcoholic, so in addition to
avoiding relapse, this stage of treatment serves to heal the
I
confusion, immaturity, and emotional scars that kept the
person drinking for so many years.
Many treatment centers advertise 30-day dry-out pro-
grams, implying that detoxification is the key to recovery
rather than a small initial step in a lifelong process.
Research demonstrates that all drugs of addiction induce
changes in the brain long after a person enters sobriety.
These changes include increased dendrites and receptors
that are primed to respond to drinking triggers and
cues through long-term memory processes, so the recover-
ing alcoholic is always susceptible to relapse .209 ,2 10
Developing a relapse prevention plan-identifying the tools
needed and implementing those resources to maintain
continuous sobriety-is vital during this phase of treatment .
Terry Gorski and the late Ernie Larsen authored excellent
texts on the relapse prevention process that can be of great
assistance to both the recovering alcoholic and the treatment
professional. 100 ,211
Psychedelics TttalmenlforBad
Trips
Th<overwhe lmingm.ojori tyoFpropl<intr<otm<n t who TI,,
"'it,; dM!loptdhblowr'CAIDT,....,.for .....
nK olloround<n,such ., l..SD,).IDMA,ond ",hroom,;."•r< nh1porson~1bad--.,:
Whit<, TrW,, •nd unda th< •11<of H. Th< majority of Q fntJm t,,..,.-,ouo ondconlden<,
marij uan.o,mok<nintrulm<nlot<m>l< • ndundath<•g<
ofHond,-.,n lydividedethnic•lly. "' 1) 11r«x1i<ll,c
,l ,tmaC..,t,,.,..,-., ,-.IIOl'l'lrol'-.,..,,.._
Mon)·p•)'chedelic,smimicm<n"-loonditions
phr<ni>,>0duringth<ini1i.alvHi
, ,uch ., !iChim-
t th<clinici>nOT in"-k<
o - ..,,. 1<1"'""' "'"' "'5 -
oti.,h,5~ • Wp1,ct_...,.,,..,_. pt<>plt_
• l,o;Jlr1)ond-hrn
ondd\otbe""' bt ol ntl'<-
coun><lorcanrrw«onlyat<nta.tiv,diagnosisandmust
wait For th< drug to cl<or, usu.oily without medication l) = ~t.::f"'"'""11
~ ~ 1ho!-
•
~fo~ .:ki~g a fi= ·l d~noois Ant:ych'!:rugs;-~ ':1'
1
·
O r.t.-<1ooin.0&wo,,c,hJ.~<Lt,j,ct,Wllh1l1eL0<r ,
clim i, ifth<)'>r<•dangatoth,m.e lv<0.A lthough>0m < lldni"'ft><o:
M = to'"""'""""-"'' '°Drll
,_
tis<ued<p<ndence (physica l addiction) i, 5ttnwilh GHB
(pmmo hydrmcybutyr:11<), PCP, k,wnin< . and marijuana
aim><, most all •ronnd<Bdo not cauKdoilycompul,fr,

:'.'.:tn i~r!'7~::~m.;,n:i:• ,~';:,~;:;:~:~ht~'.::,:

Theconditionknown • •h • llncinog<npasistingpa<:<ption
(intoxicationorm<nta.lillnus,.) . familydynomic>,and disorda(HPPD)i,th,recurrenceol!iOm<olthe,ymptom,
soci.olron,;cqn<ncuthatresultfromth<abn K ofth, hallucinogen evrn when non < ha, bun 11k<n. On e
trutm<nl thath» hod some ,ucc<S<is the u« ofh igh -
Badlrips(acuteanx ietyreactions) pot<ncy b<ruodia.zepine, ,uch "' clonuq,m,, wh ich
Th< • moun1olthep,ychedelicta.k<n,1h,,urround ings,rnd reducedth,symptomoolHPPD. "'
theu.ser',mena l ,111<rndph}-.ic alconditio n---;olld<tmn in,
ther=tion.The,ff«tofp,ychedeli cs onth<<motion.ol
~~j _u;: · :;~;:i:~:-:::ri~~;i; i;:;'::i::fc.:~D::.~:::~
C<nlaolthehr>in<Xpo5"aUKftoth<<Xtr=><SOfeuph o-
riaandpanic . Bothnovic,and,.,t<rrnn><Bwho11k<too usa, _ Though thi,ismostoltrn t rttt<dwlth tradition•!
high•d=oll..SDoranothap,)'chedeliccanexperi<nc < rouns,ling . educa tion.•nd0<lf -hdpgroupo , morijuonaand
acut<•nx i<ty,paranoia,Fnrovalossofcon t rol,orfttl - GHB cancans, true tis,n<d<p<ndmc,c , which,.,;u ll>in
ingsofgr.,nd<nr l<adingtodongaousbehaviOB withdm••l•ymptomothat moyrequirem<dicalmEl.l.g< •
m<nt(e,pecia llywith GHBd<p<nd<nce) . Th, GHBwith -
"intl,,<ighlhyod,/,tart<dMinfjacidonddruii"80lot drawa!,yndromeis, imilortothatofakoho l d<pendence
,.,,J,.,1,,. I =aboot 15. I tooltooowd.oo,l.,..,"\11,tond (includ ing delirium tremrn, and ,ei,ure acthity ) a nd of
benzod i.u epineorsedativ <-h)1>noticaddictionwith a long
~~~'"!L~':!,j:~<t;~~;;:;/
'.!;~ durationo l ,ymptom> . Tttttm<ntshouldtherdoreb<med
callym.onog<dwith,imilnintervrn1iom • ndcautionsthot
i-
tripp,doot.l,p<nt~ dmp;,,tl,,hospitalSotl,,o/""ntto
,,1,,,1,ofu
, tliat." areusedtotreatakoholorsedati,., •hypnoticd<p<ndence ." 1
Chronicdailyabu,eo/l..SDandMD).!A i,morelike • stimu -
lantaddictionb<cau K to l<rancetoth<p<ych<d,licdfrru
Theinitioltrtttmen t for,omroneonabadtripistotalkhim occunwithinon ly a fewdoys
orhadownin a calmmmnerwithoutr.ti<ingyour,..,ic,or
app,aringthrttt<ning.Moidqukkmo,'<ffl<nt,andl<tth <
pe=,nmovearound!i0tho1h,orshedoeonotf«ltrapp<d
Marijuana
Thrne a re two thing, to r=emba when u,ing the ARRRT Sincethel980sthaeho,bttn a ,t<adyincr<»<inth<
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• Fim,ifth,=i•<,q><ri<ncing,e,,er,medica l. physical dence,mostthere,u ltofcourt -mEldo ted t reotmrnlref,rral,
oremotiona lr n ctionsthatdonotr<<pondto t h<11lk - (Figure9 -~). • ccountingfor56 % ofadmi55iom . butther,c
down.medical int<rventionisn , <d<d. G<tthepe=,nto area l!iOhigh<rnumb<nofthoKwho>r<K lf-refared. 1..
ahospi Lolorcall<m<rg<n<)'m<dicalperwnn< l <,q><ri- Thisindicate,anocknow ledgmrntbymorijuana,mokus••
<nced intrutingthotkindofruction wd l •• th e criminoljus tic,sy,t<m t hotth<rei , •growing
problemwithm.orijurn • d<p<nd<nc<. Form.onyobsen,crs
• Second , • !though me>l p<ych<d,lic bad -trip T<C action,
th= f..ctoSttmtochollrngeth,p,Bi,t<ntp<rctpliontho1
arerespomh,ctoARRRT,PCP a ndke11min,moycaUS<
marij uanais a b<nigndrug
nn<,q><ct<dand,udden,iolrntorb<ll ig,rentb<ho,ior .
Exercise cau tion whrn ap proaching• "bum t ripper" Anothafoctorcontribu tingtotheincr<ll< inmorijuorui -
•uopectedofbringundatheinllurnc,cof<ithaof .,,oclat<ddepend<nc<isth<a ... ilabil ity, atth<stre<tlevd,
th,.,drugs ofmorijuonaconta.ini n gh igh<rlndsofTHC. lnth< Y m<

30
Alcohol
OnlyandMarijuana/Hashish
25
Treatment
Admissions
byAge- 2010
20
12- 14 15- 17 18- 19 20-24 25-29 30-34 35-39 40- 44 45- 49 50-54 55-59 60-64
Ageat admission
way that the refinement of opium to heroin or of coca leaves
to pure cocaine overloaded the reward/control pathway and
altered brain chemistry, the 8% to 14% or more THC content
of sinsemilla puts the long-term user at risk. Many users dis-
regard the risk by "taking fewer puffs," but tolerance still
develops quickly The University of Mississippi's Potency
Monitoring Project tested samples of pot seized by the DEA
since 1976. Its findings show that the average THC concen-
trations increased from 4.8% in 2003 to 10 .1% in 2008. 214
Clinical experience and a growing body of research show
that marijuana can cause a true addiction syndrome encom-
passing both physical and emotional dependence.
"/ ain't9onnasa~ I can quitan~time,but if I had to stop, I
couldstop. I ain't9onnasa~ I couldquit. I can't/JOcold turke~
just likethat. I could/JOma~bethreeda~swithoutand then I
smokea joint.And thenma~belikethreeor fourda~swithout,
and thenma~beI'[[smokea joint,but that'dtakesomework."
33 -year-old chronic marijuana abuser
The physical withdrawal symptoms, though uncomfort-
able, rarely require medical treatment. They consist of
major sleep and appetite disturbances, headaches, irritabil-
ity, anxiety, emotional depression, and mild tremors or mus-
cular discomfort. Craving persists for several months to
years after abstinence . One of the main reasons why people
deny experiencing withdrawal symptoms is that their onset
is often delayed for several days or weeks after cessation of
use. Marijuana has a wide distribution in body tissues and in
fat, enabling it to persist in the system over a prolonged
period of time. The urine of chronic marijuana users some-
times tests positive for three weeks to several months.
"AfterI stoppedsmokin9,it tookme aboutthreeor fourmonths
beforeI reall~cameout ofthe fo9and reall~started9ettin9a
9raspofwhat was9oin9on aroundme... and anothermonthor
so a~erthat is whenI reall~startedto understandthat I could
do this.And then I startedreall~enjo~in9it."
28 -year-old recovering compulsive marijuana smoker
Treatment 9.47
Becausealcoholdependencetakes
longer to developthan dependence
on other drugs, admissionsfor
AlcoholOnly treatment occur later in the life
Marijuan
a/Hashish of an alcoholic,peaking after the
age of 45.
The vast majority of those
entering treatmentfor marijuana
dependenceare under the age
of 30; more than half of the
referralsfor treatmentare court
mandated.
65+ TEDS, 2012
Treatment for marijuana abuse or addiction is evolving along
the same lines as that for alcohol misuse except that there are
no specific recommended pharmacotherapies for mari-
juana withdrawal or dependence. Several different medica-
tions are currently being used to treat Cannabis use disorder,
including bupropion, divalproex, and nefazodone, but their
use has not been approved by the FDA. In 2013 a naturally
occurring brain substance , kynurenic acid, was found to
mute the effects of THC in the brain, and some speculate
that it may be helpful in treating cravings and preventing
relapse to marijuana addiction.
Psychosocial interventions, education, and peer support are
the most effective methods of preventing relapse and helping
people abstain. Motivational enhancement therapy and the
development of coping skills along with intensive relapse
prevention therapy are effective psychosocial interven-
tions .167The ambivalence toward the need to treat marijuana
addiction stems from society's belief that "pot " is not a prob-
lem, and users in particular view those in treatment as over-
reacting to their use of the drug. This undermines the
treatment process. Twelve-step programs and other peer
I
support systems, invaluable in the treatment of other drug
dependencies, have not fully evolved for marijuana depen-
dence, though Marijuana Anonymous is growing worldwide.
Current research on anandamide, the neurotransmitter most
affected by marijuana, is providing clues to the nature of
marijuana's effects on the body and the mind, possibly lead-
ing to drugs to assist in short- and long-term abstinence.
There is already an anandamide antagonist called SRl 41716A
that has been used to study the marijuana withdrawal syn-
drome because the drug almost instantly blocks all effects of
marijuana temporarily The chemical name is rimonabant,
and the trade names for the products under development are
Acomplia ® and Zimulti. ® Though SR14 l 716A has been
approved in Europe for weight loss and diabetes since 2006,
side effects of severe depression and suicidal thoughts led to
its U.S. new drug application being withdrawn in 2007 and
the suspension of its European availability in January 2009 .
It can still be purchased on various Web sites.
 9.48 CHAPTER9
Inhalants
The treatment of those who abuse inhalants involves imme-
diate removal from exposure to the substance to prevent
aggravating its dangerous effects, such as lack of oxygen to
the brain, damage to the respiratory system , and injuries
from accidents. Initial treatment for the delirium that can be
caused by inhalants consists of reassurance and a quiet, non-
stimulating environment. Patients must be monitored for
potential adverse psychiatric conditions that may require
the use of antipsychotic medications targeted to treat psy-
choses and suicidal depression. Many inhalants can also pro-
duce physical dependence similar to that which occurs with
sedative-hypnotics. Clients should be monitored for with-
drawal seizures and treated with appropriate anticonvulsant
medication when warranted.
Each inhalant has its own physical toxic effects, which may
lead to heart, liver, lung, kidney, and blood diseases. The
symptoms must be evaluated and treated . These substances
are reinforcing , can cause psychic dependence , and often
require long-term psychosocial interventions targeted to
prevent relapse into addiction.
Because most inhalants are easily accessible to adolescents,
the majority of abusers are under the age of 20. Almost one-
third of inhalant treatment admissions used inhalants by the
age of 12 and another third by the age of 13. 16'! In treatment
this means that there are major developmental problems that
must be addressed. Treatment specialists talk about the need
to habilitate rather than rehabilitate the huffer.
About two-thirds of inhalant abusers admitted for treat-
ment reported the use of other drugs as well, primarily
alcohol and marijuana, emphasizing the need to evaluate all
huffers for possible addiction to other drugs.
BehavioralAddictionTreatment
It is evident that behavioral addictions--which result from a
genetic predisposition to addiction, an environment that fur-
I
ther predisposes one to compulsive behaviors , and pleasur-
able reinforcement from the activity itself-follow similar
brain pathways that lead to drug addiction . The 2013
Diagnostic and Statistical Manual of Mental Disorders (DSM-
5) added gambling to its classification of "Addiction and
Related Disorders." Though gambling addiction is the only
behavioral addiction included, sex, shopping , compulsive
Internet use , and other behavioral addictions are being stud-
ied for future inclusion as "Substance-Related and Addictive
Disorders. " Behavioral addictions require the same inten-
sity of intervention and treatment as substance-abuse
disorders. Some believe that eating disorders (anorexia,
bulimia, and binge eating) should also be reclassified as
addictive disorders.
Because many behavioral addictions have not been studied
or treated with the same intensity as drug abuse and addic-
tion, there is a scarcity of research data, treatment facilities,
and qualified treatment personnel. In addition to treatment
at mental health facilities, the front line of treatment has
been the evolution of self-help and 12-step support groups
for these nonchemical addictions. Some state governments
offer treatment programs for behavioral addictions , but there
are hundreds of thousands of addicts with behavioral addic-
tions who need professional help.
GamblingDisorder
The DSM-5 replaces past designations of problem, compul-
sive, and pathological gambling with the single designation
gambling disorder, which can range from mild (meets 4-5 of
the diagnostic criteria) to moderate (6-7) to severe (8--9 cri-
teria are met). The past designations are still commonly used
and are used here to describe the disorder.
Americans lost $60 billion to $ 70 billion last year in slot and
poker machines ; at poker, dice, and roulette tables; on sports
betting; and on 38 state lottery games. The number of com-
pulsive gamblers has grown dramatically as has the number
of games of chance found in every state except Utah and
Hawaii. The sheer availability of gambling facilities has
contributed to the increase in problem and pathological
gamblers and to multiple relapses during treatment . In one
of the few before-and-after studies, the percentage of resi-
dents of the state of Iowa reporting a gambling problem at
some time in their lives went from 1.7% in 1989 to 5.4% in
1995 after gambling became available, and it is probably
higher today-a three- to fourfold increase. 215 In a different
study, the number of pathological gamblers was estimated at
3.6 million in 2002 due to the proliferation of gambling out-
lets.216 The gaming industry estimates that 25% to 40% of its
revenue comes from the 6% to 8% who are compulsive or
problem gamblers. The figures are probably much higher for
certain types of gambling (e.g., in Oregon it is estimated that
7% of the population spends 60% to 80% of the money gen-
erated by poker machines). Problem gamblers as well as
addicted gamblers hold on to the perception that "It's only
a cash flow problem, not an addiction."
"I was at a GamblersAnon~mousmeetin3in Reno, and about
50 people werethere. The lon3estabstinencein that meetin3
wasjust four months. In meetin3sI've been to in other states,
manqpeople have qearsof abstinence.The onlq differenceI
see is that in Reno3amblin3is everqwhere,and the tri[38er5 are
everqwhere,and the temptation is everqwhere."
44-year-old recovering compulsive gambler
Society has been slow to recognize compulsive gambling as a
compulsion as powerful as any drug addiction, and conse-
quently there are proportionally few facilities to treat this
addiction.
Compulsive gambling has been described as one of the pur-
est addictions because the only substance involved is money.
Most gamblers are reluctant to seek treatment let alone
admit that they have a problem until they reach a devastat-
ing bottom. Outside interventions, especially those triggered
by legal problems (e.g., arrest for embezzlement or declaring
bankruptcy), are usually necessary 217

"I bou9htsomefurnitureon creditfroma companqand financed
it realaood. Made a fewpaqments , and theqsent me a letter
safn9 qoucan9et morecredit,so immediatelqI appliedfor
morecredit.I soldall mq furnitureand then wentand bou9ht
moreand soldall of that."
74-year-old recovering sports gambler
The Charter Hospital of Las Vegas, which treats compulsive
gamblers, reports withdrawal symptoms similar to those of
alcoholism : restlessness, irritability, anger, abdominal
pain, headaches, diarrhea, cold sweats, insomnia, tremors,
apprehension about well-being, and above all an intense
desire to return to gambling.
"I don't wantto sit hereand tell anqbodqanqthin9that's
unrealistic.I miss9amblinf3.I missit still. It brou9hta sense
of like, a poweror a satisfaction.I'm learnin9how to treat
it and howto dealwithit, but that doesn't meanit's over."
42 -year-old relapsing compulsive gambler
The standard assessment test for compulsive gambling is the
South Oaks Gambling Screen , usually accompanied by an
in-depth assessment and a formal diagnosis . Treatment
options developed over the past 30 years include self-help
groups such as Gamblers Anonymous _21 8
'The problemis that thereareno phqsicalsrossindicatorsto
a laqpersonlikehan9overs,or arossintoxication,or bodilq
chan9es,or measurable bodqfluidsthat a doctorlikesto find.
Theqare mostlqpsqcholo9ical and sociolo9ical
and, of course,
financial.And withoutthat kindof historq,we usuallqdon't
even9et to a dia9nosis.
" relapse to one substance or behavior will often trigger
Joseph Pursch, M.D. , psychiatrist
Gamblers Anonymous parallels the 12-step program used
by Alcoholics Anonymous . It also employs sponsors, group
meetings , commitment to complete abstinence , contact
numbers, and support to help the gambler get through the
initial 90-day phase. Additional support groups include
Garn-Anon for the families of compulsive gamblers and
Garn-A-Teen for children of pathological gamblers .
"Goin9to GAsroupshelpsme- seein9peoplewho have9one
throu9hthe samestru/3/3les
and seein9howeverqone of them
wishestheq had quit whentheq weremq ase so theqcouldhave
avoided9oin9throu9hthe stru/3/3les.
" alcohol and nicotine dependence ; however, a recent study
21 -year-old recovering compu lsive gambler
One of the keys to treating compulsive gamblers is helping
them overcome irrational thoughts (magical thinking)
about their chances of winning because many cannot accept
the fact that gambling games at casinos , lotteries , racetracks,
and in poker machines are designed to take their money The
more they gamble, the more they lose; and if they get ahead,
they will compulsively put that money back into the game.
Almost all pathological gamblers think that they can over-
come the computer chips in slot machines and the inevitable
laws of chance.
Treatment 9.49
"I don't thinkabout thoseodds. What enticesme to staqis
I'[[seeotherpeoplewinnin9and I'[[think,'Well,mq machine
hasn'tpaidout. It's about timethat it will."'
53 -year-old compulsive gambler
The other key to treatment is getting the pathological gam-
bler to recognize that it's the action at a gaming table or the
"zoning out " at a machine that he or she is after rather than
the money
Outpatient, inpatient , and residential treatment programs
are available (and scarce), but insurance companies seldom
pay for a primary diagnosis of compulsive gambling. It usu-
ally takes a diagnosis of a mood disorder or another coexist-
ing condition before insurance will reimbursement for
treatment. Frequently, compulsive gamblers have already
lost their jobs and their insurance coverage before they seek
help for their addiction . In the past few years, 17 states that
have government-controlled lotteries, gambling machines,
and scratch-off games are recognizing their responsibility to
provide treatment for compulsive gamblers. Connecticut
spends the most money on treatment. Oregon passed a bill
allotting 1% of its net gambling revenues, or almost $5 mil-
lion in 2010, to treatment. California, with 12 times the
population, spends much less.
Gambling often coexists with, replaces, or follows alcohol-
ism, compulsive spending, and other disorders . More than
50% of pathological gamblers are also alcohol or substance
abusers_22° Many alcoholics begin to gamble after they quit
drinking, and it quickly becomes as compulsive as alcohol. 221
All addictions should be treated simultaneously because
another addiction.
"I just9ot mq 14-qear chipat mqMondaqAA meetin9just in
timeto 90 to mq GA meetin9.I'd alwaqs9ambled, but, boq,
it tookoff aboutthreeqearsa~er I quit the alcohol."
63 -year-old "dry" compulsive gambl er
I
Although no medication is approved to treat pathological
gambling, there is interest in pharmacological interventions
for this and other behavioral addictions. A new drug,
nalmefene (Revex®), may help reduce urges in pathological
gamblers. The drug is not yet approved for the treatment
of gambling addiction and is being developed to treat
of its effectiveness to reduce gambling in pathological gam-
blers found that 59.2% were rated much improved or very
much improved compared with 34% of those on a placebo. 222
Other studies confirmed these results and also found that
lower doses of the medication (25 mg per day) were just
as effective and caused fewer side effects. Nalmefene is
actually an opioid receptor antagonist like naltrexone that
is currently used "off-label" (not FDA approved) to treat
craving and prevent relapse in gambling disorders. Studies
found that drugs that block opioid receptors make winning
less pleasurable and losing more unpleasant in lab gambling
tasks. 223
 9.50 CHAPTER 9

Current treatment of pathological gambling is therefore
more psychosocial than pharmacological, though medical
treatments will probably be approved in the near future.
Long-term peer support groups that include the cognitive-
behavioral approaches used to treat chemical dependen-
cies and participation in GA are effective_224 Treatment of
this addiction suggests that compulsive gamblers may differ
in their personalities from those addicted to substances in
two ways: Pathological gamblers are more likely to have
strong egos and a greater sense of entitlement, which makes
gamblers less likely than drug addicts to enter and engage in
treatment. They believe that they have the ability to manage
their condition and further believe that they are entitled to a
big win if they can keep in the action just a little bit longer_226
depression, and often-suicidal ideation. It usually takes 10 to
12 weeks for full nutritional recovery. The hospital or home
care includes medical treatment and nutritional stabilization
requiring weight gain of 1 or 2 lbs. per week even if the
patient is resistant. Exercise is also recommended. The com-
plexities of anorexia require a team approach: physicians
for medical complications, dietitians, therapists, counselors,
and trained nurses to ensure good outcomes. Most health
insurance covers only 15 days of treatment.
For the hospitals and clinics that treat this eating disorder, the
rate of full recovery is about 40%. In one study the recovery
rate among 84 anorexic women after 12 years was 54%
based on the resumption of menstruation (41 % based on the
criterion of general well-being); the mortality rate was 11%_22 8

The results of two fairly comprehensive national surveys

The first priority in treatment is preventing permanent dam-
found that among individuals with a lifetime history of
age and death by starvation. Severely ill patients must be
DSM-IV-TR pathological gambling, 36% to 39% did not
monitored for body weight, serum electrolytes, and diet as
experience any gambling-related problems in the past year,
the patient is returned to normal nutrition. For an adoles-
even though only 8% to 12% sought either formal treat-
cent a weight gain of 4 oz. (0.1 kg) per day is the goal.
ment or attended GA meetings. About one-third of the indi-
Patients are usually monitored for two to three hours after
viduals with pathological-gambling disorder in these two
eating to prevent self-induced vomiting. Fluoxetine
nationally representative U.S. samples were characterized
(Prozac ®), other antidepressants, and monoamine oxidase
by natural recovery. Pathological gambling may not always
(MAO) inhibitors have been used to help patients improve
follow a chronic and persistent course_227
eating behavior by treating the underlying depression.
Eating Disorders Antidepressant drugs, however, have had marginal effects in
9 230
aiding recovery_22 -

"Losin9wei9ht is eas~. I'veprobabl~lost 1,000 pounds

One of the first barriers to treatment is convincing the
over the ~ears... but I've9ained 1,055.
patient that anorexia is potentially fatal. The anorexic
46 -year-old compulsive eater
client believes that her weight is normal or above normal,
and it is usually a parent who brings a young woman to
Early intervention is key to successfully treating the three
treatment. Programs involve stabilizing the patient and
eating disorders-anorexia, bulimia, and binge eating as
psychological counseling to alert the anorexic to the prob-
well as compulsive overeating (including obesity). The lon-
lem and its causes; to devalue an overemphasis on thinness,
ger the disorder continues, the more deeply ingrained the
weight, dieting, and food; to build self-esteem; and to
behavior becomes and the more physiological and psycho-
promote healthy behaviors. Treatment also incorporates
logical damage occurs. A number of steps are recommended
family therapy to provide the family with understanding,
for treating eating disorders.
support, and the ability to cope.
• Diagnose and treat any medical complications-hospi-
talize if necessary.
Bulimia

I
• Encourage the client to exercise and eat a balanced
diet and provide education on the components of proper
nutrition_225
• Use cognitive and other therapies to change false atti-
tudes and perceptions of body image and eating.
• Encourage attendance at Overeaters Anonymous meet-
ings or other support groups.
• Use behavioral and group therapies to encourage weight
gain in anorexics and weight loss in overeaters.
• Enhance self-esteem, independence, and development
of a stronger identity
• Treat and educate the client's entire family.
Each of the three eating disorders has its own unique
problems to address.
Anorexia
Most severely ill anorexic patients are hospitalized because
of excessive weight loss, disturbed heart rhythms, extreme
Clients with bulimia usually have more long-term health
problems than those with anorexia, such as atherosclerosis
and diabetes; these problems rarely require hospitalization
but often necessitate continuing medical care. Like all eat-
ing disorders, bulimia is best treated in its early stages. It is
not uncommon for people with bulimia to be of normal
weight, so their disorder may escape detection for years.
After diagnosis patients are treated either in a hospital or as
outpatients.
Because of the multiple problems involved, a multidisci-
plinary integrated treatment is generally used.
• An internist advises on medical problems.
• A nutritionist provides help with diet and eating
patterns.
• A psychotherapist provides emotional support and
counseling and may provide therapy that involves chang-
ing attitudes and behaviors .

• A psychopharmacologist may offer counsel on which
psychoactive medications might be effective. In recent
years antidepressants have been used, especially SSRis
along with MOA inhibitors. 167-231
The Karolinska Institute in Stockholm found that condition-
ing methods that focused on physical symptoms, not on psy-
chological problems, were the most-effective treatment for
those with bulimia as well as for anorexics . When patients
were trained to eat, recognize satiation, avoid excessive exer-
cise after eating (as in exercise bulimia disorder), and other
behavioral conditioning, remission rates were 75%.232
Family and group therapies are extremely useful for pro-
viding understanding and emotional support to the patient .
Group therapy may be a great relief to a person who no lon-
ger needs to keep the disorder secret. Family, friends, and
colleagues can help a person start and complete treatment
and follow-up with encouragement to make sure the disor-
der does not recur . There are also self-help and peer support
groups organized specifically for bulimia, but these are less
effective than groups for compulsive overeating.
Binge-EatingDisorder(includingcompulsiveovereating)
Many people with these disorders have unsuccessfully
attempted to control their eating; more than 90% of dieters
return to their original weight or greater within two years.
Treatment professionals recognize that both physiological
and psychological causes underlie the disorder and address
those issues while initiating a weight -loss program. Common
treatments include:
• counseling sessions that focus on changing attitudes and
ideals
• psychiatric treatment that examines underlying traumas
• behavioral therapy to help monitor and control responses
to stress and environmental cues and to change eating
habits
• pharmacological treatment with antidepressants (e.g.,
Zoloft® or Paxil®), the opioid blocker naltrexone, the
antiseizure medication topiramate (Topamax®), or a
dozen other drugs (see "PharmaceuticalTreatmentsfor
Obesity" later in this chapter)
• surgical intervention (e.g., gastric bypass, gastric band-
ing), which mitigates the consequences of compulsive
overeating rather than serves as a treatment for the
disorder itself; 20% of patients continue or soon return
to excessive eating and weight gain after the procedure
Bariatric or gastric bypass surgery for obesity has increased
despite the potential for complications, such as gallstones,
abdominal hernias, nutritional deficiencies, and the need for
repeat surgeries. Approximately 30% of those who have the
surgery develop alcoholism, perhaps due to increased rates
of alcohol absorption or because they transfer their addic-
tion from food to alcohol. 233 Self-help groups, such as OA,
OA-HOW (HOW stands for honesty, open-mindedness,and
willingness), and GreySheeters Anonymous reassure people
who overeat that they are not alone and provide examples,
support, and specific programs for positive change_234
Treatment 9.51
Unlike alcohol or other drug dependencies where total absti-
nence is possible, abstinence from all food is, of course,
impossible . The treatment goal is managing intake and
avoiding foods that trigger binges, such as refined sugars,
chocolate, or carbohydrates. Binge foods provide a person
with much greater emotional relief than other foods,
and they vary from person to person. Some GreySheeters
actually identify their problem as an addiction to refined
carbohydrates and avoid exposing themselves to eating
those substances as an alcoholic would avoid using alcohol
in any form.
EatingDisordersand SubstanceAbuse
Researchers have noted a link between those with an eating
disorder and substance-abuse problems. About 50% of
those with an eating disorder also abuse alcohol or use illicit
drugs compared with just 9% of the general population.
Only 3% of the general population has an eating disorder,
but 35% of alcohol or illicit-drug abusers have an eating
disorder. Both conditions share certain risk factors and
personality characteristics . Risk factors such as common
brain chemistry, familial history, low self-esteem, sensitivity
to stress, anxiety, depression, impulsivity, history of child-
hood trauma (sexual, physical, or emotional abuse),
unhealthy or poor parenting experiences growing up,
unhealthy peer and social pressures, and greater susceptibil-
ity to advertising are generally found in both addicts and
those with eating disorders.
Common personality characteristics observed in both
groups consist of secretiveness, ritualistic behaviors,
obsessive tendencies, social isolation, cravings, and a high
probability of relapse after treatment. Despite the many
similarities, there are some major differences .
• Eating disorders are more prevalent in young women,
and substance abuse occurs more frequently in men,
though both are gaining diversity in gender, age, and
ethnicity.
• The approach/avoidance relationship is different . Those
with eating disorders are constantly trying to avoid food,
I
and those with substance use disorders are constantly in
search of their next hit.
• Recovery in addiction is abstinence from addictive sub-
stances; recovery in eating disorders is abstinence from
specific behaviors (purging, starvation, excessive dieting/
exercising, binging, and body loathing) and the thoughts
associated with those behaviors because one must eat
to survive.
• In recovery those with an eating disorder avoid discuss-
ing their disease with their peers to prevent reinforcing
their negative self-loathing and body image. Those with a
SUD frequently share their experiences with their peers .
• 12-step programs and other means of combating addiction
often rely on acceptance of an external locus of control
(e.g., a "higher power"); some clinicians argue that this
could actually undermine the self-empowerment and
the internal locus of control needed by those with eating
disorders to manage their abnormal eating behaviors. 235
 9.52 CHAPTER 9
PharmaceuticalTreatmentsfor Obesity
In the 1950s and 1960s, legal amphetamines (Dexedrine®
and Methedrine®) were the diet drugs of choice. Once they
were withdrawn from the market, illegal amphetamines and
then methamphetamines remained available . In the 1980s
and 1990s, varieties of amphetamine congeners-weaker
versions of amphetamines, including a combination of
fenfluramine/phentermine called "fen-phen"-were used.
Manufactures of fen-phen became the target of massive law-
suits due to alleged heart damage from the drugs. In addi-
tion, many of the other stimulants used as diet aids also
proved to have an addictive component, creating more
problems than they solved. Rapid tolerance to their anorexic
effects was another complication because weight gain would
quickly return unless the dose was continually increased,
often to near-toxic levels. In the 2000s Xenical® (orlistat, a
fat blocker that was granted OTC status in February 2007),
lonamin ® or Adipex-P ® (phentermine HCL, a Schedule IV
stimulant appetite suppressant), and a dozen other sub-
stances with varying pharmacological actions are used.
A promising line of research opened in 1999, when a Japanese
researcher discovered ghrelin, a hormone that is secreted
by the stomach and the small intestine to signal hunger.
When people diet, the level of this hormone increases, sig-
naling starvation; hunger increases, metabolism becomes
more efficient, and the up-and-down cycle of dieting is
intensified_236 A number of drug companies are exploring
developing a vaccine that would block the effects of this
hormone and stop the sensation of hunger to assist with
weight loss. 237 The other hormones in the human appetite
cycle are also getting some interest. Leptin is secreted by fat
cells in the body and released by the brain to create a feeling
of satisfaction or satiation after eating. Orexin, also known
as hypocretin, is a brain neurotransmitter that is involved in
appetite, wakefulness, and arousal. It heightens the hunger-
signaling effects of ghrelin.
Some of the other drugs in the developmental pipeline
include Axokine® (modified ciliary neurotrophic factor, or
CNTF), an injectable drug that makes the user feel full, and
I
metformin (Glucophage ®), a diabetes treatment drug that
can block the absorption of carbohydrates by the intestines.
There are countless herbal and alleged "natural" weight-loss
products heavily marketed on television, over the Internet,
and in other media.
• One-A-Day WeightSmart, ® contains multivitamins,
green tea extract, cayenne pepper, caffeine, and guarana
and claims to increase metabolic rate .
• Hoodia gordonii, a South African cactus-like plant, con-
tains chemicals that supposedly suppress appetite by
fooling the brain into thinking that the stomach is full.
• CortiSlim® contains magnolia bark, which is said to have
anti-stress properties that inhibit the brain's release of
cortisol and therefore reduce fat and the desire to eat.
• Xenadrine EFX®contains the amino acid tyrosine (a pre-
cursor to dopamine in the brain), green tea extract, and
various other herbs that are said to decrease appetite and
increase energy, metabolism, and wakefulness.
• TrimSpa® contains Hoodia gordonii, caffeine, theobro-
mine, and synephrine, which is touted to decrease
appetite and block fat.
In January 2007 the Federal Trade Commission fined the
makers of One-A-Day WeightSmart,® CortiSlim, ®Xenadrine
EFX,®and TrimSpa® $25 million for making false and decep-
tive advertising claims about their products that were not
scientifically verified. 238
Other psychoactive medications such as cocaine, coffee,
ephedrine-based medications, and nicotine in cigarettes
have been used for weight loss, often with initial successes.
Many substances work initially, but prolonged use dissi-
pates their effectiveness due to the body's physiological
adaptation (e.g., tolerance and a raising of the body's meta-
bolic set point), and the side effects of certain stimulants can
be significant. In general, diet pills (especially amphet-
amines and amphetamine congeners) are recommended
only for short-term use, so careful patient monitoring by
physicians and medication review boards is important .
SexualAddiction
"TigerWoodssexscandal:Golferbeingtreatedfor
sexaddiction
at Mississippirehab."
New York Daily News,January 18, 2010
David Duchovny, Tiger Woods, Jesse James (ex-husband of
actress Sandra Bullock), prominent politicians, and other
high-profile celebrities have all made the headlines because
of sexual addiction. Diagnosis and acceptance of this condi-
tion as an actual disorder akin to substance abuse and gam-
bling addiction remains controversial. The DSM-5 has yet to
include sexual addiction in its compendia of mental health
disorders, although some specific fetishes and abnormal
behaviors are included.
Though no official diagnostic criteria for sexual addiction
have been established, most clinicians use the following
criteria to make the diagnosis:
• continuing to engage in excessive sexual behavior
despite negative consequences (broken relationships,
financial problems, health risks)
• devoting excessive time to sexual activities (porno-
graphic materials, online sex, cruising for partners)
• frequently engaging in more sexual activities than
intended and becoming irritated when unable to engage
in desired sexual behaviors
• escalating the scope or frequency of sexual activity to
achieve desired effect (tolerance)
Behaviors associated with sexual addiction include: compul-
sive masturbation; multiple extramarital affairs; multiple
and often anonymous sexual partners; compulsive use of
pornography, phone sex, or online sex; obsessive dating
through personal ads; unsafe sex; prostitution or the use of

prostitutes ; molestation ; rape ; voyeurism ; stalking ; exhibi-
tionism ; and sexual harassment.
There are a number of theories about the etiology of sexual
addiction , ranging from brain chemistry abnormalities, to
sociocultural stressors, to childhood sexual abuse , to cogni-
tive-behaviora l theories, to psychoanalytic theories , to com-
binations of more than one theory One theory suggests that
predisposed individuals experience an intense form of
sexual stimulation when young, identify it with a parent
(usually the mother), and come to anticipate that the
behavior will provide pleasure or relieve pain or tension.
The experience is often in conjunction with covert or overt
seduction. Because of this relationship to early childhood
sexual experiences , the treatment must address childhood
development along with the mechanics of the addiction.
The treatment often includes behavior modification (e.g.,
aversion therapy) ; cognitive-behavioral therapy ; group,
family, or couple's therapy; psychodynamic psychotherapy;
motivational interviewing; and medications (often to
reduce the sex drive) .241 The concurrent use of addictive
substances is more prevalent in this group than in the gen-
eral popu lation because predisposing factors in all addic-
tions are so similar and because psychoactive drugs are often
used to affect sexuality (e.g., to lower inhibitions or enhance
arousal). Recovery from sexual addiction , like recovery from
drug addiction , is a lifelong process.
Sexaholics Anonymous Sexual addiction is difficult to treat.
The sense of being alone in their addiction or what
they consider a unique behavior is alleviated when sexa-
holics realize that there are millions of others with the
same problems.
ZIGGY0 2003 Ziggy& Friends,Inc. Reprintedby permissionof UniversalUclick
Treatment 9.53
'When we cameto SA. we found that in spiteof our differences .
we shareda commonproblem- the obsessionof lust, usuallq
combinedwith a compulsivedemandfor sex in someform. We
identipedwith one anotheron the inside.Whateverthe details
of our problem, we weredqin9spirituallq-d qin9of 9uilt, fear,
and loneliness
. As we cameto see that we shareda common
problem,we alsocame to see that for us thereis a common
solution-the 12Steps of ~coverq practicedin a fellowship
and on a foundationof what we call sexualsobrietq."
Sexaholics Anonymous, 1989
The primary issues associated with sexual addiction are
feelings of shame, guilt, anxiety, and depression . Those
issues can be addressed in therapy groups , in individual
therapy, and at Sexaholics Anonymous and Sex Addicts
Anonymous meetings . Unlike recovery from a drug addic-
tion , complete abstinence from sex is unreasonabl e, so the
goal becomes abstinence from compulsive destructive sex-
ual behaviors . Associated behaviors that need to be addressed
are control problems , secrecy; isolation, distorted thinking ,
and emotional distancing.
ElectronicAddictions
(Internet, gaming,cell phone)
"/nternet9amin9addictionled to babq's death-a South
Koreancouple'sthree-month-olddau9hterdied of malnutrition
whiletheq wereraisin9 a virtualchild in an online9ame."
CNN, April 2, 2010
Whether Internet addiction is an actual mental health disor-
der remains controversial even though 335,570 cases of this
condition were filed in South Korea in 2009, and 12.8% of its
teens are reported to be addicted to the Internet , according
to a May 30 , 2010 , KoreaHerald report .244 Part of the reason
for the lack of acceptance of Internet addiction as a true
addiction is that studies that defined it used inconsistent
diagnostic criteria, defective sampling bias, and several other
research flaws.245 To address the issue of inconsist ent diagno-
ses, researchers have proposed standard criteria for
I
Internet addiction :
• a preoccupation with the Internet (obsessing about pre-
vious activity and anticipating the next online session)
• becoming restless, moody, depressed , or irritabl e when
attempting to cut back or stop Internet use
• the need to use the Internet for increasing amounts of
time to achieve satisfaction
• repeated unsuccessful efforts to control, cut back, or stop
Internet use
• staying online longer than originally intended and using
the Internet to escape problems or relieve negative mood
states (anxiety, guilt , depression , helplessnes s)
• risking or suffering from problems with relationships , job ,
education, or career opportunities because of Internet use
• lying to family members, a therapist, or others to conceal
the extent of Internet involvement
 9.54 CHAPTER 9
Experiencing the first two criteria and any one of the other
Internet use behaviors for at least three months with at
least six hours of nonessential Internet use per day meets
criteria for diagnosis oflnternet addiction disorder. 246
Internet addiction can lead to other computer-related addic-
tions such as cybersexual addiction , online gambling , com-
puter game playing , or any combination of these .247 Because
the disorder is so new, treatment personnel and treatment
facilities are rare; and because the Internet is part of life
and work situations , it is hard to give up use altogether ,
particularly if use is connected to one's job . The abstinence
model is often impractical, necessitating a harm reduction
model instead .
Richard Davis of York University, who studies Internet addic-
tion extensively, offers these 10 suggestions to help patients:
1. Move the computer to a different room to change a num-
ber of environmental cues that have become familiar.
2. Never go online alone. Always go online with someone
else in the room (or at least in the house).
3. Create an Internet use log. The actual hours of use are
often a surprise to users.
4. Tell people about your problem . It is necessary to break
the isolation caused by excessive Internet activity.
5. Exercise regularly. This overcomes sedentary habits
of sitting in front of a computer and improves general
health .
6. Never use an alias online .
7. Take an Internet holiday, from one day to several days or
a week.
8. Stop dwelling and obsessing over Internet addiction.
9. Help someone else contro l their Internet addiction.
10. Get professional help (e.g., a psychotherapist , coun-
selor, or mentor) or attend a self-help group .248
Internet addiction has grown rapidly in China , where a
recent report found that almost 14% of Chinese teens have
I
been identified as compu lsive Internet users. The Chinese
government initiated a nationwide campaign to combat this
depend ence and funded the development of eight tough-
love military prison-like inpatient rehabilitation clinics
across the country . Parents pay upward of $1,300 per month
(about 10 times the average Chinese salary) to send their
children to these clinics, where treatment includes counsel-
ing, military discipline, medications, hypnosis , and aversive
electrical shock. 250
Although the roots of addiction are similar among all people ,
treatment that is tailored to specific groups based on gen-
der, sexual orientation, age, ethnicity , job , and economic
status is more effective.
Men vs. Women
Male treatment admissions oumumber female admissions
by more than 2 to 1 (68% male, 32% female). Men were
more likely to enter treatment through the criminal justice
system .164 In general , women substance abusers progress
to addiction more rapid ly than men, die at a younger
age, are less likely to ask for and receive help, and often
enter substance-abuse treatment throug h the mental health
treatment system.
Research at the Haight Ashbury Detox Clinic discovered that
the process of addiction and especially of recovery varies
dramatically for men and women . Men are often external
attributers , blaming negative life events like addiction on
things outside their control, whereas women are more
often internal attributers , blaming themselves for their
problems. When this is extended to their views of addiction ,
men often blame a wide variety of external forces for their
dependence on drugs , whereas women often inappropriately
blame themselves for being bad, crazy, immoral, or stupid.
The counseling and the intervention often used in treatment
focuses on early confrontation to break down addicts' denial
and make them accept their condition. While appropriate for
men who are more commonly externa l attributers of nega-
tive life events, this treatment approach with many women
merely reinforces their guilt and shame and often prevents
them from engaging in treatment or compels them to prema-
turely discontinue treatment. Treatment approaches that
are more supportive and less confrontational result in
better outcomes for women .
Because women are usually the primary child care providers
in a family, programs that provide child care make it easier
for a woman to participate in treatment. Women lack trans-
portation more often than their male counterparts , so pro-
viding bus tokens, vans , car-pooling, or other means of
transportation also results in higher success rates . About
60% of treatment facilities offer female clients such services
as transportation assistance , transitional employment , fam-
ily counseling , individual therapy, and relapse prevention .251
A survey of 400 women in recovery attending a conference
called Women Healing: Restoring Connections supported by
the Betty Ford Center , the Caron Foundation, and the
Hazelden Foundation in 2001 found that the three greatest
barriers to seeking addiction treatment were:
• an inability to admit the problem or simply not recog-
nizing the addiction (39%)
• a lack of emotional support for treatment from family
members (32%)
• inadequate child care while in treatment
Youth
The drugs of choice among adolescents vary from decade to
decade , although alcohol , cigarettes , and marijuana remain
the top three. Over the past decade, use of prescription

drugs, part icularly pain killers and sedative-hypnot ics, has
been on the rise. Many adolescents believe that prescript ion
drugs are safer than street drugs because they are legal. The
same belief applies to alcohol and cigarettes. Teens consider
marijuana relatively harmless and believe it should therefore
be legalized.
Teens often fail to recognize consequences that are not
immediate . The idea that a three-month flirtation with
cocaine will necessitate a lifetime of recovery is beyond their
scope. Reacting to the idea that 30 years down the road
smoking will shorten their life span and heavy alcohol use
will cause health problems does not register. Because the
ado lescent 's temporal hor izon is immediate and present
oriented, treatment must be molded around goals that
are achievable within a short period of time and rewarded
or reinforced immediately.
Simple treatment incentives or awards can provide immedi-
ate motivation to inspire better treatment engagement in
yout h . The "fishbowl" is an example of a simple incentive: a
fishbowl is filled with 250 or so folded slips of paper; a dozen
are passes to a local movie theater, and one delivers the top
prize of an iPod. The rest simply say, "Thanks for coming to
group." Such incentives have demonstrated an increase in
treatment adherence. 252
Because early-onset drug use is the single best predictor of
future drug problems in an individual, it is crucial to begin
treatment (and prevention) efforts as early as possible. 253
Individuals who delay their first use of psychoactive sub-
stances until after the age of 25 rarely develop chemical
dependency problems . The human brain develops slowly
from back to front and is not functionally mature until age
25 . An adolescent is less able to make good decisions
and control compulsive drug use before these areas are
fully functional, making continued use or relapse during
treatment more likely. The frontal cortex execut ive decision-
making area of the brain continues to develop until the
age of 40.
Dur ing puberty (ages 12 to 14), sexua l hormones kick in and
mod ify brain chemistry, creating emotional mood swings
that are conducive to drug use as well as to sexuality, so a
counselor must also deal with these delicate issues in treat-
ment.254·255 Decreased activity in the left ventral medial
prefrontal cortex has been observed in both chemical depen-
dency and impulse-control disorders. This affects temporal
processing, the ability to make and carry out long-term plan-
ning, as well as delay discounting, the current term used to
describe an inability to delay gratification. 256It also makes
rational thinking and development of strong cognitive
skills more difficult .
Contrary to the perception that young people are deeper in
denial about their addiction than adults because they believe
themselves to be invulnerable to drugs and other risky
behaviors, evidence ind icates that the real reason is because
young peop le have an immature prefrontal cortex, so risk-
taking may be hardw ired into the adolescent brain.
Compared with adults, teens have actually overestimated
Treatment 9.55
the true risks of their potential actions . They take risks
because their perception of the potential benefits of the
activity outweigh their exaggerated perceptions of the
risks involved . Perhaps treatment and prevention efforts
should focus more on downplaying the benefits of alcoho l
and drug use-explaining that the benefits of drug use are
much less reward ing than what most believe them to be. 257
Normative assessment exercises with youth have helped
expose many misconceptions about benefits obtained from
risky behaviors like alcohol or drug consumption.
Finally, studies confirm that young people are less willing to
accept guidance or intervention from adults than they are
from their peers, 258 so to be effective, programs for young
addicts attend must be targeted around peer interact ion and
guidance. 260
Older Americans
Medical advances have allowed older Americans to live lon-
ger than prev ious generations, and the ir numbers have
grown disproportionately to the general population. At pres-
ent 37 million Americans are 65 years or older . That figure
will increase to 54 million by 2030 primarily due to the Baby
Boom generation; by 2050, 85 million Americans, about 20%
of the projected population, will be over the age of 65.261As
th is popu lation grows, the ir prob lems with drug overuse ,
abuse, and addiction will increase along with the need for
more available treatment. It is projected that most of the
Boomer generation's problems will be the result of abuse of
legal prescription drugs, OTC drugs, and alcohol. Since
2000 the abuse of prescription and OTC drugs has doub led
in the adult popu lation and trip led in the adolescent popula-
tion. About 22% of all seniors use a potentially abusable pre-
scription drug, with users of opioid painkillers compr ising
about two-thirds of that total.262,26J
,264,26s
Data from a publicly funded treatment program in 2005
demonstrated that 80% of seniors treated for substance-
abuse problems identified alcohol as their main drug. The
I
remaining 20% reported using the following substances,
compared with other age groups seeking treatment:
• opiates (heroin or prescription pain medications), 5%
compared with 13% for other age groups
• cocaine, 4% compared with 14%
• marijuana, 3% compared with 18%
• stimulants (methamphetamine and others), 1% com-
pared with 6%
• only 17% of those treated for alcohol reported a second-
ary illicit substance of abuse compared with 52% of other
age groups in treatment 251
It is often difficult for healthcare professionals to spot drug
and alcohol abuse in this population. In many cases, it is
not part of the assessment when a pat ient presents with a
physical prob lem .
 9.56 CHAPTER 9
FactorsThat Contribute to ElderlyDrug
Misuse and Abuse
1. Illness exposes the elderly to more prescription drugs.
2. Physical resiliency declines with age, so psychoactive
drugs have a greater effect on the older user.
3. Misconceptions and attitudes on the pan of physicians
and the general public affect treatment :
• Seniors do not abuse drugs or alcohol.
• It's too late in life to address addiction.
• Seniors have earned the right to abuse drugs; addic-
tion is pleasurable.
• By age 65 a person is either too smart or has already
burnt out and is done abusing alcohol and/or drugs.
• After 65 there is not enough time left in a person's life
to develop a severe alcohol or drug-abuse problem.
4. Health professionals are inadequately trained on geriat-
ric medication and chemical dependency issues .
5. There are age-related physiological changes that
potentiate the effects and alcohol/drug toxicity. With
increased age there is:
• decreased gastrointestinal acid secretion, motility, and
blood flow
• decreased lean body mass and total body water and
thus less dilution of a drug
• decreased plasma albumin to bind and keep drugs
from being too toxic
• decreased hepatic blood flow and increased hepatic
cell/function damage
• decreased metabolism due to fewer and less efficient
liver enzymes and decreased stomach enzymes 262
• half to two-thirds the metabolic rate of middle-aged
individuals
• decreased kidney function
• increased receptor site sensitivity; alcohol and depres-
sants depress brain function more in the elderly,
impairing coordination and memory, leading to falls
I
and general confusion 266
6. There is a lack of adequate social and support services
for seniors . They need support to combat not only their
dependence or abuse but also:
• isolation and loneliness
• retirement, ageism, and inactivity
• rejection, disrespect, and abandonment by family and
the community
• relationship problems, death of partner and friends,
and survivor guilt
• lower overall satisfaction with quality of life
• financial or housing stress
• coming to terms with chronic illnesses, persistent
pain, or impending death
• loss of physical appearance and abilities
• frustration over memory loss and decreased cognitive
ability
7. The community enables seniors to manage their own
alcohol/drug-abuse problems and to avoid medical
detection and legal problems.
Also, many older Americans view addiction as a character
flaw rather than a disease, so they are less likely to seek
help for any problem use of alcohol or other drugs. Medical
professionals often ignore signs of alcoholism or addiction in
the elderly out of respect or a mistaken belief that they are
less likely to be addicted. Signs of addiction are often misin-
terpreted as pan of the aging process or as a reaction to pre-
scription medications that are commonly taken by this
group. There is less physical resiliency in those over 55,
so problem use of alcohol or other drugs occurs at lower
dosages than with younger people.
The House Select Committee on Aging has reported that
about 70% of elderly persons hospitalized show evidence
of alcohol-related problems (although they might be hospi-
talized for some other condition) . It is estimated that about
2.5 million older adults are addicted to alcohol, drugs, or
both; this is out of a population of more than 60 million
Americans over the age of 55. 261 This number has risen
dramatically as the Baby Boom generation turned 65.
Treatmentof the ElderlyAlcohol
or Drug Abuser
At present there are few treatment programs aimed specifi-
cally at older Americans; as the percentage of seniors
increases, the need will grow. Older Americans with a
substance-abuse problem do better in therapy groups with
people their own age, although mixed groups do work.
Though substantial research has been done to validate diag-
nostic criteria and treatment of alcohol abuse in the elderly,
most substance-abuse diagnoses and treatment strategies are
neither age-specific nor sensitive enough to effectively
accommodate the unique biological and social condition of
an older substance abuser. 262 Two screening tools have been
validated for assessing alcohol abuse in this population: the
CAGE and the Short Michigan Alcohol Screening Test-
Geriatric Version (S-MAST-G).267 Outcome-focused investi-
gations continue to demonstrate that older alcohol- and
substance-abusing adults who receive treatment specific to
their needs achieve positive health outcomes. The treatment
may take longer because alcohol and other drug withdrawal
may be more severe in older patients, but detoxification
can be managed safely in this population. 268
Available evidence indicates that the traditional range of
treatment modalities (e.g., residential and medical model)
and the spectrum of interventions (e.g., group and motiva-
tional counseling) that are effective in treating younger drug
and alcohol abusers are also effective for older patients if
age-related innovations are made. 268 For instance, elder sub-
stance abusers may suffer a greater degree of cognitive
impairment (e.g., problems with verbal abstraction), and
research suggests that this is associated with a poorer prog-
nosis in treatment . Treatment that addresses this impairment
can improve participation and outcomes. Groups, brochures,
 Treatment 9.57

an d wait ing-area reading material that focus on the benefits
of treatment can also promote increased participation and
positive outcomes. 269
EthnicGroups
According to the U.S. Census Bureau , one-third of the U.S .
population is non-White (Black, Hispanic, and Asian). 270
This does not include first-, second-, and third-generation
Whites whose cultura l traditions greatly influence their
lives. Recognit ion of cultural variances among groups yields
better treatment outcomes . Studies verify that treatment
specifically targeted to different ethnic and cultural groups
promotes continued abstinence more effectively than gen-
eral treatment programs .271 .273 Today cultural competency
and culturally consist ent treatment are key components of a
successful program .
Culture is not necessarily defined by the color of skin, the
region of orig in, or a common language but rather by a
dive rse const ellation of vital elements: customs, values, ritu-
als, norms, religious beliefs , and ideals . The more specific a
program is in addressing an identified group 's cultural needs,
the more effective it will be .274 •275
AfricanAmerican
African Americans made up 20.9% of the admissions to
publicly funded substance-abuse treatment facilities
although they const itute only 12% of the U.S. popu lation.
65
60.80/o
60
55
DrugTreatment
Admissions
50
byRace/Ethnicity-
2010
45
40
"-'
00
35
30
d'
Men outnumbered women by 3 to 1. African-American
female admissions were proportionately more likely to
involve hard drugs (alcohol , 7.9% of admissions ; cocaine ,
27.4%; opiates , 8.5%) than were African-American male
admissions (alcoho l, 26. 1% of admissions; cocaine, 51.6%;
opiates, 15.2%). African Americans also had significant
treatment admissions for marijuana (22.8% ma le and 7%
female for all 2008 admissions), hallucinogens ( 12.6% male ,
5.9% female) , and PCP (37.1% male, 20 .6% female) .66
A recent study examined retent ion rates in drug treatment
programs in the Los Angeles County area and found lower
completion rates among African-American clients (17.5%)
compa red with Whit e clients (26 .7%).276 Economic status par-
tially explains this disparity, but familial stressors, environ-
menta l factors, and different beliefs, attitudes, and behaviors
toward health may also have contributed to the disparity. 277
A surprising lack of research has been done to examine the
discrepancies among different ethnic groups, especially
when it comes to treatment. The follow ing differences in the
treatment/intervention needs of inner-city African-
American substance abusers are the findings of members of
the Haight Ashbury Detox Clinic and the Black Extended
Family Program at Glide Memorial Church after many years
of experience working with the African-American commu-
nity in San Francisco .278
Higher Pain Threshold Historically , African Americans devel-
oped a high pain threshold to help them survive in a harsh
and painful environment . Unfortunately, this tolerance for
suffering delays a cry for help, which causes more-severe
addiction and other life problems before entering treat-
ment. Coupled with this is a tendency to avoid bureaucratic
agency-based services that failed this popu lation in the past.
One solution to getting addicts to treatment sooner is edu-
cating th e African-Amer ican community on the true impact
of drugs .
• In some urban areas, an alarmingly high number of
African-American babies are born drug affected .
• African-American teenagers have a greater chance of

I
25 dying from drug-related crime than they do from being
20.10/o
20 hit by a car.
15 13.00/o • There are more African-Amer ican men in their twenties
10 in jail for drug-related offenses than are in college .

2.40/o
• African-American women use crack more than any
1.00/o other drug except alcohol, resulting in the dissolution
0
White Black Hispanic Native Asian/Pacific of their family structure at an alarming rate.
American Islander • Many urban neighborhoods with a large African-
American population have an extremely high infant
mortality rate due to drug use by pregnant women who
The racial compositionof admissions to drug treatment programs has abuse or are addicted.
remained fairly consistent since 1992 and proportionallyis somewhat
Drugs as an Economic Resource Few economic windfalls are
differentf rom the actual compositionof the U.S. population. Whites
are 72% of the U.S. population but only 60.8% of admissions to drug available to those living in inner-city African-American com-
programs, whereas Blacks are 12% of the population but 20.1% of munities, and when drug-dealing activity is reduced, the
admissions. resu lt is a loss of income to many families . This is in contrast
TEDS, 20 12 to the European-American commun ity, where drug and alco-
hol abuse usually drains the financial resources of families .
 9.58 CHAPTER 9
Many dealers are unaware of the true economics of the
process . Once a dealer becomes a user, the economic drain
begins. Other members of the community are devastated
and become dysfunctional; crime is brought to the ir own
backyards.
"Most African Americanscome into recoverqbq waq of the
criminaljustice sqstem, verqlate in the whole processof
addiction, and are compelled to come to pro9ramslike
Glide or Hai9ht Ashburq bq the courts. So theq have a whole
differentattitude than the people who have hit rock bottom and
decided theq've9ot to seek help. The kids are more concerned
about just finishin9their term and finishin9whateversentence
theq have and 9ettin9 out. Theq don't want to deal with
counselors.Theq don't want to deal with advice. So what
qou've9ot is a chance, at that point, to trq to hook them into
some kind of sqstem that allows them to 9et back into societq
with a sreater chance of success."
Youth drug counselor
Crime Leading to Chemical Dependency Often crime, rather
than drug use, is the first entry into the chemica l depen-
dency subculture. In the African-American community, the
pattern is to make the sale first and then sample the wares
later; in the White community, it is the opposite.
StrongSenseof Boundaries Intervention is viewed as an inap-
propriate imposition or violation of one's space . There is
resistance from within the community to approach someone
with a chemical dependency problem because that would
violate the person's boundaries or turf . Not approaching
someone perpetuates denial. These problems are the most
difficult to address and require a major change in attitude. ls
it better to respect one's turf or to attempt intervention and
try to do something about the prob lem?
Chemical Dependency:Primary or SecondaryProblem? Minority
communities often cite underemployment, poor housing,
and lack of social/recreationa l resources as their primary
problems before citing chemical dependency. This perpetu-
ates denia l and prevents many addicts from getting into
I
treatment early. Drug users must understand that no other
issues can be tackled successfully without tackling recov-
ery first. The community needs to accept chemica l depen-
dency as a primary problem.
"Recoverqis a lifetimeprocess.That's a verqdifficult thin9 for
African Americansto focus on. We're sprinters.We're real900d
at the 50-qard dash and the 100-qard dash and we have a
feelin9that, okaq, it's a dru9 problem. Once I stop usin9and
I put it behind me, I can for9et it and 90 about mq business.
But no, recoverqis a lifetimeprocess,and qou have to think
more in terms of bein9a marathoner."
Rafiq Bilal, former director, Black Extended Family Program
ConspiracyTheory The belief that the rapid spread of crack
(and AIDS) in the African-American community is deliber-
ate genocide is widely held among Blacks. Given the history
of slavery, segregation, and de facto segregation, this is
understandable . Whether or not the conspiracy theory is
true, addiction is still a disease that must be treated in the
individual as well as in the community as a who le.
Revelations In the African-American community, organized
spirituality is key to promoting recovery. Faith-based treat-
ment programs in church settings are more effective than
traditional treatment settings. In one study in Arkansas's
Mississippi River Delta region, one-third of a group of drug
users consulted with clergy, and everyone reported signifi-
cant religiosity. Members of the clergy who were interviewed,
however, said they were not as prepared or knowledgeab le as
they should be in the field of substance abuse_27'
'The African-Americancommunitq is verqspirituallqoriented
whether becauseof involvementwith the church or from
historicalassociations.Most interestin9is a recoverqpattern
of consecutiveperiodsof clean time/relapse,clean time/
relapse,until a revelationor 'snappins' occurs that resultsin
a continuoussustained recoverqeffort. This is differentfrom
the more classicexpandin9periodsof sobrietqleadin9toward
more-sustainedlon9-term recoverq."
Rafiq Bilal, former director, Black Extended Family Program
The Black Extended Family Program under the guidance of
the Reverend Cecil Williams uses the power and the emo-
tional force of the extended family to help keep people in
treatment and give them an alternative to the lonely, isolated
life of the addict. This concept reestablishes family, spiritual-
ity, and self-worth-qualities that have been weakened by
drug use. The Terms of Resistance, a 10-step equivalent of
the 12 steps, was developed by Reverend Williams in 1992:
1. I will gain contro l over my life.
2. I will stop lying.
3. I will be honest with myself.
4. I will accept who I am.
5. I will feel my real feelings.
6. I will feel my pain .
7. I will forgive myself and forgive others.
8. I will rebinh a new life.
9. I will live my spirituality.
10. I will support and love my brothers and sisters_278
Hispanic
In 2010 the U.S. Census Bureau estimated that 47.8 million
Americans (15 .5% of the U.S . population) were of Hispanic
origin, including those currently living in Puerto Rico
(3.4 million) and undocumented Hispanics living in the
United States (5 million). In Los Angeles, Hispanics repre-
sent 4 7% of the population and in San Diego, 25%.
The breakdown nationally is approximately 58.5% Mexican-
American, 9.6% Puerto Rican, 4 .8% Central American,
3.8% South American, 3.5% Cuban-American, 2.2%
Dominican, and 17.6% other Hispanic groups. 28 0
• In 2008, 258,000 (13 .8%) of all those in substance-
abuse treatment in the United States were of Hispanic
origin . This percentage nearly matches the Hispanic
percentage of the general population.
 • Th<>< •dmi»ions w<r< Mexican (~ .7"1',), Pu<rto Rican on•ndadminiotntoB,•ndb<willingtotre>tthewhol,
:~:-!~~ban (0.2%) • nd other . nonsp<cified (4.1)%) familybttau«Wllilyis!iO•ignific>ntinHi•p•nicculture•
Hi,panic -Am,rican&mili<>baveac< ll<ntn<lworking,yo-
• Th, me>l common primny ,ub5tanc,s of >bu« m:iong l<mslbat canb<u«dextrn5v<ly "nth<tr<almrnlproc<>•
Hispanic, who pr<«nt<d th<m«lv<> lor tr<>.tm<nt lnaddition . thetr<almrnl&cilit)"shouldb< •w:1reofth<di ..
W<r<>lcohol(21.i%).op i• t<•(l2.9%).rndmarij= tinct a ndcleorrol<>tbat uch!amily m<mb<rpb.y, inth<
(18 .8%) . The•dmi>oionsforop i•t<abu«w<r<twicetbat Hi,pankfamilydyruomic.Thi,isincontr:l>ttomon)"Whit<
of non -Hispanic groups &milie,, whue the role, of <>ch m<mh<r can ,,.'}. ~ • ~Y-
• Hispanic admi>oions w<r< 78% ma!, • nd 22% f,ma l, The COT< .,p<cto of Hisp>nic rulture, ar< dignidatl • .-csp<to
rompamlwith66%mal e •nd32%f<mal<ov<nll. "' ycarillo-dignity,rupect , •ndlov,.Th,conc,ptofroutine
urin<l<stingcanb< a touchy,ubjectbecaus,ther,qu<>tfor
Gratdisporiti<saistforHisJ>llllc,ubstane<•buser, . Th,
•urin<l<>l impli<>•lxkoftrust . Anothu .. p<ctofHispanic
20\0,stimat«!HispanicJX>pul.otionisl~ ..'!%ofth<US.pop-
rultur,sisthe,trongro leof,piritu>lity.ln•dditionto a
ul.otion •nd +t% to -t~% of fed,W drug offend=; • gratu
numb<roflir,t -timeoff , nd er,•reofHi>panicorigin,a,;w e ll Catholich<ritage,thenumbeTSofPrnt<oostalandJeh=h•
\'1·ne,s churches are "nc · "n "is, .n·c commu "ti ,
l.i!<time,tal<orfedefllldrugincarcu:otionprobobilit)"fOT
md!iOme«gm<n"holdnonorthocloxreliglou,lxlid, . ,uch
HisJ>llllcsislourtimesth.otof\Vhit<s,andpercapitaiocar -
c,ntionforHisJ>llllcmol,sistwic,tbatofWhit<male,_ "'' a,;spirituali,m . Sant<ria,Bruj<TU..•ndCurmd<rism

ThereisgreatrultunldP,'e15ity • mongHispanic• . • ndtha,

•re•imil.oritie,Hw<llHdiff<r<ntt<>monggroup•.The
most common simil.oriti,s •re >p3Ilish b.ngwoge. Catholic
backj;round, lndi>n or AfriC2n tr.tits . lbaun herit2g<. •nd
,trongWlli l,-otructure . Thediffuenc<>>r<th<numh<rol
yu,.orgenentionsthcybavelivedinthel'nit«!Stat<s;th<ir
oountryoforigin(primari ly).leJ<ico. Pu,noRico.andCuba);
thdr levdofeducation;•ndthdr<ronomic,tatu,(,.g .,•re
th<)" Mexic•n migr:,nt WOTk<rswho immignl< to ,urvive
povuty•nd hdptheirfamilybackhom<;>r<the)"upp<r-ct...
).\exic•n,;OTCo,;taRic•ralookingtoprot<ctth eirwalth;•re
the,-midd le- •ndupp<r-ct...CuNmwhofledFiddC.,tro a
g<n<ration•go•ndarenow a dri,inglorce!nthe Florida Asian and PacificIslander
<ronomy;or • r<theylowu -,middl< -,>ndupper-cl._..Pu,no
There a r<n<lllyl0millionAsi>nsand Pacific bl.onden
RicanslAmericanciti,<n>I whomowdtotheEastC oastlo
(APl,) lh-inginthe UnitedStat<> ."° • ndthi>figur<is
find a b<tt<rlifrfOTthdrfamili<>l)
expectedtogrowto33millionby2050. Most of the AP!
One, my <Til<I)!<ncyph)~ ical or men12l health needs have popul.otions•r<concrntnt<din \Oor 15 ,tat<>.Califomi>
lx rn addr<>«d . • treatmrnt facility m ust then d<t<rmin, h2'1heb.rg<>IJX>pub.tion(•bont6million) . lollowedb)"
th< Ind oFaocultur.o tionofHi,panicclirntoromi ngin NewYork(l.7million) . Thi,demographicrepre,ents56 .4%
fortre>tmrnt . Howw,lldothey,pakl'nglish;•r<th<)" ofth,101>IJX>pu la1ionofH..w•ii ..-.. A,ub<ta nti>lproJX>rtion
n<Wl)"• rrh-edimm igr.,nts;how inl<gr.,t<d•re the,-inthe ofthisJX>pul.otionr,pr,sentsr<crntimmigr,nto . moretham
predominantly Wh it< !iOCi<ty;are they fi,., ., ,econd-, or 35%olwhom•p<•k•nAsianbngu.,.g<Olhom<
third-g<n<ralionHispmicowhoare awar<ofthdrrulturol
heritageandk<epincontactwithfri<ndsrndreb.ti,.,.in Like Hispanic JX>pulation,, A,iaru and Pacific bl.ond<n
repr<=t•widevori<tyofculture, . Thedifferenc<Sinclud<
~~::,:,ou::~ou~ . ::t;ih:.::..~? caught b<tw«n two • distinctand«parat<<thnicgroup,(,uch a, Japan=,
Filipino.Cambodian, lndian, a ndS.IDNn-mor< than
lnNewYorkth<r>pidinfluxofPu,noRicam inthel950,, '40distincti,,egroupsofAPl,lh,eintheUnitedStat<,)
1960.,•ndl970.oft<nc•used•f,_ntationofthe
• many lang,ug<>(,uchuKOT<>n.Chin=.T•galog,•nd
ext<ndedWilily,yst<m, •JX>l.ori::a tionb<tw«ng<n<rotiom,
hundredsmOT<)
•lossofmE1y np<c"ofthePuerto Ricancultur<e.and>n
identirycri,is . Th"""'"'°"••longwithl.onguagediffer - • diff<r<nt religion, (from Buddhism •nd Hinduism to
rncn.werefoundtob<re,JX>n,ible(in a NewYorkStat<,ur - Animism,l,Lom.mdChristianity)
•'<)·)lorincru«sinsub5tane<abuse . WithCubanAm<rican,, • • vari<t)"ofstrongculturolcbar.tctuisticsbas<donthou -
however,theropidint<gr.,tionintoAm<rican50Ci<ty~ Yndsofyar,ofhistory

:r,,:~~/c:::;~;:J,:1:'
;:~:.!'.;~.=~ of the • distincth,e culture, md langu•g,s a mong immigr.,nto
lromthe,.mecountry(, .g..Canton«<.Sbanghaln=,
All ofth e«& ctorsr,qulreHispanictr<atmrntprogr.uru;to and T• iw• n,.,_ 11from Chin.a)
hellaibl,.hli v<•dP,',n,e,uffwith•prepondrnmc,of • wryi nglevebof • ccultu rotiond <p<ndingonthenumh<r
Sp>nish .. pnki ngand/o,bili nguilan d biru ltunlcounsel-- ofgrnaationsthcybav,lxeninthel'nit<dStal<>
Mon)· Chine «-A m<TiC2I1and J• pane« -Am<TiC2I1famili<, begins . lJnleHtreotmentprogmns for Asian Americans
lracetheirfamili<,backfoororfivegrnentiom,wherea,the involvethefamily , theoddsoF,uoce,..,egrtttlylowered
newer ·mmigr.ma, ,uch a,; L. "• 'Vtruom<><, Korean,
ANilobleJ>rosr01MBeaweolthewidevari<1yofA,W1 -
Hmong,andThai,gobackonlyoneortwogenerations. '"'
Am<ricanculture ,,th ehistori cal imporunce • nd•vail •bi lity
ofceruindrug,,andthewidegeogr.,phicdistributionincit-
• manp~ide•longthePacificRim ie,sa nd, tatesofvar:iou,group, . neighborhood•urv<y!l a r<
criticalinthedesignandthe,electiono l tele-.c,nttrttlmrnt>
• ••trongregardfOTWllilywitheruneshedfmtlly')"t<IIIS
For u:,mp le, the we of trntmrnt ,uvic,. by Asian
• •highresptttforeducation Am<Tican, inSanFranci5COinthel980s" .. '"'tr<melylow.
• :,i:~i:L:enr><M in their communication •bout peo- This wa,; misint<rprrt<d to m ean that Asian Am<Ticam hod
fewer drug probl em, than othu ethnic group, . Community
• r<S<Crvationsaboutexp=ing m:ompl;.l,mena becau .. ,ur,~ ... howevu , lounduhighanincidrnceoldrugabuoe
of•beliefthatthi,wouldbe•fonnolarrogontboa,ting inth<Aslancommunity••inanyotherethnicgroul"' . The
• areluct1ncetodiocu .. healthi,sue,ordeathbeauseof diffuencew•sthat Mia n Americans ' drug,olchoic:,,,,..,,.,
a,upu,titiou,belielthatitwouldcawethoseproblem, -ti,..,.,particulariy m«1Qu .. ludes • (a hypnotic now
onlyillicitlycounl<Tfeited) mdSoma, • •.,da tingmu,cle
r,ciaxant,which"1er<notaddre,,edinmo,ttrtttmentpro -
gra ms . \Vhen ,.n Francisco Bay Area treatment service,
developedthe Aili.nAm<Tic mRecov ery><JVices,•ru ltur -
Keyi,.ue,forAPJpopulationsincludeimmigration,accul -
allyconsi<ten t A,i • n-Americanprogr•mincorporatingfam -
tuntion , andint<Tgenentionalconllict,. Thedifficulti<,of
ilythe r.tpyinth etrtt tmentof,e daJve abu«, administ<nd
a newlanguage,thepr<>0uresolbeing • minority , andthe by pe=mnel who w= bilingu •I and birultural , there wa,; •
l« ling,ofloss , griel,"'P"ration , andHO l•tio n uthey • djust dra 1 J 'ncraseofA 'anAme ·canscom · ~ · to treatment
toanewoountry---;0llcanacta.sri,k!actor,lordrug•~
atale,,.,loonsistentwiththeiro,1er.tllpopula1ioninthe
Thelouoftroditionalcultura l , .. lue,duringtheproce<Sof
region . Utiliz:otionol1U. tioruoldrugtrtt1mentservic<>by
..,i milationcan leadtodrinkingandothadrugwea,•woy
APlpopu l•ionsincreasedJ7%betw«nl99'1and 1999 ."'
tode.olwiththatst=c a nd . firuolly, becau .. theyounger
grnaationad.pamorequicklytoth e newcoltme,conflicts Themo,t commonlyU>rodrug,in APlco mmunities wry
withthrirparenaovatraditional, .. lue,•rH< .'"' Therei, • Chinese-tobo.cco,alcohol,md«dati,.,,
al,o a high co-occorr=ce of problem and pathological • J•pa ne......., lrohol, marij uana, to bacco, crack cocaine
~~:~nf,. !~~~:n•:~::::;abusing populations that -•iv<> . and meth•mphewnine
• Kore.o,......., kohol (whiskey and rice wine) and cnck
AslanAmerican,respondmoretocredrnti•ledprofeHion-
a l,thantopttrcoun,elors a ndpreferindividuolroun,d - • Filipino-;aokohol,marijuan,,,andcocaine
ingtogroupcouruding.Theybelieveitistheirper,onal • \lie1JU.me,e- tobocco,marijuana,andalcohol
responsibilitytohandletheiraddictionntherthangiveit • C.mbodlan....,.kohol, tobacco . crack cocaine . and
ovatoahigherpoweroranvtt<rrwcon t rol. They a lso m,okable meth•mph<wnine *
believethattocomplainabouttheiri>ounwouldbeimpos- lnlOlOMi>nsandPocificl.t.nder,intr<>tmrntfor,ub-
ingonoth<T5.Savingfaceandindividualhonor•reimpor -
•tancc-a- problem, in the United Stat<> consi<ted of
tant,,otheyar,l .., re,pon,ive,will •voidro nfrontation
J8 .J% for a lcohol aboS<, 2H% for m<thampheum ine
andpreler•lternati,1ew•y,ofe,q,ressingtheirf«ling,,,uch
l0.4%lorinariju•ruo, 10.1%forheroinandothuoplat<>
ucre.oti veor<,q>r<55ive•ruther.tpy A, italromponrntof 7.4%forcocai ne,O .J% lor,edaJve -hypnotic,s,and0.1%lor
,uccesdultreotmrnti,theinoorpor.ttionolfamilytherapy halludnogrn , .""
L.ong,ugeandculturally•pproprioteeducation.interven -
tion,and..,..,mrntresourcesmustbee,tablishedtobest American Ind ian and Alaska Native
engage and mainWnAPI dirnain rigorou.strntmrnt
MostAmericanlndlans oreloca1edinl7,ute,,withmore
&c.westronggenderrolesexist,sep.,..t<maleandfemale
thanhalFlivinginAri:wna.Americanlndiangroup,hove •
gronp• • remoreeffectivethanmixedgroup,
wide, .. rietyolrultur • ltradit ion,. Th efiveea,;t<mruot ion,
(trib<S)ofOklahomo , who • reliterat<and,uccessful,ha,.,
~n%:n~~•:mrni:.'.:or AslanA;~"'.'n' ~°"!~-=u~ lat<
lowrat<sofakoholism . Thi,i>incomparisonwithsom e
admis,ionoflouolrontrol. Addictionu,uallyre,ultsini>.o- we,tem moun ta·n t ' bes who , ·non e study, ,..,., ' md to
lationfrombmilyorintr<mendouodrnWofaddictionby haveameof a koholi,msevrntime,thenotional avaage . ln
' ·•;members,,ocommon · tuvrnt'on technique,""' 2007Am<TicanlndianandAWkaNoth,e(Al/AN)popula -
1..,effecti,1e. The=S<Coffamilyolumeoftenkeep,the tions"1e"' !""likely thanpe=>nsolotherr.tclal back -
&milyerwlling•ndre,cuingtheaddictrepntedlyrather grounds to haveu«dalcohol intheput)=r(60 .8'1\,,..
thaninsistingthotheor,hegetinto t rtttment.Thestrong 63.8%), buttheyweremorelikelyto have a n•koholu,e
,,,,....,offamilyhowevu , make,lorgre at<rcompllancewith d00rder (I0 .7%vs . 7.6%) . lllicit-drug,marijuono , rocoine
protocols that incorpor.tt< family therapy one< treatment andhallucinogrnu,edi,orden"1ereaisohighuin th<><
popul.otionslhaninotherr.tcia l grouP". U><olillicitdrug< chall<nged . orado«nothergroupo,thekcytodfective
(1 8.i% v. . H .6%) and pr=ce of illicit-drug u« dOOrd= tr<atmrnti,involvemtntwithpttrgroul"'who=•p,ak
(~.0% "' · l .9%) wne higher in AUAN popul.otions ,rum and hdpbe cau« they ha, ., up<ri<r1c«l comJ>U>ble life-
in p<r~ns o l other racial backgrounds . Ova.II 63.11% of style,problems.prtjudicn.,hunning,_jo}-. , andi<su<>with
Al/AN trtttmtnt admissionswm, foraleoholrompar<d «lf-«tttmorrrbtion,h il"'
with.W .J%forthegenn:alpopulation. '..
The commonality among all groul"' i, that addiction H
Drug<withahistoricalconwu.,uchastob acco a ndp,yot<, addiction. Toimagin e thotprobl=withaddicti>'<beh avior
ar< U>cd mostoft<n incm:moni<> rather than rrn u tioilllly, wou ldd i,a pp<llifonlysomeotherconditionsorio<uewer<
soth e introductionofdiff<r<ntdrug, . particularlyalcohol takrncar,ofH a ,ur< pa thtocontinuedaddict ivebehavior.
andinhal.ont>,withnoculturaltraditionolrrmict<du><ha• Thi<Hnotto,aythatothuthing,,uchasraci<mandm<r1 tal
cau«dnum erou.problems .'°' in,tabilityohouldnotbeoddr<><edandtreatedatthe,am,
tim e becau.><IIUI>)"ofth<rootsofcompul<iveu«li<ina
T1tttmrntadminiot<rulbybilinglWandbirultur.dp<n<>l>'
ndgratly incrn,,e,thtchancrsof,uccus.Mniynationo rn~:t-effontorop,withthepainuperienceddue
incorpor.tt<culturaltradit ions inhuling,includingu lking
circl<>,purification =oni<>, <W<>t lodg<>, mediutiv< PhysicallyDisabled
pra<:f <>. >lamm ' fc cer,mon ' . and rommun'ty ", ing>." AmuiC2mwithdi<abiliti<>ar<amuch -neglectedgroupof
Talkingcircl<,havebernu«dfo,hundrul,ofyuBin,,.ri - chemically deprndrnt propk Some of the mor< common
ou,;Am eric.anlndl.ontrib<. as aw aytosoh '< probkm,and
di<abiliti<>areblindn<» . deafn<» . h<adorbaininjury
h<>.Icommunity nxmh<n. Th< proc= i, ,imil.or to p,er ('50,000 pu~ ar) , and ,piruol rordin j ury(I0,OOOtol~ ,000
grouP",thoughinst<adofround -robinulkingwithnoint<r - new cn,, p,r )-Ur) . D<<pil< th< l\l90 passage of th,
ruptions,therrHcro5S -talkandqu<>tion • The5<S5ionsusu - Amuie2n< with Di<abiliti<>Act, most progr~ n, r<main inK -
allylasttwotothr«hour,.thoughtheyC2I1 lastmuchlong,r. e«<ible to many with mobility. ,i<ua l,or hu ring im p;air-
D<tmcificationcrnl<n,halfa .. yhou0<>,outpa t i<ntprogr.,m,, m<r11> . In addition . there ;. ,.,ry
lit~ e intrnli<ciplinary
andho>piu l unitsar<lundedbyth e lndianHealthS.r.ice ta ining lortho«whoworkwithphy,i callydi ,a bled,ub-
and cma'n ,ut< and count) 0 ,nments . Becaux mor< •tane< ab=. l'roblem • occw-whena t rttnnrntprofeo-
than60%ofAm<TiC2I1 lndWl>liveawayfrom traditional ,ionalfocuse,onth<phy,icaldioab ilityandmios,•the
commu 't' 'nmulf-rthn'curbanar< as, 11Utm<r1tcrnten ,igmofr,lap><orfocu-too,tronglyonth<addiction and
inthoo,locab,houldha, ., the<Ened iv<T<ityolbilingual do<>nottakeintoaccountth<ext.-.,tr< .. c•U<Cdbythe
and biculturalpu,onndfor AmericanlndWl> a, thcydofOT dioability.Conve=ly.ar,habiliutionpro/..,ioil.l!mightfed
other<thnicandcultur algroul"' unqua lified or uncomfonable lu.ndling ,ub,tancr -abu«
probi<msormightno t rrrognizethe,ign,andthe,ymp tom"-

:.::'s:_~~t;;~~ ~!'t~~-w
m,l,a, jt,"""'tra.lioom.U~tdlj.a,..,,,,/,,,ofclinic
!,oci<ty-. attitudetow a rdprop lewithdi<abiliti<>cansome
tim<>promot<l<2rnedh<lp l<»ne .. andd ep,nd encyonoth -
-

u,and,ubs,qu entlyondrug<.Oneironyof,ubsunceab0><
Jim:lon"""'"""oon,,J,oar, /:.r""9"t U1(roiothtout"'1t inp,op lewithphy,icaldi,abiliti « Hthat,ubstonce0><is a
'"7,,t,wbl,..,J,,.t,wli"!Jtlwtrodioon, , ,ottq~"""'"" Uctor inupto68%oft raumoticd i<l.blinginjuri<> ."" A thOT-
,tandarJf"'l<lio.oc;,,ltlwraf>j.
dlicO~oot"',ff«tawa,.I oughmed ical anddrughiotoryiohdpful injudgingwh<ther

t:.=in::-~"tt:!"~!
O,to tr<aDll<•t.,it~ UIth, "'#rom,,11¥0bj . Ojl,n
":f,1::
lh<ljar,oot
th e ,ubstane<abu«prul at<dthedisability,wastrigg<r<db)·
it.oroccurrulind<p<nd<r1tofit

""""of"'"'tbottom~. /tt,:,l:,,w,""'°""o,acoort..,..lotr P!ty,icaldiubiliti<,oFteninvolvepain . whichleadstothe

ta..J.,J.ane,,.Onti,,od,,,J.,nJ.o,utl,,~/ytr«:OV<rlj , !Mj u11<ofpreocriptionmed icationsthatcanb<abu0<d
a«..dilru~takti,>ltrlltl,,mtl u talcol.,l;,,,.~~I,
·1.,,,Jm ~ <fual,ihtijtotlw~t,xt,otoftl,,!a111.lcooW
~;;:ti:bji.:;::,_·rproo~J!:;:a7
P"·
6
f<'!""""""'""l:,,,p , rollin"""' ~ """'"'·a.ida><ru,,.,,-t
Joctor,oot of "'"ltllioeload.,,,,Joctar8""\9fo,"""al
llob
C.....,.
,A__,L°"""<,
• ....-- ""'"tl,, _l ..... taW\910"""'0Virodin" attl,,~,,.,toar1"""
tltn'.>IW\9"P
· ""Jl"""'1dt,Uhimtoar10o.dl,,adad1nanJ
"CuatS,,inl~""t""tlt,,,,,, i !ljofadc,,,t,:,acc,pttlt,
lhatru<1«J,,.,tolhroll!"p.10l,,"'°"IJcomin<1<togw""
:~:::~.J~i:9'~!.::;~!j"~it:.c~:~.- tlt,pain,,.,dic<Jtioo tltat..,.IJ..,l,,,.,lhroll/"/'
ta<>roW?d98pow,dsattl,,,nJoftltatnm. I J.,.,O,,n~
. /"-"'Joo.,,

A""""""""""'_"'
..,""°'
''""''"""'"'~ Aooo,..,,...
lhatfo,17~Ulandootof,,habf .. ~mn.·

Other Groups
Ther, many groups of American, who requir< targeted
treatment . Whetherthey a r,,ubotanceabu0<rswhoha,.,
phy,ica!di'2hiliti<>.g:ay•orleobian, . homde .. ,mrnully
A pre-<Xisting,usceptibilitytoaddictiona,wellasa,,.lid
needforpainr,li<fareconditionsthatpot<r1tiallycanca0><
a pu,onwith a phy,icaldi<abil itytodevdopadqxndenc,
problem with pain medications .'" lnastudyof96propl<
 9.62 CHAPTER 9
with long-term spinal cord injuries, 43% used prescription
medications with abuse potential, and one-fourth of those,
or about 10% of the total, reported misusing the medica-
tions. The group that regularly misused the prescription
medications was less accepting of their disability and more
depressed. Another study found that the existence of a pre-
existing substance-abuse problem made it more likely that
the client would not participate fully in rehabilitation,
thereby slowing recovery and increasing stress. 292
Lesbian,Gay, Bisexual,and Transgender
There is a lack of research on substance abuse in the gay and
lesbian communities, and the studies that have been done
are not exhaustive, merely suggestive. The population of the
lesbian, gay, bisexual, and transgender (LGBT) community
is difficult to determine. One early study estimates that in
the United States, 9.8% of men and 5% of women report
same-gender sexual behavior since puberty, whereas 2.8% of
men and 1.4% of women report a homosexual or bisexual
identity. 293 The studies that have been done put the incidence
of drug and alcohol use in the gay community significantly
higher than in the general population. 284 ,295
Circuit parties-erotically charged, two-day dance events
attended by up to 25,000 self-identified gay and bisexual
men-were originally created to raise HIV/AIDS awareness,
but in some cases they have become venues where HIV is
likely to be transmitted. 296 "Crystal" meth is the drug of
choice (along with alcohol) at gay clubs and circuit parties.
At a Los Angeles clinic, one in three gay or bisexual men
who tested positive for HIV admitted to using this powerful
methamphetamine, a percentage three times greater than a
similar survey found four years earlier. 297
A directory of gay and lesbian AA groups listed more than 800
meetings in the United States in the midnineties. Various
studies have estimated that 20% to 35% of gay men and les-
bians are heavy alcohol users, compared with 10% to 12% of
heterosexuals. 298 ~<xi.
3 oi.3 o2 Marijuana was also used at a signifi-
cantly higher level, almost one-third more than in the general
population. 306 Besides alcohol, marijuana, and "crystal" meth,
I
a sample of gay men found them 21 times more likely to use
nitrite inhalants and 4 to 7 times more likely to use hallucino-
gens, painkillers, sedatives, and tranquilizers. 303
The high incidence of HIV and AIDS among gay men is
aggravated by drug or alcohol use for two reasons: the use of
drugs lowers inhibitions and leads to unsafe sex, and the use
of contaminated needles spreads HIV quickly. This problem
is magnified by a social life that involves bars and other
settings that promote drug and alcohol use. 304
"I'dbeenusingdrugsforqearsand qears,but whenI foundout
I waspositive,I said, 'Oh, I'mgoingto die,'and I just started
slammingdopefasterand harder,and I did that for two qears;
and whenI wasn'tdead, I said, 'Waita minute,I'mnot dfn9,
I gotta keep9oingwithmq life.'And I startedrealizing that I
couldget clean,and I couldstaqas healthqas I could,and I
couldmakesomethingout ofmq life.''
Gay recovering substance abuser with AIDS
Though sexual minorities must suffer society's hostility,
indifference, fear, or misunderstanding and are subject to the
stress that accompanies those attitudes, addiction results
from common roots in any population-genetics tempered
by childhood stressors and inflamed by drug use.
"WhenI first camehere,I wassonervousaboutbeinggaq,one
ofthe minoritqin the9roup,'causethere'sa lot morestrai9ht
men,but I reallqlikeit nowbecauseI can workon mq issues
aboutbeingheterophobic-1get fearsaroundheterosexuals.
I stereotqpestraightguqs:"Oh, theqall hate me, and theqall
thinkI'm lessofa man.''And I 9etto findoutthat's nottrue,
and I get to findout that if someonedoeshavethat belief,
thenthat'stheirs.It ain't mine.''
Gay recovering polydrug abuser
Societal homophobia, heterosexism, and internalized
homophobia (the fear and hatred of one's own homosexual-
ity) are often the greatest barriers to long-term sobriety and
recovery. 305 In recent years these ideologies have become less
strident due mostly to a decrease in societal homophobia,
which might lead to better recovery outcomes for sexual
minorities. 298 Polls still indicate that homosexuality remains
unacceptable to certain segments of the population. This can
make LGBT clients reluctant to speak about their sexual ori-
entation . This reluctance leaves out pieces of the personality
puzzle for treatment personnel and makes defining the cli-
ent's family and involving them in treatment difficult. 295
Has the family of origin rejected their son, daughter, or
sibling? What is the structure of the family?
Relapse prevention is particularly difficult when a client's
lifestyle involves contact with people who are still drinking,
smoking marijuana, or using "crystal" meth. Often the social
contact and events in the LGBT community are an important
way for an individual to cope with the homophobia and the
isolation that comes from the straight community; unfortu-
nately, alcohol, "crystal" meth, and other drugs are often a
part of this scene .297 Treatment programs such as the Matrix
Model developed at UCLA or various inpatient programs
that focus on meth and specific communities are proving
that meth treatment is effective when it is focused, intensive,
and persists over a sufficient period of time (up to two years
for outpatient treatment).
Denial and lack of financial or treatment resources have
always constituted the biggest obstacles toaddiction treat-
ment. But as the treatment of addictive disease continues to
evolve, other significant obstacles are being identified that
require intervention for successful treatment outcomes.
DevelopmentalArrestand
CognitiveImpairments
The use of psychoactive drugs can delay users' emotional
development and keep them from learning how to deal

with life's problems without drugs . In terms of trea tment,
the counselors or other professiona ls must iden tify the level
of development in the individual: they must be aware of how
much of what they are teach ing is being understood. In addi-
tion, if a client is not fully detox ified or has not been given
enough time to start functioning normally, there is a chance
that even the most soph isticated treatment will fall on deaf
ears. Extens ive assessment is one way to overcome these
prob lems .
Brain scans (e.g., SPECT, PET, fMRI) reveal that chronic
abuse of most psychoactive drugs actually deactivates sig-
nificant portions of the brain, caus ing cognitive impairments
during early recovery 3 07 Research also confirms that abuse of
most psychoact ive drugs results in actual damage to brain
cells or brain functioning, which results in cognitive defi-
cits, especially during the first several months of absti-
nence and recovery. For example, methamphetamine abuse
causes major damage to the hippocampus and other limbic
conices 98 as well as a 24% loss in dopam ine transporter
mechanisms. 308 The prefrontal cortex involved in the execu-
tive functions of the brain also exhibits functiona l anomalies
in the chemically dependent brain, resulting in 30% to 80%
of substance abusers having mild to severe cognitive
impairments .3 09
Consequently, there is a neurocognit ive basis for the observed
prob lems of attention, memory, learn ing, tempora l process-
ing, goal setting or "delayed discounting" (inability to
appreciate delayed gratification), problem solving, decision-
making, abstract think ing, and other cognitive dysfunctions
in recovering add icts that often lead to slips and relapses.
Most treatment protoco ls employ psycho-educational or
cognitive-behavioral components that require goal setting
and planning, sustained attention, response inhibition,
skill acquisition, problem solving, and decision-making
skills-the same cognitive abilit ies that are most impaired in
many substance abusers. Current treatment interventions
may be inadequate for substance abusers with cognitive
deficits. This leads to early dropout, chronic relapse, and
poor long-term treatment outcomes.
Cogn itive impairment findings in substance abusers led to a
recommendation that cognitive status examinations be
conducted upon admission and then repeated at regular
intervals during treatment to direct the level and the inten-
sity of treatment interventions. One treatment approach
focuses on accelerat ing cognit ive recovery of brain funct ion.
Cognitive performance shows improvement with contin-
ued abstinence and recovery, but these skills are needed
earlier in the process if the treatment is to be cost-effective.
Successive relapses are often worse and result in increased
harm, guilt, and loss. Clients should be given work assign-
ments or participate in sessions designed to improve identi-
fied deficits, such as specific sessions targeted for memory
training or problem-solving skills development.
Another approach is to modify existing treatment protocols
to the cognitive abilities of the client based on cogn itive
status examinations. Such treatment adaptat ions cou ld
include shorter but more-frequent counseling sessions,
Treatment 9.63
repeated presentation of therapeutic material, multi-modality
(visual, workbook, audio, and experiential) presentations,
memory aids, stress management, use of simple language,
immediate feedback to clarify misunde rstandings and reward
progress, and homewo rk assignments to reinforce learning
exercises. When pract ical, the length of a treatment episode
can also be increased so that more-difficult and abstract
concepts can be presented later in treatment, when cogni-
tive processing has improved. Three to six months of
continuous abstinence has been associated with the return
of many but not all cognitive abilities .
Follow-Through(monitoring)
Nothing is more indicative of poor treatment outcome than
early program dropout or lack of compliance with the treat-
ment protocol. Ironically, the client confident iality that is so
vital to the addiction treatment process has contributed to
the prob lem of poor treatment compliance. Clients who have
not or will not release information about their treatment
progress can be noncompliant with protocols without the
knowledge of their families, employers, or friends until more
harm is caused by the ir resumed addiction.
Professional licensing boards (medical, nursing, and legal)
now mandate the release of confidentiality as a condition of
retaining a license when addicts who are professionals are
mandated into treatment after their add iction has been dis-
covered. Many CJS referral sources such as drug courts,
probation, or parole-mandated treatment have adopted this
policy. Federal confidentiality laws were amended to permit
the process ing of an irrevocable release of information for CJS
referrals . Other releases can be canceled at any time at the
mandate of the client. This practice, though ensuring better
program compliance, created another obstacle for the treat-
ment professional: How cou ld a therapist engage an addict in
deep and sensitive issues about the add iction without being
viewed as an extension of the licensing boa rd , the family, or
law enforcement? To address this obstacle, some licensing
boards and employee assistance programs now emp loy a pro-
I
gram mon itor who oversees the progress of an addict in treat-
ment to ensure compliance with program protocols.
An increased use of case management, once thought to be
enabling of addiction, has resulted in greater treatment com-
pliance and follow-through. Medically oriented programs'
use of medical review officers to maintain, review, and vali-
date urine drug-testing procedures has also provided clients
with a way to monitor their compliance with their treatment
or serv ice plans. Professional recovery coaches, sobriety
mentors, and sober companions are also promoting better
compliance and follow-through with addiction treatment
interventions.
ConflictingGoals
An individual addict's treatment goal may conflict with a
program's goal. Some addicts may enter treatment merely to
better manage their abuse of drugs or to qualify for certain
 9.64 CHAPTER 9
social benefits. Most treatment programs insist on an imme-
diate commitment from a client to a drug-free lifestyle . Any
difference in goals results in a poor treatment outcome .
Program goals may conflict with society's goals for treating
addicts . Programs naturally focus on the care of their clients,
using interventions that they believe will lead their clients to
the best possible life outcome. Society is more interested in
supporting programs that decrease the social costs of addic-
tion (e.g ., crime, health costs, accidents, and violence).
The problems of conflicting goals are best managed by
establishing clear program objectives and goals and doing
a better job of assessing and matching clients to the right
programs. Although these concepts seem straightforward
and easy to practice, only now is an investment in these two
areas beginning to occur.
TreatmentResources
The number one obstacle to addiction treatment remains
the lack of treatment resources . Nationally, individuals who
apply for treatment are put on a waiting list; it then takes
from two weeks to three months or longer before they can
get into treatment. Studies have shown that for every 100
people on waiting lists, 66% will never make it into treat-
ment. A study of heroin addicts on a waiting list for compre-
hensive methadone maintenance therapy in Baltimore,
Maryland, documented that only 20.8% were available to
access treatment when space opened for them, an attrition
rate of 79.2%.310 What happens to those potential clients is a
matter of deep concern. Many die from drugs or from suicide
while waiting for treatment. 311
Most become more heavily involved in drugs due to a "demo-
tion" on Prochaska and Di Clemente's scale of readiness to
change, which means that any delay in accessing treatment
results in a loss of motivation . A high proportion end up in
the criminal justice system. Because treatment has been
shown to be very effective, it is a national tragedy that we
continue to have long, protracted waiting periods for clients
I
wanting to access treatment. The national TEDS document
that almost 1.8 million individuals received treatment for
alcohol- or substance-abuse problems in 2010; this trans-
lates to only 1 of every 15 to 25 projected substance abusers
receiving treatment that year. 78 , 164
Introduction
Drug replacement therapies, medical pharmacotherapy,
chemically assisted detoxification, drug-assisted recovery,
antipriming medications, drug restoration of homeostasis,
medicated "resetting" of the brain, and other medical inter-
ventions currently in development to treat drug addiction
would have been considered oxymoronic in the field of
recovery a few years ago. These are still considered unortho-
dox by many chemical dependency treatment clinicians and
recovering addicts who firmly believe that the use of any
potentially addictive psychoactive drug will result in a
relapse .
The 1990s Decade of the Mind Project was an international
initiative to advance our scientific understanding of how the
mind and complex behaviors are related to the activity of
human brains . As a result of this project, advances in the
understanding of the neuropharmacology of addiction cre-
ated a direction for the development of medications targeted
at treating chemical dependencies. During the early 2000s,
the number of new drugs in development to treat addictions
was second only to those in development to treat other men-
tal health disorders and far outnumbered the drugs being
developed to treat infections, heart disease, cancer, AIDS,
and other illnesses . Chemical dependency treatment special-
ists must broaden their understanding and acceptance of
medical therapies, as they are certain to be incorporated into
addiction treatment in the near future.
MedicationsApprovedto Treat
SUDsvs.ThoseUsedOff-Label
The FDA has approved several medications for use by physi-
cians to treat substance use disorders .
ForAlcohol Use Disorder
Approved:
• Disulfiram (Antabuse ®) was approved in 1948.
• Naltrexone (ReVia®) was approved in 1984 to block
relapsing to opiate addiction and in 1994 to treat alco-
hol craving.
• Acamprosate (Campral ®) was approved to treat craving
in alcoholism injuly 2004 and has been used effectively
in Europe for this indication since 1989.
• Naltrexone injectable suspension (Vivitrol®) was
approved in 2005 for the treatment of alcohol craving.
• Chlordiazepoxide (Librium®) was approved in the early
2000s for the treatment of withdrawal symptoms of acute
alcoholism; it had been in off-label clinical use for that
purpose for many decades .
Off-Label
A number of other medications yet to win FDA approval are
being used to treat alcohol dependence off-label:
• clonidine ( Cata pres ®)
• antiseizure medications like carbamazepine (Tegretol®),
topiramate (Topamax ®), and divalproex (Depakote ®)
• baclofen (Lioresal ®), a GABA receptor agonist
• the opioid antagonist nalmefene (Selincro ®and Revex®);
though approved for use in Europe, it is currently under
FDA research to determine its ability subdue alcohol
cravings 312

For Nicotine Use Disorder
Approved:
• Varenicline (Chantix ®) was approved in May 2006 to
treat nicotine craving.
• Bupropion and amfebutamone (Zyban ® and
Wellbutrin ®) was approved in December 1996 as the
first oral pill to treat nicotine craving.
• Nicotine products: gum by prescription was approved
in 1984; in 1996 Nicorette ® gum was approved for non-
prescription nicotine replacement therapy . From 1991
to 1992, four transdermal patch delivery systems for
nicotine were approved . Nicotine nasal sprays (Nicotrol
NS®), inhalers (Nicotrol ® aerosol powder or liquid),
and lozenges (Commit ®) have also received approval for
nicotine addiction therapy.
Off-Label:
• Nortriptyline (Aventyl®) and clonidine ( Catapres ®) have
not received FDA approval for the treatment of tobacco
addiction but are in clinical use for that purpose.
For Opiate/Opioid Use Disorder
Approved:
• Buprenorphine (Suboxone ® and Subutex ®) was
approved in October 2002 for opioid detoxification and
replacement therapy.
• Naltrexone (ReVia® and Trexan®) was approved in 1984
to treat opioid dependence.
• LAAM (Orlam®) was approved as a replacement therapy
for opioid addiction in 1993 but is no longer manufac-
tured.
• Methadone (Dolophine, ® Methadose, ® Tussol, ® and
Adanon ®) was approved in the 1960s for detoxification
and replacement therapy for heroin addiction.
Off-Label:
• Clonidine ( Catapres®) and lofexidine (BritLofex ®) are
used to treat high blood pressure and have been used
for many decades to suppress opioid withdrawal symp-
toms.313 Nortriptyline (Aventyl® and Pamelor ®), an
antidepressant, is also being used to treat nicotine with-
drawal and cravings .
For Stimulant Use Disorder
Although no medications are approved for the specific
indication of treating methamphetamine or cocaine depen-
dence, many FDA-approved medications are being used to
treat the symptoms associated with stimulant addiction
withdrawal.
Off-Label:
• Antidepressants (SSR!s, tricyclic antidepressants, and
bupropion)
• Antipsychotic neuroleptics (risperidone and olanzapine)
• sedatives (buspirone and lorazepam)
• disulfiram (used for alcohol); reduces cocaine 's desirable
effects 171
Treatment 9.65
• antiseizure medications (e.g., carbamazepine , topira-
mate, vigabatrin, and tiagabine) to decrease sensitivity
(anti-kindling) to stimulant drugs and dampen cravings
• N altrexone, believed to decrease cravings in both drug
and behavioral addictions (besides alcohol and opiates)
• Selegiline, an MAOI-B enzyme inhibitor, to block the
breakdown of stimulant neurotransmitters in the brain to
provide relief from depression and stimulant withdrawal
• Miscellaneous medications-calcium channel blockers,
ibogaine, ondansetron, ALKS-33,mecamylamine, done-
pezil, dopamine agonists (e.g., bromocriptine , L-DOPA,
pergolide, and amantadine), hydergine, and many
more-used to treat stimulant drug addiction, though
none has yet to gain FDA approval for this indication 168
For Sedative-HypnoticUse Disorder
Off-Label:
• Addiction to barbiturates, benzodiazepines, other seda-
tive-hypnotics, muscle relaxants, some inhalants, GHB,
and alcohol can result in fatal seizures during with-
drawal and must therefore be medically managed .
Though no medications have been FDA approved to
specifically treat this condition, many drugs approved
to treat seizure disorders (e.g., phenobarbital, various
benzodiazepines, phenytoin, carbamazepine, and gaba-
pentin) are currently used effectively to treat sedative-
hypnotic drug dependence. More often a six- to 12-week
taper with the sedative medication being abused is ini-
tiated to safely detoxify the sedative-hypnotic addict.
A benzodiazepine antagonist, flumazenil (Mazicon ®
and Ro-Mazicon ®), approved by the FDA for overdose
treatment, may be of benefit in the treatment of alcohol,
benzodiazepine, and other depressant drug addictions .
For Marijuana Use Disorder
For the first time, the full range of marijuana withdrawal
symptoms were included in the DSM-5. This inclusion
validated the use of various medications to mitigate those
symptoms in early recovery .
I
Off-Label:
• Bupropion (Wellbutrin ®), an atypical antidepressant used
in nicotine and other addiction treatment, has been found
to lessen withdrawal and craving in marijuana addiction .
• Divalproex (Depakote ®), used in seizure and bipolar dis-
order treatment, has been used to treat marijuana with-
drawal and craving . Lithium, used for bipolar disorder,
has also been used to treat marijuana addiction.
• Nefazodone (Serzone ®), an antidepressant, has been taken
off the U.S. market for causing liver failures. It was also
thought to mitigate marijuana withdrawal and cravings .
• Kynurenic acid is a natural inhibitory neurotransmitter
that results in anti-excitoxic and anti-convulsant effects
in the brain. It is currently being investigated for poten-
tial treatment of marijuana use disorder, as it mutes the
effects of THC on dopamine in the brain and makes
marijuana less appealing when used. 341
 9.66 CHAPTER 9
Medical Strategiesin Development
to Treat SUDs
The strategies used to develop different types of medications
to help addicts recover can also be classified based on the tar-
geted stage of recovery and how they affect neurochemistry
Rapid Opioid Detoxification
This strategy uses various medications to manage opioid
withdrawal symptoms in combination with naloxone or
naltrexone, opioid antagonists that force the rapid onset
of the abstinence syndrome. Opioid addicts experience
few symptoms and are quickly able to return to their daily
lives without suffering prolonged withdrawal or long-term
treatment that may be life disruptive . Medications used to
alleviate the naloxone/naltrexone-forced onset of opioid
withdrawal include:
• clonidine, a medication that dampens brain hyperactiv-
ity associated with withdrawal; physical detoxification
from opioid tissue dependence is accomplished in two to
three days
• midazolam, a benzodiazepine sedative that is said to
accomplish opioid detoxification in 24 hours
• lorazepam or midazolam combined with clonidine , used
while an addict is anesthetized with propofol (a common
anesthetic)
Detoxification of an opioid addict is alleged to occur within
only six to eight hours. These methods of rapid detoxifica-
tion are medically dangerous and require intensive medical
management . These techniques accomplish only physical
detoxification and do not address the long-term behavioral
and emotional components of addiction .314 -31,.J10.,1,.,1s.3lo
Replacementor AgonistEffects
Controversy over whether this type of therapy is simply
harm reduction rather than recovery-oriented remains very
heated in the addiction treatment community. But few can
deny the effectiveness of methadone and buprenorphine
I
replacement therapy in producing positive benefits for both
the addict (reduced morbidity and mortality while increas-
ing overall life functioning) and society (cost-effectiveness
and reduction in crime) .320Positive results from methadone
and buprenorphine maintenance have stimulated the
search for other replacement or agonist therapies.
Methylphenidate and pemoline for cocaine and stimu lant
dependence and SSRI antidepressants and GHB for alcohol
and sedative-hypnotic addiction are examples of replace-
ment therapies in development to treat addictive disor-
ders.93·342Propoxyphene (no longer available) and tramadol
as opioid replacement therapies have also been investigated.
Antagonist(blocking)Medicationsor Vaccines
Medications or vaccines that block the effects of addictive
drugs without inducing their own major psychoactive effects
are widely accepted as recovery-oriented treatment
approaches. While taking these types of agents, addicts are
unable to experience the effects of an abused drug should
Cornered by Baldwin
4-10 C2003 Mike BaldwinI Dist by UnlversalPress Syndicate www.cornered.com
cornered@COmlc
.com
'j~ p12ll~(,O·
"Do a double -blind test. Give the new drug to rich
patients and a placebo to the poor. No sense getting
their hopes up. They couldn 't afford it even if it works."
© 2003 Mike Baldwin. Printedby permissionUniversalUclick All nghtsreserved.
they slip. This destroys the addict's motivation for using and
promotes continued abstinence. Significant examples of this
treatment approach are the development of depo-naltrexone
and depo-buprenorphine injections for opioid addiction as
replacement blocking agents along with an actual heroin
vaccine (undergoing clinical trials as of 2013). UH-232 or
NGB-2904, a blocking agent, is in development for cocaine
addiction. A cocaine vaccine, TA-CD, produces antibodies
for cocaine. 93,321 ,322
,323 ,324
,342Although the cocaine vaccine was
just over 50% effective in preventing the reinforcing effects
of cocaine administration , it is being recommended for gen-
eral FDA approval. 325 Two vaccines for nicotine-CYT-002-
NicQb (Nicotine-Qbeta ®) and NicVAX®-to prevent these
drugs from reaching the brain are also in development.
An alcohol/benzodiazepine antagonist-imidazobenzodia-
zepine, or Rol5-4513 , researched more than 20 years ago-
is currently under investigation as a treatment for
alcohol or benzodiazepine addiction." 6 Some estimate that
there are almost 400 vaccines in development to treat
various drug addictions.
Mixed Agonist-Antagonist
A single medication can have an agonist effect at one recep-
tor site and an antagonist effect at another site . A combina-
tion of drugs used together that work independently at
different receptor sites can accomplish the same overall ago-
nist-antagonist goal. The agonist component of this approach
is targeted at preventing withdrawal, while the antagonist
effects prevent craving by blocking any further drug use.
Examples of this approach are the developments of butor-
phanol and buprenorphine in opioid addiction , cyclazocine

in cocaine dependence, and the combination of low-dose
nicotine with mecamylamine to treat nicotine addiction.
Rapid opioid detoxification described previously also
employs this technique of combining agonist with antago-
nist medication to treat heroin and other opioid addic-
tions.93,32 7
Anticravingand Anticued Craving
Medications that can check or curb the endogenous craving
and/or environmentally cued craving responses have been
dramatic developments in treating addictions .93 Naltrexone
(Vivitrol®) has been fully approved as an anticraving treat-
ment for alcoholism and opioid addiction and is under obser-
vation to determine if it blocks cocaine craving, as well. 35 -93 -328
A concern regarding potential liver toxicity with naltrexone
has limited its use in treating alcohol dependence. Nalmefene,
another opioid antagonist, has been shown to reduce alcohol
craving without any liver toxicity and is now being developed
to treat alcohol addiction. 93 -' 29
Baclofen, a non-opioid muscle relaxant, also exhibits alco-
hol anticraving effects through modulation of GABA and
dopamine neurotransmitters. It is also under development to
block cravings for cocaine and opioid dependence .93
Topiramate and other antiseizure medications appear to
block cravings for alcohol and other drugs by enhancing the
effects of GABA.330 -331
Mecamylamine appears to block environmentally cued
craving of cocaine and is currently in development for this
indication and also as a nicotine anticraving medication. 343
Bupropion, approved for the treatment of nicotine craving,
is also in development as a cocaine and methamphetamine
anticraving medication . Bupropion research demonstrated
that it prevented nicotine craving in patients who did not
have symptoms of depression, which indicates that it lessens
craving by another unknown mechanism. Similarly, SSRI
antidepressants like paroxetine decrease alcohol use in non-
depressed alcoholics. 93
The craving response is physiologically similar to the body's
stress reaction; this prompted researchers to study drugs that
can antagonize corticotropin-releasing factor ( CRF), which
triggers the stress reaction in the brain. The hypothesis is
that craving can be prevented by blocking the body's stress
reaction . Ketoconazole and CP154,526 inhibit the release of
CRF in the brain and are being developed to treat cocaine
craving. Metyrapone also is being developed to treat cocaine
craving because it inhibits the synthesis of body corticoids,
which are also involved in the stress reaction. 342
Metabolism Modulation
Medications like disulfiram (Antabuse ®), which alter the
metabolism of an abused drug to render it ineffective or
cause noxious reactions when the abused drug is taken, are
also being developed. The effectiveness of disulfiram relies
on the compliance of the alcoholic to take it in support of the
stated desire for abstinence. Historically, Antabuse® has had
limited success in treating alcoholism due to compliance
Treatment 9.67
problems. The increase of coerced-treatment practices over
the past decade, like drug courts and probation stipulations,
improved disulfiram treatment compliance, increased posi-
tive outcomes,9 3 •332 and raised interest in the metabolism
modulation approach. 342 One such development employs
butyrylcholinesterase (BCHE), which increases the metabo-
lism of cocaine to render it ineffective when abused. 333
Restorationof Homeostasis
The homeostasis paradigm for drug addiction was first pro-
posed by C. K. Himmelsbach in 1941. 101 Abuse of addictive
drugs imbalances brain chemistry, which subsequently rein-
forces the need to continue using the drug . Medications and
nutrients that restore brain chemical imbalances are theo-
rized to restore homeostasis and mitigate the need for con-
tinued drug use. Drugs that have dopamine-activating effects
in the brain (e.g., selegiline, amantadine, and pergolide) and
antidepressants that increase serotonin in the brain (e.g.,
desipramine, nefazodone, paroxetine, sertraline, and venla-
faxine) are being developed to treat cocaine and alcohol addic-
tion by restoring brain chemical homeostasis .342
Amino Acid PrecursorLoading
This strategy consists of administering protein supplements
(e.g ., tyrosine, taurine, d,l phenylalanine, glutamate, and
tryptophan) to addicts in an effort to increase the brain's
production of its neurochemicals to restore homeostasis .
Though this technique has not yet been validated by rigor-
ous research, many treatment programs report good patient
compliance and positive outcomes when amino acid precur-
sor loading is added to the treatment process for cocaine,
amphetamine, alcohol, and opioid dependence. 334 More-
recent studies, however, find that many of these nutritional
supplements are no better than placebo administration in
reducing cocaine use .168 -33 5
Modulation of Drug Effectsand Antipriming
The use of medications that can modulate or blunt the
pleasure-reinforcing effects of addictive drugs is a recent
treatment direction. Research demonstrates that the risk of
I
relapse is greatest when a recovering addict is primed or uses
an addictive substance. Subreinforcing doses of abused sub-
stances or drugs that can block this priming action can
decrease relapse. This antipriming strategy is behind the
development of low-dose nicotine delivery systems, such as
the nicotine patch, gum, spray, and inhaler, to treat nicotine
addiction .342
Two classes of drugs under study for their ability to blunt the
reinforcing effects of abused drugs are the calcium and
sodium ion channel blockers.
Calcium channel blockers prevent calcium ions from enter-
ing brain cells, which blocks the release of dopamine and
prevents the reinforcing effects of cocaine, opioids, and alco-
hol from occurring. Nimodipine, amlodipine, nifedipine,
and isradipine are all calcium channel blockers being devel-
oped to treat addiction to cocaine, opioids, and alcohol.3 36 •342
Sodium ion channel blockers include such medications as
riluzole, phenytoin, and lamotrigine, which interfere with
 9.68 CHAPTER 9
neuron transmission by blocking the cells' uptake of sodium,
enhancing the effects of GABA. Increased GABA activity
results in muting cocaine's reinforcing effects . Cyclazocine,
a mixed opioid agonist-antagonist, also reduces cocaine
reinforcement by interfering with cocaine's action on presyn-
aptic neurons' sodium ion channels. 342
The Europeans developed vigabatrin/CCP-109 to prevent
opioid addiction or relapse . This antiseizure medication
blocks the metabolism of GABA and is said to block the
euphoric but not the painkilling effects when it is used in
combination with opioids. 337
Drugswith Unknown Strategies
Psychedelic drugs like ibogaine and ketamine are said to be
effective in treating cocaine, alcohol, and opioid addiction
even though the early use of ibogaine to treat opioid addic-
tion resulted in some fatalities.
• Dextromethorphan (DM), a non-prescription anticough
medication, is being studied to treat opioid addiction.
DM has been shown to be a weak glutamate agonist, but
its mechanism to decrease opiate withdrawal symptoms,
craving, and relapse is unclear .
• Cycloserine, an antibiotic used in the treatment of tuber-
culosis, is being studied for its ability to decrease opioid
use by some unknown mechanism.
• Anti-convulsant medications like topiramate, valproate,
and carbamazepine appear to diminish cocaine's craving
and "kindling" effects by enhancing the effects of GABA.
• Topamax ® (topiramate) is also said to decrease the crav-
ing and priming effects of alcohol abuse .
• "Smart" drugs, also known as nootropic agents, are
believed to increase brain activity by unknown mecha-
nisms and are being tested to treat cocaine and stimu-
lant addiction . Camitine/coenzyme Ql0, Ginkgo biloba,
pentoxifylline, Hydergine, ® and piracetam are current
nootropics being studied for use in cocaine addiction
treatment.
• Tiagabine and gabapentin, anticonvulsant medications,
I
are believed to increase brain GABA while decreasing
glutamate activity, but their ability to decrease alcohol,
methamphetamine, or cocaine relapse occurs by some
yet-to-be-discovered mechanism. 93 -168 -342
• Disulfiram, the oldest FDA-approved alcoholism treat-
ment drug, reduces cocaine abuse by causing unpleas-
ant effects if cocaine is used. Although many cocaine
abusers also abuse alcohol, this cocaine effect has been
shown to be unrelated to its effect on alcohol metabo-
lism. Researchers speculate that this may have something
to do with the dopamine-enhancing effects of both drugs
in the brain, but the adverse effects seem to occur more
in men than in women. 172 ,339, 340
Other Strategies
Some companies, such as Drug Abuse Sciences, Inc., are
developing time-release delivery systems for naltrexone
(Naltrel ®), methadone (METHALIZ®), and buprenorphine
(Buprel ®) to improve treatment compliance by administer-
ing an injection of the medication(s) once a month.
Patented medical protocols to treat addiction are a recent
development in chemical dependency treatment. An exam-
ple of this is the Prometa protocol for medical treatment of
alcohol and stimulant drug dependence. Prometa employs
FDA-approved medications (though not approved to treat
addiction) in a rigid short-term protocol to abate drug hun-
ger and promote recovery. Medications like flumazenil
(Mazicon ® and Ro-Mazicon ®) are administered in a hospital
over one or two days along with gabapentin (Neurontin ®)
and hydroxyzine (Vistaril®), which are continued over the
next 30 days.
Another example is the Healing Visions Clinic on the
Caribbean island of St. Kitts. Its medical protocol uses ibo-
gaine and other medications over three to seven days for the
treatment of opioid and other addictions. Ibogaine is banned
in the United States.
Packaged clinical protocols to treat addiction are another
new development. These are copyrighted and sold to treat-
ment providers to facilitate clinical interventions and pro-
mote better outcomes . The Matrix Model for cocaine,
methamphetamine, and other stimulant drug addictions is
one example . Individual treatment manuals, educational
resources, and video presentations organized around a 90-
to 120-day clinical process that encourages recovery are
included in the copyrighted packet for use by addiction
treatment providers.
Many other manuals and packaged protocols are marketed,
providing valuable tools for addicts to help them address
recovery issues like relapse prevention, PAWS, cognitive
impairment, environmental cues, cravings, and family and
other issues that can trigger slips and addiction relapse .
PAWS (sleep, memory, thinking, anxiety, emotional, and
reflex coordination problems) can last for several months or
years. An increased documentation of cognitive deficits dur-
ing early recovery (impairments of learning, attention, per-
ception, information processing, memory, temporal or time
processing, cognitive inflexibility, problem solving, abstract
thinking, and physical coordination) also lasts for several
months after initiation of abstinence. 99 Treatment manuals
and packaged clinical protocols can be very helpful during
the cognitively impaired early recovery process.
The New Drug DevelopmentProcess
The FDA has established a structured, evidence-based pro-
cess for the approval of new drugs to treat specific therapeu-
tic indications or for the approval of existing drugs to be
used for new therapeutic applications. This consists of three
steps and four phases.
Step 1: PreclinicalResearchand Development
This covers the initial chemical development of a drug
along with animal studies to determine the general effects,
toxicity, and projected abuse liability of the substance. If

these results indicate that the drug is useful and marketable,
the drug's sponsor will app ly for an invest igationa l new drug
number that will permit human research on the substance to
be conducted.
Step 2: ClinicalTrials
Step 2 comprises three phases that study the efficacy and the
safety of the drug in humans.
• Phase I: Initial Clinical Stage. A small number of human
subjects are used to establish drug safety, dosage range
for effective treatment, and the occurrence of side effects
or adverse reactions.
• Phase II: Clinical Pharmacological Evaluation Stage.
Double-blind studies (neither the researcher nor the test
subject knows if the subject has received the actual test
drug or a placebo) are used to evaluate the effects of the
drug, determine the side effects, and gauge the effective-
ness of its use in treating a specific medical condition.
A Diseaseof the Brain
• The most prevalent mind disorder is substance abuse.
It causes more illness, death, and social disruption
than any other chronic medical illness as well as costs
our society more than any other medical condition.
Current Issuesin Treatment
• There is an expanding use of medications to treat
detoxification, control withdrawal symptoms,
lessen craving, and promote short- and long-term
abstinence.
• Advanced imaging methods and other diagnostic
techniques visualize anomalies of the human brain
that could lead to addiction-or that are a result of
addiction-and serve to predict treatment outcomes.
• There are more-effective tools to diagnose addiction
and to better match clients to specific treatment inter-
ventions.
• An evolving science of the neurophysiology involved
with craving and recovery is helping explain why
some people experience chronic relapses while others
do not.
• There is an emphasis on evidence-based best practices
and a decreased appreciation of practice-based clinical
management.
• Research supports the theory that coerced treatment
(e.g., drug courts) when linked to community pro-
grams is as effective as voluntary treatment admis-
sions .
• There is a lack of resources to provide proven
treatment.
Treatment 9.69
• Phase III: Extended Clinical Evaluation. The new drug
is made available to a large number of researchers and
patients with the indicated medical condition to further
evaluate its safety, effectiveness, recommended dosage,
and side effects .
Step 3: Permissionto Market
If the drug successfully completes steps 1 and 2, demonstrat-
ing acceptable efficacy and safety, the FDA will allow the
drug to be marketed under its patented name. The process
from step 1 to step 3 usually takes up to 12 years to com-
plete. After the drug is marketed, the FDA continues to
monitor it for adverse or toxic reactions because it can take
years for some negative effects to manifest and be identified .
This post-marketing scrutiny is often referred to as "phase
IV" because the FDA can remove the drug from the market
at any time if negative effects outweigh the benefits of using
the drug.
• The conflict between abstinence-oriented recovery and
harm reduction treatment philosophies continues.
• Improvements in positive treatment outcomes show
12-month continuous recovery rates ranging to 80%
in some treatment practices, resulting in $4 to $39
savings for every $1 spent on treatment and a 75%
reduction in crime.
Principlesand Goalsof Treatment
• Principles include offering a variety of readily avail-
able programs, using medications in conjunction with
individual and group therapy, and treating coexisting
conditions along with the addiction.
• Goals include motivating clients toward abstinence
and reconstructing their lives to exclude drug abuse .
Selectionof a Program
• Assessment tools help treatment professionals match
a client to the best program .
• Providing a range of treatment approaches-custom-
izing treatment for culture, gender, and ethnicity-
improves outcomes.
BeginningTreatment
• The first step is breaking through denial.
• Hitting bottom often leads the user into treatment as
does direct intervention.
 9.70 CHAPTER9
TreatmentContinuum
• Once a person is addicted, treatm ent and recovery
become a lifetime process that involves rebuilding
one's lifestyle to live sober and drug-free.
• Detoxification uses medical care, emotional sup-
port, and medications to contro l withdrawal symp-
toms, reduce craving, and move the client to initial
abstinence .
• Withdrawal assessment tools help determine the med-
ications necessary to effectively suppress withdrawal
symptoms.
• Initial abstinence entails counseling , anticraving
medications , drug substitution , and desensitization
techniques to rebalance body chemistry, continue
abstinence, and prevent relapse due to environmental
triggers.
• Long-term abstinence requires continued participa-
tion in counseling and groups to prevent relapse and
learn new living habits.
RelapsePrevention
• This is the focus of every level of treatment.
• Treating cognitive deficits, post-acute withdrawal
symptoms (PAWS), and internal (endog enous) and
external (environmental) triggers are important
strategies.
• Outcome and follow-up evaluations improve the
value of treatment.
Individualvs. Group Therapy
• Individual counseling , peer groups, 12-step groups,
facilitated group therapy, and educational groups are
components of treatment and support recovery.
I
Treatmentand the Family
• Treatment must involve the whole family. The prob-
lems of codependency, enabling , and how children are
influenced by an alcoholic/addicted family member
must all be addressed.
Adjunctiveand Complementary
TreatmentServices
• Abuse and addiction have a negative impact on the
user's physical , emotional , social, and spiritual well-
being.
• Evidence-based treatments that address these compo -
nents result in positive outcomes .
• The benefits of alternative approaches (e.g., yoga,
equine therapy, and acupuncture) have not been
empirically tested but are alleged to improve outcomes
as complements to more-established treatments.
Drug-SpecificTreatment
• Certain psychoactive drugs call for specialized
medical and counseling treatment techniques (e.g.,
methadone maintenance, stimulant-abuse groups , or
dual-diagnosis groups).
• Office-based opiate addiction treatment using
buprenorphine is now an option.
BehavioralAddictionTreatment
• Behavioral addictions require the same intensity of
intervention and treatment as do substance-abuse
disorders.
TargetPopulations
• Because needs vary; treatment must be culturally
specific (i.e., ethnicity, gender , and language).
TreatmentObstacles
• Developmental arrest , lack of cognition, conflicting
goals, relationship/family strife, insurmountable debt/
financial problems, continued association with dys-
functional peers , poor follow-through, and lack of
facilities are the main obstacles in treatment.
Medical InterventionDevelopments
• More than 60 medications focusing on detoxifica-
tion , replacement or agonist therapies , antagonist or
vaccine effects, anticraving effects, and restoration of
homeostasis are in development .
I
Brad Pitt has been commended
by mental health agenciesfor
coming out about his experi-
ences with depressionin the
1990s. Mr Pitts bravery and
candor on this topic gave
many people hope about this
treatablecondition.
ion by
© 2012 lan West, permiss
Assoc
iated Press
 Mental Health
and Drugs

•
Both mental health and substance-related and addictive disorders are conditions
that consist of differences or anomalies located in the brain. Vulnerable individuals
develop variances in their brain cells, chemistry, anatomy, and neural pathways
that make them unable to respond to drugs, stressors, or life situations that those
without the vulnerability take for granted. Because differences in the same organ-
the brain-is the basis for both of these chronic persistent medical disorders, it is
not uncommon for individuals to simultaneously experience both conditions.
When a comorbidity of addiction and serious mental illness exists, it can heavily
complicate the diagnosis and the treatment of the co-occurring disorders. Further,
if both are unaddressed or if they are not treated simultaneously, it can result in
very poor life outcomes for the afflicted individual.
In this chapter we review the incidence of comorbid addiction and serious mental
health disorder and explore the causes that are common to both conditions. The
terminology, classification, incidence, and treatment of major mental health disor-
ders are presented. Recurring challenges faced by mental health and addiction
treatment professionals are identified and discussed. And the important distinction
between pre-existing and substance-induced mental disorders is presented.
Substance abuse treatment professionals should never make a formal diagnosis or
treatment recommendation regarding mental health disorders, but they should be
knowledgeable about these conditions and their treatment, to work more effec-
tively with mental health professionals to improve positive outcomes for those
who suffer from both addiction and serious mental illness.

"MACBETH: How does ~ourpatient, doctor?

DocrnR: Not so sick, m~ lord, as she is troubledwith thick-comin9fanciesthat
keep her from rest.
MACBETH: Cure her of that! Canst thou not ministerto a mind diseased,
pluck from the memor~a rooted sorrow,raze out the writtentroublesof the brain,and
with some sweet obliviousantidote cleansethe stuffed bosom of that perilousstuff
which wei9hsupon her heart.
DocroR: Therein the patient must ministerto himself"
William Shakespeare, Macbeth
www.cnsproductions.com/e7vka

10.1
 10.2 CHAPTER10
'Whq do I takea bladeand slashmq arms?Whq do I drink
mqselfinto a stupor?Whq do I swallowbottlesof pillsand end
up in the emer9encqroomhavin9mq stomachpumped?Am I
seek.in9attention? Showin9off? The painof the cuts releases
the mentalpainof the memories,but the painof healin9lasts
weeks.A~er everqself-harmin9or overdosin9incidentI runthe
riskof bein9sectionedand returnedto a psqchiatricinstitution,
a harrowin9prospectI wouldnot recommendto anqone."
Alice Jamieson, TodayI'mAlice:Nine Personalities,One TorturedMind
Whether some lines from Shakespeare's Macbeth 400 years
ago or a paragraph from author Alice Jamieson's autobiogra-
phy about her mental illness in 2009, problems arising due
to mental stability have always concerned the human race.
Research over the past 150 years or so has increased aware-
ness of the close connection between mental health disor-
ders and psychoactive drug disorders, highlighting the
reality that both conditions involve many of the same brain
chemicals, particularly neurotransmitters. The incidence of
comorbidity is quite high.
The National Alliance on Mental Illness (NAM!) reviewed
various reports published in the Journal of the American
Medical Association and found the following.
• 50% of individuals with severe mental health disorders
are affected by substance abuse.
• 3 7% of alcohol abusers also have at least one severe men-
tal health illness.
• 53% of drug abusers also have at least one severe mental
heal th illness.
• 29% of people diagnosed as mentally ill abuse either
alcohol or drugs_l.2
NAM! also reports the following from the Epidemiologic
Catchment Area Survey
• 47% of those with schizophrenia had a substance use
disorder (SUD)-more than four times as likely as the
general population .
• 61% of those with bipolar disorder had a substance use
disorder-more than five times as likely as the general
population. 1•2
The different classes of disorders consisted of anxiety disor-
ders, 28.8%; mood disorders (includes bipolar disorders),
I
20.8%; impulse-control disorders, 24.8%; and SUDs, 14.6%.
Median age of onset is much earlier for anxiety and impulse-
control disorders (11 years) than for SUDs (20 years) and
mood disorders (30 years). 3 •4
"I didn't thinkthat I wasa mentallqill person.I thou9ht,well,
I'm a dru9addict and I'm an alcoholic,and if I don't drink
and I don't use, then it shouldjust bea simplematterof just
chan9in9mq entirelife;and I felt a littlebit overwhelmedbq
the thou9ht."
35-year-old male with major depression
Of the 40 million Americans who experience a mental dis-
order such as schizophrenia, major depression, bipolar
disorder, an anxiety disorder, or a personality disorder
over the course of a year, about 7 million to 10 million also
experience a substance-related disorder.• .1.•
It should be noted that studies on the incidence of those expe-
riencing both addiction and serious mental illness vary
tremendously depending on the populations studied. For
example, several early estimates of the U.S. prison population
experiencing both conditions were reported as high as 72%.
BrainChemistry
The interconnection between mentaVemotional health and
drug use is so pervasive that understanding this link gives
valuable insight into the functioning of the human mind at all
levels. The reason for the link is that the neurotransmitters
affected by psychoactive drugs are the same ones involved in
mental illness. Many people with mental problems are drawn
to psychoactive drug use in an effort to rebalance their brain
chemistry and control their agitation, depression, or other
mental problems . The opposite is also true: Psychoactive
drugs can aggravate a pre-existing mental illness, or mimic the
symptoms of one, if a user's brain chemistry becomes unbal-
anced enough. 10, 11 Psychoactive drugs can mask the presence
of imbalanced brain chemistry caused by a mental illness and
delay diagnosis until the drug use has ceased.
"/ preferredheroinbecauseI felt relaxedwhen I wouldsnort it.
I felt likeI didn't haveanq troubles.I felt likeI had some
peaceof mind;and the dru95that wereuppers,likespeed
and cocaine,made me feelreallqanxious."
Recovering drug abuser with major depression
This connection between mental health and drug use can be
seen in the similarity between the symptoms of psychiatric
disorders and the direct effects of psychoactive drugs or
their withdrawal symptoms. For examp le:
• Cocaine or amphetamine intoxication mimics mania,
anxiety, or psychosis.
• Cocaine or amphetamine withdrawal mimics major depres-
sive disorder or generalized anxiety disorder (GAD).
• The manic effects of cocaine or amphetamine followed
by the exhaustion of withdrawal mimic a bipolar illness
that includes manic delusions followed by depression.
• Excessive use of alcohol causes a depressed mood, a lack
of interest in one's surroundings, and a disruptive sleep
pattern characteristic of a major depressive disorder.
• Psychedelic drugs (e.g., mescaline and LSD) mimic the
delusional hallucinations associated with a psychotic or
thought disorder. 12
Classificationof Substance-RelatedDisorders
Addiction disorders are classified in the Diagnostic and
StatisticalManualof MentalDisorders,Fifth Edition (DSM-5),
released in May 2013, as mental disorders_l4 The diagnostic
category "Substance-Related and Addictive Disorders "
includes gambling (both online and in person) as a true
addiction . Gambling and each substance addiction have
their own specific classes.
 MentalHealth and Drugs 10.3

0 2005 Glennand Ga,y McCoy/Dist.by l,Jniver5a

t Press Syndicate
DeterminingFactors
Heredity, environment, and the use of psychoactive drugs
are the three main factors that affect the central nervous
system's balance and therefore a human being 's susceptibility
to mental illness as well as addiction. 1' · 16 For example ,
nearly every neurochemical system involved in depression
is also abnormal in substance use and substance-induced
disorders. 17•18
Heredityand Mental Balance
How does heredity affect mental health? Research has already
shown a close link between heredity and schizophrenia,
bipolar disorder, depression, and anxiety. The risk of a
child developing schizophrenia is somewhere between 0.5%
and 1% if the child has no close-order relatives with schizo-
phrenia ; if the child has a close relative who has schizophr e-
nia, the risk jumps 15- to 30-fold. 19

"M~9reatuncle's9ot schizophrenia and m~nephew's9ot

schizophrenia. He's 90t it real/~bad becausehe can't controlhis
fits.I didn't thinkaboutthat arowin9up, onl~whenI started
hearin9the voices.Then I thou9ht,Hmm,just likem~nephew."
28-year-old male w ith schiz ophrenia

Studies suggest that the genetic influences that make a per-

FlyingMcCoys© 2005 Glenn and Gary McCoy. Reprinted by permission of Universal
Udick.All rights reserved.
For instance, marijuana is described as Cannabis-use disor-
der with a specific diagnostic that can be coded by severity
from mild to moderate to severe. 14 Diagnostic criteria are
specified for Cannabis intoxication and cannabis withdrawal.
"Cannabis-Induced Disorders " and "Unspecified Cannabis-
Related Disorders" are also delineated. Gambling is the only
behavioral disorder that was accepted for inclusion in the
DSM-5. It is referred to as gambling disorder with specific
coding for mild , moderate , or severe, replacing the previous
DSM-N-TR codes for problem or pathological gambling.
son susceptible to schizophrenia are those that control cer-
tain brain structures , particularly synaptic activity. Glutamate
transmission along with dopamine and GABAsignaling are
involved. 20
Some individuals are born with a brain chemistry that makes
them susceptible to certain mental illnesses. If genetically
susceptible brain chemistry is stressed by a hostile envi-
ronment or, to a lesser extent, psychoactive drug use, that
person has an increased likelihood of developing mental
illness. If there is a very heavy genetic susceptibility , it may
not take a very severe environmental stressor to activate an
illness. Persons with low genetic susceptibility must experi-
ence much stronger environmental or chemical stressors to

General
population
Genetic
Susceptibility
to Schizophrenia

I
First cousins
Uncles/aunts
Nephews/nieces
Grandchildren
Half siblings 60/o
Parents 60/o The risk of developingschizophreniaif a genetic
relative has the diseasevaries with the number of
Siblings::;::::=~- go_v,... shared genes. The number of shared genes is 25%
Children ---- -- 130/o in the case of a second-degree relative such as a
Fraternal twinsP"'"'---- --- 170/o niece, 50%for a parent, and 100%for identical
Identicaltwins 480/o twins. Because of epigeneticchanges, however, only
one identical twin can have the disease.
00/o 100/o 200/o 300/o 400/o 500/o Gottesman,1991
Lifetimeriskof developing schizophrenia
 10.4 CHAPTER10

dopamine. Schizophrenia is linked to an overabundance of

Rela
tedto person with
nomood disorder dopamine. Cocaine stimulates the release of dopamine, so
Genetic
Susceptibility
to Bipolar
t] o.sO/o long-term or high-dose use can induce a schizophrenic-like
Disorder
or MajorDepression
psychosis. Excess dopamine is a key contributor to both
5.4% 24
Bipolar disorder real psychosis and drug-induced psychosis.
Related to patientwith Major depression
bipolar disorder Environment and Mental Balance
6.0% There is an ongoing debate over which factor-genetics or
12.0% environment-is more important. The consensus leans
toward genetics, but some research shows how environment
Relatedto patientwith and drug use can alter genetic factors. The same environ-
major depression
mental factors that can induce a susceptibility to drug abuse
2.6%
can induce mental/emotional problems. 25 The neurochemis-
15.0% try of individuals who are subject to extreme stress can be
so disrupted and unbalanced that their reactions to normal
Lifetimerisk for first-degreerelatives
situations differ from those of most other people, suggest-
ing mental illness . Continued stress depletes norepineph-
rine, which causes depression. Some people react to stressful
The risk of developingdepressionor bipolardisorderis greatly situations by running away, falling apart, expressing anger,
increasedif a first-degreerelative (parent,sibling, or child) has or using psychoactive drugs . The stressors can be normal
the disease. family exchanges, like a mother's saying, "It's eleven
Goodwin, 1990 o'clock-I wish you 'd get out of bed, " which triggers extreme
anger , further disrupting the child's balance , thought pro-
cesses , and therefore behavior. 10
trigger the illness. Even with a high susceptibility and strong
"Mqparentshad a troubledmarria9e , and theq'd fi9htand
environmental stressors, mental illness may not develop. In
a1pue, and mq motherwasbeaten I thinkmaqbesome
families where a close relative has major depression, statis-
of the ra9eand someofthe an9ermanifesteditselfinto the
tics show that five in six children or siblings will not develop
schizophreniaor just tri9Beredit. A~er mq schizophrenia
that illness. 21 •22
becamereallqprominent , I noticedthat littlethin9s, like
on-the-jobstress, would9et to me and I'd moveon because
"In mq familqmq mom, mq aunt, and mq9randmotherwere
it wouldtri99erall sortsofproblems."
dia9nosedas manicdepressive J It runsin the
[bipolardisorder
28-year-old with a dual diagnosis
familq.It didn't haveanqthin9to do withdru9s.It wasjust a
lackofsomethin9in the brain"
Abuse and sexual molestation are major negative environ-
16-year -old male in treatment for bipolar disorder
mental factors . Well over 50% of the young adults who are
psychotic and have a problem with drugs experienced at
Genetic links for behavioral disorders, such as binge-eating
least one form of abuse as children. More than 75% of female
disorder, compulsive gambling, and attention-deficit disor-
addicts suffered incest, molestation, or physical abuse as a
der, have been found in twin surveys. Identical twins raised
child or an adult.
by two different sets of foster parents often exhibit the same
character traits and behaviors regardless of environmental
"Mq dad beat mq mom whenhe wasunderthe inpuenceof
differences. 23
alcohol.He wasan alcoholic.He also beat mq oldersister
Heredity affects susceptibility to drug or behavioral addic- and me. When he came home, I wasalwaqsrunnin9and
tion in much the same way that heredity affects susceptibil- hidin9.A few qearsa~erhe left the familq,I wasmolested.

I
ity to mental illness . A high genetic susceptibility does not
mean that that mental illness or addiction will occur, only
that there is a greater chance that it will occur .
"Bothmq parentswerealcoholics.Mq brother's an addictand
an alcoholic.I basicallqfollowedin mq father'sfootsteps-
the drinkin9
, the runnin9around, losin9wives, kids, all that."
38 -year -old recovering alcoholic with major depression
The relationship among heredity, mental illness, and psycho-
active drugs can be seen by examining the connections
among the neurotransmitter dopamine , the drug cocaine ,
and schizophrenia. Heredity can affect the formation of
dopamine receptor sites and the brain 's ability to produce
I wasscrewedup, but whenI wentinto the serviceI found
that the marijuanaand the heroinI abusedin 'Nam kept
mq emotionsundercontrol."
Vietnam veteran with post -traumatic s tress disord er
The evolving science of epigenetic processes is beginning
to link environmental influences and genetics . Half of a
person's DNA is inherited from the mother and half from the
father. If the father has brown hair and the mother has black
hair , one of the genes may be expressed more than the other
in coding the hair cells to produce a certain color.
Environmental events like trauma, toxins, drugs, and even
some behaviors can result in twisting DNA tighter or loos-
ening it around proteins during the duplication process,

exposing an alternative gene for duplication . Some envi-
ronmental processes also tum on or off specific genes when
they are being dup licated in the body. This results in a differ-
ent expression of genes, and it explains why identical twins
with exactly the same DNA can have very different physical
and emotional traits. It also explains why some siblings
may have severe addiction problems and others don't. 27 ·28 ·29
PsychoactiveDrugs and Mental Balance
Along with heredity and environment, the use of psychoac-
tive drugs can deplete, increase, mimic, or otherwise disrupt
the neurochemistry of the brain. This disruption of brain
chemistry by drugs can lead to mental illness (often tempo-
rary), drug addiction, or both.
If a nervous system is affected by enough psychoactive
drugs, any individual may develop mental/emotional prob-
lems, but it is the predisposed brain that is most likely to
have prolonged or permanent difficulties . There is no set
time for this to occur . The process may take years or, as in the
case of psychedelic drugs, one use can release an underlying
psychopathology. 30 A brain that is not predisposed is most
likely to return to predrug functioning during abstinence .
of
"Apparent/~.throu9h three9enerations m~ famil~and our
alcohol drinkin9or opium smokin9,I inheriteda tendenc~
toward manic depressionthat wouldn't awakenwith just alcohol
abuse. It took a moreexotic dru9, one that was a little bit
of to
be~ondthe ran9e a northernEuropeanfamil~. brin9out
m~ illness- and that was marijuana."
45 -year-old with bipolar disorder
The type of drug used has a great impact on the symptoms
of co-occurring disorders. Women with a dual diagnosis of
cocaine abuse and post-traumatic stress disorder (cocaine/
PTSD) had greater occupational impairment, lower monthly
income, more legal problems (e.g ., frequency of arrest for
Mental Health and Drugs 10.5
prostitution), and greater social impairment (e.g ., few close
friends, no social network) than those who had an alcohol/
PTSD dual diagnosis. Those with an alcohol/PTSD dual diag-
nosis were more likely to have serious accidents and extraor-
dinarily stressful life events . Rates of major depression and
social phobia were also higher among this group than in the
cocaine/PTSD group. 31
Every time a psychoactive substance enters the brain, it
changes the equilibrium and requires the neurochemistry to
adjust. When exposure to that drug ceases, the brain does
not always return to its original balance. This process of
altering neurochemistry and genetics to maintain a new bal-
ance is called allostasis . In a brain predisposed to major
depression, heavy abuse of alcohol and sedative-hypnotics
or withdrawal from stimulant drugs can aggravate that
mental problem .32 •33 In a brain predisposed to schizophre-
nia, that illness can be activated and a psychotic episode
triggered by abuse of psychedelics. One mental disorder-
hallucinogen persisting perception disorder (HPPD)-is
marked by the transient recurrence of disturbances of per-
ception (flashbacks) similar to those experienced while actu-
ally using a hallucinogen. The symptoms are disturbing and
can impair everyday functioning. They may disappear in a
few months or may last for years.
Definition
Co-occurring disorders are defined as the existence in an
individual of at least one independent major mental dis-
order as well as an independent addiction and related
disorders. This means that a cocaine abuser might also have
The Extraction of the Stone of
Madness by Pieter Brueghel the Elder
is a satire of ways to treat mental
illness. It shows that even 300 years
ago people thought that mental illness
was caused by somethingphysical
inside the brain. Compare this with
the modem view of many clinicians
I
that mental illness can be treated by
changing the neurochemistryinside
the brain through psychotropic
medications.
Courtesy of the National Libraryof Medicine,
Bethesda, MD
 10.6 CHAPTER10
a psychosis even when not using the drug. An alcoholic
might be severely depressed even when clean-and-sober.
Another example is a person with a pre-existing attention-
deficit/hyperactivity disorder (ADHD) who has become
dependent on methamphetamine and self-medicates the
condition. Although co-occurring disorders is the most com-
mon term in the substance-abuse and mental health fields,
other terms, such as comorbidity, double trouble, substance-
abusing mentally ill, mentally ill chemical abuser, and espe-
cially dual diagnosis, are also used. 34 Co-occurring disorders
and dual diagnosis are used interchangeably throughout
this chapter.
"A~er more than 30 qearsof use, when I gave up the codeine
and the Valium® in treatment, I started to rememberthe pain.
Youknow, the firstthing that nashed through mq mind was
mq uncle'sface when he was hurtingme real bad when I was
10. I hadn't rememberedit for 32 qears."
45 -year-old female with major depression
'The previouspatient is a case wherethe diagnosisbecomes
clearerthe longershe is clean-and-sober.She appearsto have
sufferedfrom a major depressivedisorder,but there'salso
evidenceof a post-traumaticstressdisorder.The sqmptoms
of the PTSD did not emergeuntil she was able to remain
clean-and-soberfor a periodof time. Her treatment would
necessarilqinclude the simultaneousaddressingof her
substanceabuse and mental health problems."
Pablo Stewart, M.D., psychiatrist
The mental health conditions most often diagnosed as part
of a dual diagnosis fall into two categories: pre-existing
and substance induced. Examples of pre-existing mental
disorders are:
• schizophrenia (thought disorder)
• bipolar disorder
• major depression (affective disorder)
• anxiety disorders (e.g., panic disorder, obsessive-
compulsive disorder) 12 •14 ,3s
Examples of substance-induced mental disorders are:
• stimulant-induced psychotic disorder
• alcohol-induced depression
I
• marijuana-induced delirium
"/ have this illness,mental illness,with manic depression,
and when I take alcohol, mq functioningisn't as clear-cut,
not as sharp as, saq, the averagepersonwho isn't suffering
anq mental problems."
52 -year-old with a dual diagnosis
There is an important distinction between exhibiting
symptoms of mental illness and actually having a major
psychiatric disorder. Everyone feels down and sad some-
times. Everyone has the capacity for grief and loneliness, but
that does not mean a person is medically depressed and
requires medication or psychiatric treatment. It is really a
question of severity and persistence of the symptoms. 14,21 ,36
It is vital that a clinician trained or licensed to assess and
diagnose mental health disorders make the determination
when someone exhibits symptoms consistent with mental
illness. The connection between substance abuse and mental
disorders is real. One study found that the chance of major
depression combined with alcoholism in women was sub-
stantially higher and was probably the result of genetic fac-
tors, but environment still had an influence .37
It is common for people who are abusing substances to pre-
sent with symptoms of a personality disorder, particularly
borderline or antisocial personality disorders. As a person
achieves and maintains sobriety, however, the majority of the
symptoms of the personality disorder often dissipate unless
the person has a pre-existing condition. There is much debate
as to the actual prevalence of personality disorders.
Epidemiology
As mentioned, NAMI reviewed various reports published in
the Journal of the American Medical Association and found
that 3 7% of alcoho l abusers and 53% of persons abusing
other substances have at least one serious mental illness. 1•2
In another study in Taiwan, about 60% of those seeking
treatment for heroin addiction had at least one serious psy-
chiatric disorder. 38 Certain drugs increase the likelihood of
mental illness . Three-fourths of cocaine abusers had a diag-
nosab le mental disorder, as did half of all compulsive mari-
juana users . The majority of the mental illnesses were caused
by substances, although some users were self-medicating a
pre-existing psychiatric disorder with street drugs. 39
"/ believeI had depressionall along, even beforeI started using,
and so through alcohol, marijuana,and even heroin, I was
treatingthat depression."
24-year-old with a dual diagnosis
Conversely, it is estimated that about 50% of individuals
with severe mental disorders are affected by substance
abuse . Of all people diagnosed as mentally ill, 29% to 34%
had a problem with either alcohol or other drugs . 1,2 ,40 ,4 1 The
overlap is greater with certain mental disorders: 61 % of peo-
ple with bipolar disorder and 47% of people with a thought
disorder also had a problem with substance abuse. In prisons
the prevalence of a psychiatric illness in inmates with an
addictive disorder was a remarkable 81 %.
Although studies vary widely, of the 7 million to 13 million
people who do have co-occurring disorders, about 20% to
23% received only mental health care and 7% to 9% received
only substance-abuse treatment, leaving just 7% to 8% who
received both and 60% to 66% who received no treatment at
all.42 •43 Focusing on just those with mood/anxiety and sub-
stance use disorders, only about 5% received treatment for
both disorders and 25% received some treatment, leaving
70% afflicted by both conditions receiving no treatment. 44

Patternsof Dual Diagnosis
The substance and how it is used help determine the two
general patterns of dual diagnosis.
Pre-ExistingMental Illness
One kind of dual diagnosis involves the person who has a
clearly defined mental illness and becomes involved with
drugs (e.g., a teen with major depression who discovers
methamphetamine). In these instances the drugs are often
used to self-medicate symptoms of the mental illness.
"Mqmomaskedmq littlebrotherif he thou9htI'd been
depresseda lot in mq life,and he said I'd beendepressedever
sincehe couldremember. The speed9ot me out of it except
whenI wascomin9down."
16-year-old male
The presence of a pre-existing mental illness does not pre-
vent a user from developing a substance-abuse condition, so
mentally ill people can often have a concurrent substance-
abuse problem that does not involve self-medication. An
example of this is a schizophrenic who also suffers from
alcoholism .
Substance-InducedMental Illness
This type of dual diagnosis is given when there is no pre-
existing problem. As a result of substance abuse and/or
withdrawal, the user develops psychiatric problems
because the toxic effects of the drug have disrupted the brain
chemistry .45-46The chemical imbalance in this type of diag-
nosis is usually temporary, and with abstinence the mental
illness disappears within a few weeks to a year. 30 A signifi-
cant number of these problems, however, manifest as unre-
solved and chronic mental illnesses. This is more likely to
occur in those with a pre-existing susceptibility to mental
illness .
"Mqinitialpip-outhappeneda~ersnorting'crank'for six weeks
strai9ht,about halfa grama daq. I startedhearingvoicesand
thinkingthat mq phonesweretapped.Friendsbroughtme to
the psqchiatrichospital,whereI wastreatedwithantipsqchotic
medication.Mq dia9nosiswasmethamphetamine-induced
psqchoticdisorder."
28 -year-old with a dual diagnosis
Substance-induced mental disorders include delirium,
dementia, persisting amnesic disorder, psychotic disorder,
mood disorder, anxiety disorder, sexual dysfunction, sleep
disorder, and HPPD.
'This speedrun'sonlqbeen13 da~s, but I 9et thesesoresand
I get paranoidand realcrazq. After I comedown,it'll be weird.
It willtakeweeksto 9et backinto shape.And all that other
crapwilldisappear."
43 -year-old heavy intravenous methamphetamine addict
Mental Health and Drugs 10.7
Makingthe Diagnosis
Assessment
When someone observes a friend or relative acting oddly and
having trouble coping with everyday life over a prolonged
period, ascribing that behavior with certainty to relationship
problems, trouble at home , drug use, or mental illness is dif-
ficult. Substance-abuse and mental health professionals have
the same problem, as is evident from the variations in diag-
noses of the many mental health disorders cited earlier in this
chapter . Thus when assessing mental illness in a substance
abuser, treatment professionals initially begin with a "rule-
out" diagnosis, which means that several possible diagnoses
will be considered during the period of assessment.
Treatment continues to evolve into a behavioral health model
for dual diagnosis with a policy of "any door" or "every door
is the right door," which means that resources should be
available for mental health treatment through substance-
abuse programs and addiction treatment resources through
mental health programs. It is important that diagnosis of
this condition, regardless of the "door, " be made by experi-
enced clinicians who are trained to evaluate both conditions .
'The doctortold me that a personwho drankfor 25 qears
likeme wouldprobablqtakea qearto clear.That wasone
reasonwhq I neverfiguredout that I was manicdepressive.
I didn't noticeit. I figuredI was depressedbecauseI was
drunkall the time."
35 -year-old male with a dual diagnosis
Because many psychiatric symptoms can be the result of
drug toxicity and/or withdrawal, it is wrong to immediately
assume that all of these symptoms are due to a pre-existing
men ta! illness. The prudent clinician addresses all sym p-
toms but avoids making a specific psychiatric diagnosis
until the drug abuser has had time to get sober and is
beyond drug withdrawaJ. 47.4B.49
"/ wason opiatesand antidepressants, and I wouldhaveverq
severerespiratorqproblemsat ni9ht,Jot no sleep,and wantedto
crawlout of mq skin.I wasparanoi . I thou9htthat everqbodq
wasagainstme, and it probablqtookme a good two weeksof
beingin treatmentto get throughwithdrawals. The nicething
aboutcominginto treatmentis theqdo taperqou.Theq help
I
qou throu9hthosefirst fewdaqsof withdrawalwhenqou feel
likeqou want to die."
38 -year-old pharmaceutical opiate abuser
Multiple factors may influence the diagnosis:
• the particular pattern of substance use
• the presence of a pre-existing mental illness
• the evidence of self-medication
• the age of onset of any psychiatric symptoms
• the relationship of the psychiatric symptoms to the
substance use
 10.8 CHAPTER10
Cornered by Mike Baldwin
t2 •15 C2004 Mike Baldwfn / OISL t:iyUniversal Press Syndicate www.cornereo .can
cornered@comtc
.com 'J~
~MAt..>\l
ss,ve
.., 0E1>11.E
© 2004 Mike Baldwin. Pnnted by permission of Universal Uclick All rights reserved.
Reasonsfor IncreasedDiagnoses
The vast number of dual-diagnosis clients on the streets
today is the result of five decades of failed mental health
policies. In the 1960s states emptied the mental hospitals but
failed to launch programs to provide treatment for those
released. By the 1980s the numbers of seriously mentally ill
persons among the homeless and the incarcerated had risen
dramatically.
• There are fewer inpatient mental health beds (Figure
10-3) due to decreasing mental health budgets , decreas-
ing mental health coverage by other insurance programs,
increased effectiveness of psychiatric medications, and
occasionally misguided government policies on mental
health support.
• There is a proliferation of substances to abuse, particu-
I
larly stimulants. Because cocaine , methamphetamines,
and psycho-stimulants are more toxic to brain chemis-
try than most substances (except inhalants and alcohol),
people with fragile brain chemistry are more likely to be
pushed over the edge into chronic neurochemical imbal-
ance and mental illness.
• There are more licensed professionals with greater
expertise working in the field of chemical dependency
treatment , resulting in greater recognition and documen-
tation of dual diagnosis.
• A heightened awareness of substance abuse and its
effects by mental health workers has placed co-occurring
conditions higher on the list of options.
• Managed care and diagnosis-related group payments for
treatment services usually provide more financial incen-
tives for the treatment of multiple medical and psychiat-
ric problems than for just addiction treatment. 50 These
payment structures sometimes prompt some clinicians
to over-diagnose mental illness. 5 1,52
For these reasons many people with psychiatric disorders are
now forced to deal with their problems on an outpatient
basis or on their own. Once detached from hospital super-
vision, clients are more likely to exhibit poor control over
their prescribed medication , which aggravates their mental
problems and makes them more likely to tum to street drugs
for relief.
All of these factors have contributed to a rise in the number
of mentally ill homeless people whose problems are exacer-
bated by the lack of a support system. About 3.5 million
Americans experience homelessness in any given year (1%
of the total population and 10% of the poor). The number of
homeless (sheltered and unsheltered) in the United States in
any given week in 2013 was estimated at 610 ,042. 253 ,254
(Approximately one-half to two-thirds of this homeless
population meets diagnostic criteria for substance depen-
dence.) At least 25% of the total homeless population also
suffer from pre-existing mental illness. Of the mentally
ill homeless, more than 70% suffer from substance
dependence. so,s1,sa
"I had usedherointo controlmq depression sortof as a mood
stabilizer, so withdrawin9 fromit causedan evenworsedepression.
When I cameout of the fo9fromthe prstpvedaqsof not havin9
it, I felt better,but the pinkcloudfeelin9vanishedquitequicklq
and wasreplacedwiththe depression that I wasusedto."
25-year-old with major depression
Understandingthe Dual-DiagnosisPatient
Understanding and adapting to the treatment complexities
of a client with a mental health problem and a substance-
abuse problem is a challenge for treatment professionals .
'When I wentinto the hospital, I wouldtell them I had a
problem- that I wason Valium ®and codeine.The prstthin9
theqwouldthen9iveme wasa shot of Valium. ® I told them
that Valium®addictionwasoneof mqproblems.Theq still
9aveit to me."
40-year-old female with a dual diagno sis
In the past the inability to treat a person who manifested
both substance-abuse and mental problems , combined with
an outright refusal to develop treatment strategies for the
dual-diagnosis client , resulted in inappropriate and poten-
tially dangerous interactions with clients. They were often
shuffled aimlessly back and forth between the mental
health care system and the substance-abuse treatment sys-
tem, never receiving adequate care from either. Although
more facilities are addressing the dual-diagnosis client , inap-
propriate care is too often the rule rather than the exception
because of budget considerations and a lack of expertise .
 MentalHealth and Drugs 10.9

700,000

600,000
- Patients
inPrivateandStatePsychiatric
in theUnitedStates
Hospitals
.i
0
500,000 - -
] 400,000

>-
·;;;
"
300,000
-----
-
u,
200,000
1 The psychiatric hospital census has gone
100,000
down while the number of people diagnosed
0 J_ L_..!_L_.LJ
L_ '---'--''--'---'-L-'--'--'---'--'--'----'-L--'-L_..LJL_'---' - L_
with mental illnesses has gone up.
1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2010 NIMH, 1991
(estimate)
Year

Substance-abuse treatment facilities usually avoid accepting current treatment of their substance-abuse and mental health
these patients because they see them as too disorganized, problems. Both disciplines acknowledge that "co-occurring
too disruptive, or, in many cases, too inattentive to participate disorder" is a primary diagnosis separate from individual diag-
in group therapy, which is frequently the core element of treat- noses of a mental illness and substance abuse.
ment. Psychiatric treatment centers also avoid admitting
these patients because they are perceived as substance abus-
ers, disruptive, and manipulative and because they frequently
D MentalHealthTreatment Substance
Abuse
Treatment

relapse into active substance abuse, which interferes with the IntheMHsystem,partialrecovery InSAprograms, mostprofessionals
ismorereadily
acceptable. believethatlifelong
abstinence
medications used to treat their mental illness. 59 fromallabuseddrugs,including
alcoholandmarijuana,isnecessary.

Mental Healthvs. SubstanceAbuse Abstinence in an environment supportive of sobriety along

with rigorous continued SA treatment is necessary for ongo-
ing recovery in a dual-diagnosis client. Both mental illness
There are at least 12 ideological differences between the
and substance abuse are chronic persistent disorders, and SA
mental health (MH) treatment community and the sub-
professionals have become more accepting of patients taking
stance-abuse (SA) treatment community. Although certain
long-term MH medications, though traditionally SA treat-
difficulties persist, these two communities are moving
ment avoided the use of any psychoactive substance in the
toward a closer working relationship. Evidence shows that recovery process.
better outcomes are achieved when both conditions are
treated at the same time in the same facility-"every door is
the right door"-so more facilities are employing both men- MentalHealthTreatment Substance
Abuse
Treatment
tal health and substance-abuse treatment staff and have Clients
aremorereluctant
to seek Clients
aremorelikely to seekhelp
taken a team approach to treatment. helpfromthe MHsystemthan fromSAtreatmentprograms,
fromSAtreatmentprograms. probably becauseofthestigma

I
Although integration of both MH and SA treatment in a sin- attachedto mentalillness.
gle facility offers an on-site continuum of care for the dual-
Clients and their families hope that the problem is "only"
diagnosis client, some conflicts between the two clinical
addiction from which they believe they can recover more
disciplines persist.
fully than from a mental illness. There is a persistent stigma
and a negative stereotype attached to being a female addict
D MentalHealthTreatment Substance
AbuseTreatment or alcoholic, so many women seek mental health treatment
MHtreatmentprovidersbelieve: SAtreatmentprovidersbelieve: as a way to address their chemical dependency problem.
"Control
the underlying
psychiatric "Getthepatientclean-and-sober,
problemandthedrugabusewill andthe mentalhealthproblems "I tell membersofm~ famil~that I'm in a halfwa~housefordru9
disappear." willresolvethemselves." addictionas opposedto mentalhealthbecauseit seemswith
While both of these statements have some validity, both disci- dru9addictionI can 9et better,but with mentalhealth,people
plines recognize that perhaps one-third to three-fourths of see it as a chroniclon9-termproblem."
their clients are legitimately dually diagnosed and require con- 19-year-old dually diagnosed male with major depression
 10.10 CHAPTER10

II MentalHealthTreatment Substance
Abuse
Treatment MentalHealthTreatment Substance
AbuseTreatment
MHreliesheavily
on medications
to SAprogramstendto be divided MHhastraditionally
employeda ManySAprograms continueto use
treatclients. betweenpromotinga drug-free supportive
psychotherapeutic confrontation
techniquesthatmany
philosophy
andsubstituting
a approach. MHprofessionals
thinkare
less-damaging
drugsuchas inappropriate.
methadoneor buprenorphineina
harm-reduction
maintenance MH clinicians offer suggestions and invite their clients to
program.
Theseareknownas initiate changes in their lives. SA clinicians educate clients
replacement
therapies. about the tools they need to control their compulsivity and
Recent developments in the understanding of addiction and then direct them to employ those tools, imposing conse-
its treatment due to the Affordable Care Act are moving sub- quences if the client fails to use the interventions provided.
stance abuse treatment into a medical model. This will result A major conflict often occurs when a patient is not respond-
in an increase in medications used to treat substance abuse. ing to traditional SA treatment because he or she also suffers
from a psychiatric disorder. The same behavioral threshold
used to terminate someone who suffers only from sub-
MentalHealthTreatment Substance
Abuse
Treatment stance abuse cannot be applied to a dual-diagnosis patient.
MHusescasemanagement, SAprograms traditionally In programs that provide dual-diagnosis services, the staff
shepherding clientsfromone emphasize self-relianceinaneffort must learn to recognize psychiatric symptoms that could
serviceto another. to preventclientsfromtransferring interfere with SA treatment. It is inappropriate to discharge
theirdependence to the program.
patients from treatment who are psychiatrically unstable.
More treatment involvement with MH services has demon- This conflict is slowly being resolved by the increased recog-
strated to traditional SA professionals the need for and the nition that a large portion of behavioral health (SA and MH)
value of case management services for dual-diagnosis cli- clients have suffered major trauma during their lives. All
ents. A recent development in SA treatment is the participa- behavioral health programs are now encouraged to employ
tion in the treatment process of a recovery coach, also trauma-informed care, and their clinicians are being trained
known as a sober companion. This function is becoming in trauma-focused care to better engage clients in treatment,
more widely recognized as established certified paraprofes- so traditional SA confrontational approaches are beginning
sionals provide more-intensive interactions and interven- to fade away.
tions to keep clients engaged in their goals and activities.
MentalHealthTreatment Substance
AbuseTreatment
TheMHsystemishampered from TheSAsystemisalsohampered
sharinginformation
becauseof fromsharinginformation
because
IM TRYING AN At_i~R.NA71Ve- confidentiality
regulations. ofconfidentiality
lawsand
71-1f:R.AP'y TO COPf: ~ITH MY regulations.
DcPR.€SSION. MH shares information with allied fields more readily than
does SA, and this has become a challenge to MH profession-
als working in dual-diagnosis programs.

,IMC MentalHealthTreatment Substance

AbuseTreatment
ANPO In MHthetreatmentteamis InsomeSAprograms, recovering
composed ofprofessionally substanceabusersoftenmakeup
preparedindividua~:
socialworkers, the bulkofthetreatment
staff.
nurses,psychiatrists,
psychologists,
andlicensedcounselors.
Personal recovery does not prepare someone to professionally

I
treat substance abusers, and most states now require individu-
als to have specific training and credentials before they work
with addicts. "Having been there" does, however, engender
instant credibility among substance abusers. An individual
certified or licensed to provide MH counseling is not always
adequately prepared to provide SA counseling. Many states
now require dual certification or specific dual-diagnosis coun-
seling certification for clinicians to treat patients with this
condition . Gambling is now recognized as an addictive disor-
der, and this has given rise to specific credentialing for gam-
bling treatment professionals in many states. Clinicians are
REALLIFEADVENTURES©2003 Garlanco. Reprinted by permission of Universal
Uclick All rightsreserved. also certified in some states as specialists in dual diagnosis and
even as pain and addiction specialists.
 MentalHealthand Drugs 10.11

MentalHealthTreatment Substance
Abuse
Treatment Although the situation may be improving from the perspec-
tive of the MH treatment community, dual diagnosis has rep-
MHreliesonscientifically
based SAprograms oftenrelyonthe
treatmentapproaches. philosophyWhatworksfor mewill resented an almost insurmountable challenge to the clinical
workforyou. expertise of the staff of SA programs . Their assessment skills
coupled with their underlying concept of recovery or sobriety
No longer can traditional SA treatment programs rely solely have been challenged by patients with a dual diagnosis. It can
on personal experience and tradition, as SA treatment has be difficult to differentiate pre-existing mental illness from a
evolved into a very scientific, evidence-based paradigm that substance-induced mental illness . Patients are often misdiag-
is mandated in most states. MH staff, however, can learn nosed with mental illness early in the treatment or assess-
much from traditional SA treatment, especially as it applies ment process and are referred to MH programs that all too
to spirituality in recovery. often reject them because of their concurrent SA problems .

"All I can tell someoneis, '/ have a problem. I don't know As the "every door is the right door" strategy continues to
which wa~ ~ou'regoing to deal with it or tackle it, but I expand, both MH and SA programs are developing the
have a problem,and I can't function, and I need help."' expertise and the program modifications needed to diagnose
and treat patients who present with co-occurring disorders .
38-year-old dual -diagnosis client with major depression
Fiscal and other limited-resource problems, however, pre-
vent the expansion of services necessary to meet the needs of
dual-diagnosis clients in many programs, creating a ten-
MentalHealthTreatment Substance
Abuse
Treatment
dency to establish mental health problems as exclusionary
MHseeksto preventtheclient SAprograms historically
tooktheir criteria for treatment admission or continued treatment in
fromgettingworse. cuefromearly12-stepfellowship
many SA programs and establish addiction an exclusionary
beliefs
andallowed peopleto hit
bottomto breakthrough theirdenial. criteria for MH programs . SA programs with expertise in
mental health often mistake psychoactive substance-induced
Most SA programs consider the traditional approach outmoded mental illness for proof that there is an existing psychiatric
and dangerous. To engage people in treatment, they rely more diagnosis. Despite heavy promotion and alleged integration
on motivational interviewing, a way to help people recognize of SA and MH treatment, dual-diagnosis patients are primar-
and do something about their problems. It is particularly useful ily still treated in separate and distinct facilities focused on
for people who are reluctant or ambivalent to change .60 .61 either SA or MH treatment without integration-the "silos"
The dual-diagnosis client needs support throughout the change approach to addressing this prevalent condition .
process, more so than the single-diagnosis client. 62

Recommendations
MentalHealthTreatment Substance
Abuse
Treatment
In MH,treatmentisindiv
idualized. Manytraditional SAprograms
tend "Our consumersdo not have the opportunit~to separatetheir
to be "onesizefitsall." addiction from their mental illness,so wh~ should we do so
administrative/~and programmaticall~?"
Best practices dictate that appropriate techniques from both
Osher, 2001
disciplines be utilized with the dual-diagnosis patient
because both conditions require simultaneous treatment .
Research over the past decade confirms that dual-diagnosis
Traditional educational approaches used in SA treatment
patients must be treated for both disorders simultaneously.
must be integrated into individualized MH treatment plans.
They are best treated in a single program when appropriate
resources are available-known as the "every door is the
m MentalHealthTreatment Substance
Abuse
Treatment right door" strategy .63 If programs equipped to handle dual-
diagnosis cases are not available, SA programs need to
MHandSAeducat ion during SAeducationalso places
treatmentarestructured
and importanceon long-held traditions establish links with MH service providers and vice versa so

know ledgebased. andpeerexperiences.
Information based on scientific discoveries of the brain
and its functioning has increased the understanding and
the knowledge of both MH and SA. Many of these discover-
ies support the long-standing traditions of chemical depen-
dency treatment, and peer experiences remain a valuable
relapse prevention resource. There is also a strong and con-
tinued tradition in SA treatment to incorporate spiritual
participation (i.e., faith-based treatment, 12-step groups),
which is not part of the MH treatment paradigm . Research
shows some of these approaches, such as 12-step participa-
tion, are very effective and are becoming more accepted as
evidence-based treatment interventions.
I
that they can work together to provide the client with their
combined treatment expertise . This is particularly important
when patients are admitted for treatment for psychiatric
problems because they are more willing to acknowledge
coexisting SA problems and more receptive to facing the
need for additional treatment. 64
Each discipline needs to recognize that mental health
and substance abuse are both long-term and chronic persis-
tent medical conditions; therefore a need exists to establish
both short-term and long-range services that address
the problems of dual diagnosis. 65 Research also suggests
that incorporating behavioral (motivational) approaches
to substance-abuse treatment is more effective for the
 10.12 CHAPTER10
0 More SevereMental
Disorder
e LessSevereMental
Disorder
More SevereSubstance More SevereSubstance
UseDisorder UseDisorder
0 LessSevereMental
Disorder
LessSevereSubstance
UseDisorder
Minkoffs Four-QuadrantModel shows the differinglevelsof substance-
abuse disordersand mental health disorders.Assessing these levels
enables treatment personnel to tailor dual-diagnosistreatmentfor
the client.
dual-diagnosis client because the structure is better suited to
overcoming cognitive difficulties that accompany schizo-
phrenia and certain other mental illnesses .66 Research has
found that intensive case management was associated with
the greatest improvement in dual-diagnosis clients . A
smaller but measurable improvement was also shown with
standard aftercare and outpatient psycho-educational
groups .67 A recent study found that existing effective treat-
ments for reducing psychiatric symptoms also tend to work
for dual-diagnosis patients; and, conversely, existing effec-
tive treatments for reducing substance use also work for
dual-diagnosis patients. 68
Dr. Kenneth Minkoff's Four-Quadrant Model of differing
levels of mental health and substance abuse is useful when
determining the most appropriate treatment placement
and direction for a dual-diagnosis client.
Quadrant I Clients with less severe mental disorder and less
severe SUD can be treated in primary care settings.
Quadrant 2 Clients with more severe mental disorder (severe
persistent mental illness) but less severe SUD can be served
in the MH system or by MH professionals guiding the treat-
I
ment interventions in programs providing both treatment
services.
Quadrant 3 Clients with less severe mental disorders but
more severe SUD can be served in the SA treatment system
or with SA treatment professionals leading the treatment
plans in programs providing both services.
Quadrant 4 Clients with serious persistent mental illness and
severe SUD (active addiction) should be served initially by
medically managed hospital-based systems, the criminal
justice system, emergency rooms, and other acute medical
systems. 69
Occasional disagreements about treatment intervention or
direction for a dual-diagnosis client enrolled in a program
that treats both conditions can be resolved by identifying
where a particular client falls on the Four-Quadrant Model.
Multiple Diagnoses
As the substance-abuse treatment community becomes more
aware of other simultaneous disorders that complicate the
treatment of addiction, new challenges must be addressed :
• multiple drug (polydrug) abuse
• other medical disorders such as chronic pain syndrome
(e.g., fibromyalgia and migraine disorders), hepatitis,
epilepsy, cancer, heart and kidney disease, diabetes,
sickle cell anemia, and sexual dysfunction
• triple diagnosis (dual diagnosis complicated by the pres-
ence of HIV disease)
"Oneofthe bi8[Jest thingsthat causedme the mostanxietqis,
qouknow,I'm HIV-positive and I reallqstarted havingproblems
withsleep.I foundthat out and I wasreallqtornbetween
cleaningup and staqingcleanor justgoingout and using.
I felt like,Well, I'mgoingto dieanqwaq,a nastqhorrible
death,and I had nightmares and then mq feelingssurfaced to
a pointwherea lot ofotherfeelingscameup aboutold stuff"
Recovering HIV-positive alcohol abuser with a general anxiety disorder
The evidence is very clear: when people are dually diag-
nosed, they must achieve sobriety from all drugs of abuse,
not just their drug of choice . This means that recovering
heroin addicts, for example, must refrain from alcohol or
marijuana even though they have never had a stated problem
with these substances.
Research using the Addiction Severity Index links successful
substance-abuse treatment with addressing a person's medi-
cal problems. For clients to achieve any degree oflong-term
sobriety, substance-abuse treatment must be linked to
appropriate medical care . This includes the treatment of
legitimate pain syndromes that may require narcotic anal-
gesics. Substance-abuse treatment programs must creatively
incorporate the treatment of legitimate pain syndromes into
their overall approaches. Establishing topical groups specifi-
cally for those who have chronic pain can help patients
take abusable pain medications appropriately rather than
abusively, which will help prevent a relapse.
Of particular significance is the epidemic growth of hepati-
tis C and other severe liver diseases in chemically depen-
dent patients. The prevalence of hepatitis C in intravenous
(IV) drug users is now much greater than that of HIV, empha-
sizing the need to avoid hepatotoxic drugs (drugs that are
toxic to the liver), especially alcohol. In addition, a variety of
medical disabilities such as hearing or mobility impairment,
language barriers, and social concerns including cultural
attitudes toward chemical dependency and mental health
treatment can also present impediments to successful treat-
ment of those with multiple diagnoses.
 MentalHealth and Drugs 10.13

Women, particularly those who are pregnant or parenting, PsychiatricDisorders:

have special treatment needs. Women process psychiatric
medications differently than men do and have higher plasma
levels for a given dose of a prescribed drug , so lower doses
are appropriate. 26 A pregnant woman with both a drug addic-
tion and a mental illness may receive conflicting information
from treatment programs that address only one of those con-
ditions. Drug use and mental illness pose health risks to a
fetus and interfere with a woman 's instinctive nurturing
Pre-ExistingMental Disorders
"A neuroticis the personwho buildsa castlein the air.
A psqchoticis the personwho livesin it.
And a psqchiatristis the personwho collectsthe rent."
Anonymou s

behavior toward her newborn. 70 ·71 These problems require

drug programs that are holistic, use several modalities, and Overall an estimated 26.2% (almost 81 million) of the U.S.
are multidisciplinary to meet the challenge of the compli- population age 18 and older is affected by one or more
cated clinical needs of the chemically dependent patient." mental disorders during a given year. About 6% suffer seri-
ous mental illness. Many suffer from more than one mental
Triple diagnosis is defined as the presence of an HIV infec- disorder at a given time. Nearly half (45%) of those with any
tion in a dual-diagnosis client . Persons with AIDS, an AIDS- mental disorder meet diagnostic criteria for two or more dis-
related condition, or an HIV-positive blood test or who have orders with a severity strongly related to comorbidity.
a partner with AIDS require additional treatment expertise Anxiety disorders are the most prevalent , followed by mood
and specific services to effectively address their chemica l disorders (especially depression). Schizophrenia is extremely
dependency debilitating but occurs much less frequently than anxiety
As the AIDS epidemic expanded from the gay and IV and mood disorders .3 ,78
drug-using populations into the cocaine- and other drug- Although there are hundreds of menta l illnesses recognized
using heterosexual populations, triple diagnosis strained by the mental health community, the following are most
health department resources and further complicated often associated with co-occurring disorders.
treatment.73•74 .15
• Schizophrenia spectrum and other psychotic disorders:
schizophrenia , schizoaffective disorder , and substance/
'When we lookedat the first49 consecutiveHIV-infectedpatients medication-induced psychotic disorder, among others
who camein to oursubstance-abuse servicesat San Francisco
GeneralHospital,the bottomlinewasthat 84% had someAxis I
psqchiatricdia9nosis
. A thirdhad depressivedisorders,and
anotherthirdhad anxietqdisorders.And 18% had or9anicbrain MentalDisorders
inAmericans
sqndromes,mild-to-moderatedementia,or or9anicpsqchosis. " (1-Year
Prevalence)
Steven L Batki, M.D. , psychiatrist and medical director, PERCENTAGE
OF
San Francisco General Hospital Substance Abuse Seivic es ADULTS
18AND AVERAGE
AGE
DIAGNOSIS OLDER OFONSET
According to the National Treatment Improvement Evaluation Schizophrenia 1.1% Men:lateteens,early20s
Study, dual-diagnosis patients were more likely to share a Women : early30s
needle, trade sex for money, have sex with an IV drug user, Bipolar
I disorder 2.6% 25years
and report being raped than someone with no psychiatric Majordepression 6.7% 32
co-occurring disorder. Dual-diagnosis clients should be
Anxiety
disorders 18.1% 21.5years(firstepisod
e)
targeted for more-intense HIV interventions to avoid adding
AIDS to their condition .76 ,77 Obsessive-compulsi
ve disorder 1.0% 19
Panicdisorder 2.7% 24andabove
NOTE The following sections explore the different kinds of Simplephobia 8.7%
psychiatric disorders; discuss the relationships among hered-

I
Socialphobia 2.0% l3
ity, environment, and psychoactive drugs as they relate to
Genera
lizedanxiety
disorder 3.1% 31
mental illness and drug addiction; and examine the various
treatments available for the mentally ill substance-abusing Agoraphobia 0.8% 20
patient , particularly the use of psychotropic medications in Post-traumatic
stress
disorder 3.5% 23
therapy The information provided is not intended to enable ADHD(attention-deficit 4.1%
accurate diagnoses of psychiatric disorders. It is meant to hyperact
ivitydisorder)
help mental health and substance-abuse professionals recog- Personality
disorders
(PD) 9.1% Various
, usuallychildhood
nize a client's abnormal thoughts and behaviors so that
Antisocial
PD 1.0%
someone qualified to make a mental health diagnosis can be
consulted . Diagnosis of psychiatric disorders should be con- Borderl
inePD 1.6%
ducted only by trained mental health professionals licensed Avoidant
PD 5.2%
to make such diagnoses.
 • BipoLl.r•ndr<eLl.t<ddiwrdeB:bipobrl•ndll,cydothy -
:~,~~:::~=b,tancdrned ication -induced bipolll md

• Dq,re .. ivedi!i0rdm : m.ojOTdepressivedOOrder . dy,--

thymi>, , ub5<.mc,/medica1ion -ind uceddepressh'<di>or -
der, • ndoth <n Schizophrenia "tiku mm and womm with equal fre-
• Anxi<tydisorden: panicd i!iOrd<r, g<n<n lized•nx i<ty quency.ltusually a ppeaninmenth<irlat<tttn , orearly
di!iOrd<r, ,ub5ancdrnedk•tion-induced • nxi<ty dOOr- tw <ntiu . and inwom<nduri ngth<irtwm t i<so r n.rlythir-
der, • nd • gorophooia tie,. This thoughtdOOrduu,u•llypu,i,;tsthroughouton<'s

~~~=::
:
• Obsnsive-compul,ive•ndrelat<dd i!iOrda.including life. •lthoughoc caoioruollythueis,pontaneou,r=iMion
hoarding ~o::"r~:!':d~::~hose with th< ill -
• Tnuma-•ndstr<e§SOT•r<Ll.t<dd iliOrden:poot -troum.otic
,tre.,di!i0rd<r,ocut<,1r<Mdi!i0Mer,mdoth<n Wh<n di.ogna,ing !i<hizophreni>, a d<t<rmin .i ion mu,t b,
• Pawrl2lity disord<B: bord<rlin< . paranoid. rnti,od•l mad•••towhichpsychoactivedrug,th<patientisuoing . or
=·.,·,fc . •voidant . !i<h'm "d,ob...\,e com1'oi, ,. thueis a rakolafalseorincompl<tediagnooi,.Athorough
(pe=m•litydOOrder,notOCD),•nddependentper,on - medica l history,int<r.-iew,withcla«fri<nds and family. •nd
•litydi>.on:l<n urin<•ndhair•n.aly,..•re<quallyimportanttomaking•
v.tlidd i'-l!no,i,
• Fttdingand e>tingdisordeB: anorvti•, bulimi• . • nd
bing e-e>tingdOOrder Seve.-.l • buoeddrug,mimic!i<hiaophr<eni• • ndl"ychooi ,
• Sub,a.ncc-relat<d and addictive di!iOrdeB: psychoac - produdng,ymptomsth.icrnbeaoilymisdi>gnosed
ti,,edrug,•ndaddicth,eb<ha,ior,; • Coc•ine and •mphewnin•• can cou .. • toxicp,ychosi,
(<>peciallywhenuoedtouce .. )tho ti,•lmo,tindistin -
SchizophreniaSpectrum and guish.ablefrom•1ru<po=o idp<ycha,is
Other PsychoticDisorders • St<roid,concauS<C • !")'<ho,i, . Stuoid -inducedpar>. ·
Sdtizophrenlai ,a chronicp,ychotic illn, .. th.ot • ffects noi•cmbeiruhstingu!,hab lefromtru<par.,noi.o
a pproJ<imatdyOSl.tol. 5'll, ofthepopul>tion.Th<re •re • Uppers,,uchumtthamphetomint . coca.ine, bathults,
manyoth<rp<ychi>tricilln<=thotha,.,P'ychot ic,y mp- cothinon,-. MDMA (ecstasy ), •nd psycho,timul.anl5
toms.,ponofth<irpr=nta1ion . Th=indudebu1•renot (2C -B. 2C -T-7), ormorijuan.ac • ncamep>I2IWi•
limit<dto!iChizoaffectivedOOrder . ochizophreniformdOOr- • Th< psych edelio . ,uch., LSD. pcyol< (m<>calin<l.
d<r,p>=oidtype,majOTd<pre"ivedOOrduwithp<ychotic p,ilocybin, •ndPCP, dioas!iOCU.t<uKrofromtheirour-
~-:;~;~;~~;onal di!iOM,r, md ,ubstanc:,c-induced p<y• J'OUndingo. !i0h•lludnogmic•bu«canb<mistak<nlor
•thoughtdOOrdu .
Athough t di!i0rda,uch .. ochirophreniaisb<lievedtobe • Alroho l •busecou.,.•thi.omin(vitaminB ,) ddiciency.
mostlyinherit<d.ltischaract<rizedby which re,ults in brain damage known .., Wernick<'s
<ne<pha lopathyandKo=kofl\psychooi,(W<rnicke -
• h.ollucin.otion,(f.olsevisu.ol,ouditory . or tactil<
Kor>80ff,yr,drom<)
«Ma tion,andperc<ptiom)
• Withdra ... tfromdownrrscanb<mistak<nforathought
• delusions(falsebeliek) dioordubtta.uKoFth,extr<me agia.tio n itproduce•
• iruippropriat<affect( a nillogi cale motiona l r<>pome • Unu,u•lorunup,ct<d ,,..ctio mto«v<r:1lth<r:1peutic
to a g'vm 't1.1tim) medi catiom(,uch • •Chantix,•T• lwin ,•• ndbromocri p-
• ::,~:~~"' (difficulty ffllling even the ,imp l<5t tin e)o r to•ntipsychoticm<dication,lik<Thoruin~ • md
1-hldol• h.o,.,=ultedin!i<hizophrenla-lik<,ymptoms.
• poor a.. oci>tion(difficu ltyconn<ctingthoughts • M•nyofthe drug -inducedp<ychi.otric,ymptom, u,u -
•ndid,., ) ~lly d~!i'."' ' ::h• body's drug levels ,ub.ide through
• imp•iredabili tytoc>r<forone•df
• autistic •ymptmru (a pronounced d<t.ochment from Bipolarand Related Disorders
reality)
• disorg,.niud,peech "l¼atacr«rtw,of,tro"9',,.,,,J,[W..,to,,Ow,d,;l/]i> -
• poorjobperfonruonce ~ attl,,mp o{tl,,lllh<,lof,onf.J,,oaorotfh,botto..
ofai,int,,,,,d,p,,,,.,,,-
• •trained!iOCi.alrebtion,
Dqxndingonthe,ubtype,oneormoreofthe,ign,mu,tb,
pr«<ntlm>tl,..,tonemonth(OT . for!iOm<. <ix month, )lo r Bipobrdioordu(fonnu lycalled"truonicdepns,ion")ischar-
thedi.ogno,istob<m.ode ." Delu,ion,•ndhalludn,uiono•re acterind by•lt<matingp<riod,ofdepr<e .. ion,normalcy,
thekeysymplom, andmoni>. Th<cyc lingtimebet"'<mlh<Kp<riod,VID,-.but

when four or more episodes of this illness occur within a
12-month period it is defined as bipolar disorder with rapid
cycling. 14 Median age of onset for bipolar affective disorder is
25 years. 83 The depression phase is as severe as that of major
depression. If untreated, many bipolar patients frequently
attempt suicide. The mania is characterized by:
• a persistently elevated, expansive, and irritated mood
(anger and rage)
• inflated self-esteem or unrealistic grandiosity
• decreased need for sleep and increased energy
• the pressure to keep talking, rapid speech, and incessant
talking
• flights of ideas and racing thoughts
• distractibility, hyperactivity, impaired judgment, and
impulsivity
• an increase in goal-directed activity or psychomotor
agitation
• excessive involvement in pleasurable activities that
have a high potential for painful consequences (e.g.,
drug abuse, gambling, or inappropriate sexual behavior
often leading to unsafe sex) 14
These symptoms can be severe enough to cause marked impair-
ment on the job, in social activities, and in relationships.
'The manicfeelingis a realfeelingof elationand euphoria.
There'sthat grindingangrq,sort of- I don't reallqget angrq
and violent,wellI did in jail, but I don't reallqwantto hurt
anqbodqor anqthing.And as faras beingdepressedgoes, I can
reallqsaq I'veonlqbeendepressedabout threetimes,once to
the pointof beingsuicidal."
30-year-old male with bipolar disorder
Bipolar affective disorder affects men and women equally
Many researchers believe that this disease is genetic. Toxic
effects of stimulant or psychedelic abuse often resemble a
bipolar disorder . Users experience swings from mania to
depression, depending on the phase of the drug's action, the
surroundings, and their own subconscious feelings and
beliefs. More than half of those with a bipolar diagnosis
(56%) have an alcohol use disorder. 86 •87 Integrated group
therapy-a new treatment developed specifically for patients
with bipolar disorder and substance dependence-is proving
effective in treating this condition. 88
DepressiveDisorders
Depressive disorders (affective disorders) include major
depressive disorder and dysthymia (mild depression) and
are the second most prevalent psychiatric disorders after
anxiety disorders. Almost 15% of Americans will experi-
ence a major depressive disorder in their lifetime, 6. 7% in
any one-year period. 82 ·83 Although onset of this disorder can
develop at any age, the median age is 32 years old. Major
depressive disorder is more prevalent in women than in
men. 83 It has been estimated that depression costs employers
$44 billion per year . Depressed people may make it to the
workplace, but their performance is substandard . And
Mental Health and Drugs 10.15
These imagesfrom the National Institute of Mental Health show
differencesin tissue thickness in the brains of someone sufferingfrom
major depressionvs. a normal control subject. A preponderanceof
blue and green shows normal thickness in the control subject on the
left, while a preponderanceof yellow, orange, and red denotes thinner
tissues in the brain of a patient with depression(on the right).8 4A
Courtesyof the National Institute of Mental Health
though more Americans are seeking help for depression,
only one-fourth receive adequate treatment. 84
Major Depression
Major depression is characterized by:
• feelings of helplessness and hopelessness
• diminished interest and pleasure in most activities
• disturbances of sleep patterns and appetite
• decreased ability to concentrate
• feelings of worthlessness or guilt
• suicidal thoughts 14
All of these symptoms may persist without any unsettling
life situation to provoke them. For example, a patient with
major depression may win a lot of money in a lottery but
remain depressed. For the diagnosis of major depression,
these feelings must occur every day, most of the day, for at
least two weeks . Medical illness or drug abuse would prob-
ably rule out a diagnosis of major depression as would natu-
ral reactions to a divorce, a strained relationship, or the death
of a loved one . These conditions, however, can cause a sus-
ceptible individual to develop major depression.
'The depressionjust camewhenit wantedto come. I just
sat thereand thoughtabout somethingand I got depressed.
The angercame becauseeverqmalethat has everbeenin
I
mq lifehas beatenme or usedme, qou know,mentallqand
phqsicallq-not sexuallqthankgoodness."
17-year-old male with major depression
Excessive alcohol use, stimulant withdrawal (cocaine,
amphetamine, or bath salt stimulants), and the comedown
or resolution phase of a psychedelic (LSD or ecstasy) can
result in temporary drug-induced depression that is almost
indistinguishable from major depression; it dissipates with
the completion of withdrawal or comedown. The depression
and the anxiety experienced by substance abusers are, in
about 80% of the cases, due to the drugs and not to a pre-
existing mental disorder. 85
 10.16 CHAPTER10
AnxietyDisorders
Anxiety disorders are the most common psychiatric distur-
bances seen in medical offices. About 18.1% of adults (18 to
54 years old) will experience an anxiety disorder in a given
year. Anxiety disorder frequently co-occurs with depressive
disorders or substance abuse. Most individuals diagnosed
with one anxiety disorder also have another. About 75% of
those with anxiety disorder will experience their first epi-
sode by age 21.5. 78 There are a number of anxiety disorders.
PanicDisorder
This is a common anxiety disorder. It consists of recurrent
unexpected panic attacks. A person with this disorder has a
persistent concern about having subsequent attacks , worries
about the implications of having an attack , and changes
behavior due to the attacks. A panic attack is a discreet
period of intense fear or discomfort in the absence of real
danger that is accompanied by at least four of the following
12 somatic or cognitive symptoms:
• palpitations or sweating
• trembling or shaking
• sensations of shortness of breath or smothering
• feeling of choking
• chest pain or discomfort
• nausea or abdomina l distress
• dizziness or lightheadedness
• derealization or depersonalization
• fear of losing control or of going crazy
• fear of dying
• paresthesia (numbness)
• chills or hot flushes
The attack has a sudden onset and rapidly builds to a peak
(usually in 10 minutes or less); it is often accompanied by a
sense of imminent danger or impending doom and an urge
to escape. 14 Panic disorder typically develops in early adult-
hood (median age of onset is 24), but onset can occur
throughout adulthood . Of the 2. 7% of Americans age 18 or
older who have panic disorder in any given year, about one-
third will develop agoraphobia, a disorder causing the indi-
vidual to be fearful of being in any place or situation where
escape might be difficult or help unavailable in the event of
a panic attack. 83
I
"I'd be waitin9for mq prescription at a dru9storeand someone
wouldjust lookat me and all of a suddenmq wholebodqjust
went insideitselfand I startedshakin9.Mq heartwas racin9.
I couldn'tsaq anqthin9.I wasjust in total panic. I couldn't
move.Ml mind keptsafna there'snothin9to be scaredof,
but I cou dn't controlit. I had no idea what reallqtri99ered
it. Mq husbandwouldcome up and hold me and sit thereand
saq, 'Breathe.' And a~era coupleof minutes,I wouldbe all
ri9htand I woulduse one of mq pillsfor anxietq,L.orazepam ,®
a benzodiazepine. I thinkthat mq use of cocaineovera period
of severalqearsmessedup mq neurochemistrq, particularlqmq
adrenalinesqstem."
SO-year-old femal e with a panic disorder
Panic attacks can occur in someone who has a panic disorder
or a major depressive disorder as well as in a cardiac patient
experiencing tachycardia. Panic attacks can also be induced
by stimulants, psychedelics, and marijuana.
Others anxiety disorders include the following.
• Agoraphobia without a history of panic disorder (a gen-
eralized fear of open spaces); median age of onset is 20.
• Social phobia, the fear of being seen by others in a
humiliating or embarrassing way (e.g., fear of eating in
public); onset is typically around age 13.
• Simple phobia, an irrational fear of a specific thing or
place; onset is in early childhood, and median is age 7.
• Obsessive-compulsive disorder (OCD), uncontrollable
intrusive thoughts and irresistible and often repeated
actions, such as checking that a door is locked or exces-
sive hand washing; first symptoms of OCD often occur
in early childhood or adolescence, but the median age of
onset is 19.
"I had a numberof obsessions.The obviousone ri9htnow is
mq hair. I cut mq hairobsessivelq
in a crewcut, constantlq,
bq mq own hand. The thou9htwouldjust comeinto mq mind.
It wassomethin9I didn't reallqhavecontrolover.I would
smokemarijuanaalmostas compulsivelq as I cut mq hair."
Client with an obsessive -compul sive disorder
GeneralizedAnxietyDisorder
GAD is defined by an unrealistic worry about several life
situations that lasts for six months or longer.14It is another
common anxiety disorder along with miscellaneous disor-
ders such as acute stress disorder. About 3.1% percent of
Americans age 18 and over have GAD in any given year.
GAD can develop at any age, though the median age of onset
is31.•'
Differentiating the anxiety disorders is difficult. Many are
defined more by symptoms than by specific names. Some of
the more common symptoms of anxiety disorders are short-
ness of breath, muscle tension, restlessness, insomnia, irrita-
bility, stomach irritation, sweating, racing heartbeat ,
palpitations, hypervigilance, difficulty concentrating, head-
aches, and excessive worry. Often anxiety and depression
occur simultaneously. Some physicians believe that many
anxiety disorders are an outgrowth of depression. 89
Toxic effects of stimulant drugs and withdrawal from
opioids, sedatives, and alcohol (downers) also cause
symptoms similar to those of anxiety disorders and can be
easily misdiagnosed as such. 85 In one study of college
students, the odds of having an anxiety disorder were
much greater if alcohol abuse and dependence were present ;
and the odds of having alcohol dependence were also greater
if an anxiety disorder was present .90 The effect of excessive
caffeine, especially in susceptible individuals, can also
produce symptoms.

Trauma- and Stressor-Related Disorders
Post-Traumatic Stress Disorder (PTSD)
PTSD was given a new classification as "Trauma- and
Stressor-Related Disorders" in the DSM-5. PTSD is a per-
sistent re-experiencing of a traumatic event that involved
actual or threatened death or a serious threat of injury to
one's physical integrity (e.g., combat, physical or sexual
assault, or motor vehicle accident). The event can be experi-
enced personally or witnessed . Associated symptoms include
intense fear and horror as well as persistent avoidance of
stimuli associated with the trauma, re-experiencing the
trauma, and persistent symptoms of height ened arousal
(e.g., sleep problems, irritability, anger, and hypervigilance).
"Seemin9lq,mq sensesand boclqwouldhijackmq mind,
and I could onlqbea witness, lookin9out as I re~exivelq
reactedto apparenthostilitq."
Iraq War veteran
Some 3.5% of Americans age 18 and older will have PTSD in
a given year; the median age of onset is 23. 78 This disorder
can be chronic in nature and very disabling. 91 One study esti-
mated that 20% to 25% of those in treatment for SUDs may
have PTSD.92 At Veterans Administration (VA) hospitals ,
treatment centers, and domiciliaries , the incidence of PTSD
among substance abusers is higher . PTSD is twice as com-
mon in women as in men , often due to physical and sexual
abuse. A recent Veterans Affairs multisite study found that
people with PTSD who used cocaine were worse off when
they entered treatment and took longer to recover.94 About
19% of Vietnam veterans experienced PTSD after the war.78
"I brokeclownafterabout six monthsoverin Vietnam,and I was
in char9eof aJun crew.And when I brokeclownfromseein9
the deathsan all the abuseoverthere, somepeople'slives
werelost. I'm responsible
and it hurts. When I was meclicallq
evacuatedbackto the States, I immecliatelq
jumpedinto alcohol
and heroin."
Vietnam veteran with PTSD
Other Trauma-and Stressor-RelatedDisorders
• Reactive attachment disorder-a consistent pattern of
inhibited, emotionally withdrawn behavior toward adult
caregivers in children characterized by detachment and
min imal response to comfort when distressed
• Disinhibited social engagement disorder-children who
actively approach and interact with unfamiliar adults
with no or minimal hesitations and diminished or
absence of checking back with their adult caregiver after
venturing away
• Acute stress disorder-recurring , involuntary; and
intrusive distressing memories of a traumatic event with
negative moods and dissociative , avoidance, and arousal
symptoms
Mental Health and Drugs 10.17
Recovery (continued abstinence from addictive substances)
is often complicated by the occurrence of post-acute with-
drawal symptoms (PAWS). This is the episodic recurrence
of symptoms associated with acute drug withdrawal and
cravings though one has been abstinent for several months
or years. Some suspect that PAWS are actually a form of
PTSD resulting from the trauma and hypersensitivity to
stress caused by addiction.
Dementias
These are problems caused by brain dysfunction brought
on by physical changes in the brain due to aging, miscella-
neous diseases , brain injury, or psychoactive drug toxi-
cities. One example is Alzheimer's disease, which results in
an unusually rapid death of brain cells, causing memory loss,
confusion , loss of emotions, and gradually the loss of the
ability to care for oneself. Prevalence studies on dementia
vary widely, but it is estimated that about 0.65% of Americans
age 18 and older have severe dement ia in any given year, with
another 0.3% to 1.6% having mild-to-moderate dementia.
For those 65 and older, 5% to 8% experience severe dementia ,
and the incidence doubles every five years after age 65.95
Mental confusion from heavy marijuana use and various
prescription drugs may mimic symptoms of this disorder.
NeurodevelopmentalDisorders
These disorders , usually first diagnosed in infancy, child-
hood , or adolescence, include mental retardation, autism,
communication disorders , and attention-deficit/hyperac-
tivity disorder. (See Chapter 3 for more information about
ADHD.) Symptoms caused by heavy and frequent use of psy-
chedelics like LSD and PCP can be mistaken for develop-
mental disorders .
SomaticSymptomand Related Disorders
People with these disorders have physical symptoms with-
out a known or discoverable physical cause; the disorders
are likely to be psychological, such as hypochondria
(abnormal anxiety over one's health accompani ed by imagi-
nary symptoms). Cocaine, amphetamine, and other stimu-
lant psychoses create a delusion that the user 's skin is infested
with bugs when no infestation exists.
PersonalityDisorders
I
These disorders , such as antisocial, avoidant, and border-
line personality disorder, are characterized by inflexible
behavioral patterns that lead to substantial distress or
functional impairment. Most patients with such personality
disorders act out , exhibiting behavioral patterns that have an
angry; hostile tone; violate social conventions; and result in
negative consequences. Anger is intrinsic to personality
disorders as are chronic feelings of unhappiness and alien-
ation from others, conflicts with authority, and family dis-
cord. These disorders frequently coexist with substance
abuse and are particularly hard to treat because the patient
may continue to act out by relapsing to drug use or creating
a major disruption in the treatment setting. 30 ,96 ,97 In children
 10.18 CHAPTER10
and adolescents, conduct disorder and oppositional defiant
disorder are predictors of alcohol and drug use problems. 98
Borderline personality disorder (BPD) is defined as a per-
vasive pattern of instability of interpersonal relationships
and self-image and marked impulsivity beginning in early
adulthood and present in a variety of contexts, as indicated
by five (or more) of the following:
• frantic efforts to avoid real or imagined abandonment
• a pattern of unstable and intense interpersonal rela-
tionships characterized by alternating extremes of ideal-
ization and devaluation (called "splitting")
• identity disturbance-markedly and persistently unsta-
ble self-image or sense of self
• impulsivity in at least two areas that are potentially self-
damaging (e.g., spending, sex, substance abuse, reckless
driving, or binge eating)
• recurrent suicidal behavior, gestures, or threats of self-
mutilation
• affective instability due to a marked reactivity of mood
(e.g ., intense episodic dysphoria, irritability, or anxiety
usually lasting for a few hours and rarely more than a
few days)
• chronic feelings of emptiness
• inappropriate, intense anger or difficulty controlling
anger (e.g., frequent displays of temper, constant anger,
and recurrent physical fights)
• transient, stress-related paranoid ideation or severe dis-
sociative symptoms
BPD is frequently seen as a co-occurring disorder in the
treatment of addiction. It is estimated that 50% to 60% of
those with BPD also have a problem with addiction and
related disorders compared with just 1.6% to 2% of the gen-
eral population. BPD often coexists with other mental ill-
nesses such as PTSD and mood, panidanxiety, gender
identity, attention-deficit, eating, multiple personality, and
obsessive-compulsive disorders. Patients with BPD compose
about 10% of all mental health outpatients and 20% of psy-
chiatric inpatients. It occurs more often in women (75%),
and 75% of those suffering from BPD have a history of phys-
ical or sexual abuse often in early childhood or adolescence. 14
Dialectical behavior therapy, developed by psychologist
Marsha M. Linehan, combines cognitive-behavioral therapy,
I
reality testing, and mindfulness awareness to treat those with
the comorbid conditions of addiction and BPD.99 •100
Feedingand EatingDisorders
Feeding and eating disorders (bulimia nervosa, anorexia
nervosa, and binge eating) often co-occur with SUDs and
other psychiatric and personality disorders. Women are
three times more likely than men to develop anorexia ner-
vosa (0.9% women vs. 0.3% men) and bulimia nervosa (1.5%
vs. 0.5%). Women are also 75% more likely than men (3.5%
vs. 2%) to develop binge-eating disorder. 78 Weak impulse
control is often associated with eating disorders and SUDs,
a possible common etiology along with genetic factors for
both conditions_l01 Eating disorders are often found in con-
junction with major depression and PTSD_l02 Anorexia ner-
vosa is a very serious mental health problem. The annual
mortality rate among those with this disorder is estimated to
be 0.56%, which is about 12 times higher than the death rate
due to all causes of death in females ages 15 to 24 in the
general population. 78
Gambling Disorder
Gambling disorder is now classified as a "Non-Substance-
Related Disorder" in the DSM-5. The disorder is character-
ized as continued gambling despite the development of
harmful negative consequences or the desire to stop in addi-
tion to compulsive preoccupation with gambling that
includes five or more defined pathological, life-disruptive
symptoms. The DSM-IV sub-classifications of problem and
pathological gambling have been eliminated and replaced by
the specification of the severity (mild, moderate, or severe)
of this disorder depending on the number of pathological
symptoms noted. Brain research discovered many anomalies
in those with gambling disorder that are almost identical to
those found in SUDs_l03
Earlier research found gambling disorder to be more com-
mon (10% to 11% prevalence) in clients who abuse or are
dependent on alcohol or other drugs. 104 .1° 5 , 106 Gamblers often
drink while gambling in casinos or bars. Methamphetamine
abuse is also found in many compulsive gamblers because it
enables them to remain alen in the casino or at a poker
machine for hours at a time. Often a recovering alcoholic or
addict will switch addictions and become just as patho-
logical about gambling as he or she was about drinking or
using other drugs. 106 Severe gambling disorder is sometimes
called compulsive gambling or ludomania .
Other Disorders
There are dozens of other mental disorders, including adjust-
ment disorders, sleep disorders, sexual and gender identity
disorders, and factitious disorders that exist independently
or in combination with other mental disorders and drug use
disorders.
Substance-Induced
Mental Disorders
Among patients who suffer from a dual diagnosis, the major-
ity of the mental health problems encountered are caused
by substance use rather than pre-existing conditions. Most
are temporary, with symptoms persisting only until the
patient is no longer under the influence of the substance or
in withdrawal. A clinically sound approach in dealing with
these patients is to first assume that the mental illness is sub-
stance induced until proven otherwise. 49
Alcohol-InducedMental Disorders
Impulse-Control Problems People who abuse alcohol often
demonstrate impulse-control problems, which include but
are not limited to violence, unsafe sex, other high-risk
behaviors, and suicide. These behaviors are not due to an
indepmdrntimpul,c-contro!di>order!ltheyoccuronlyin ordu;theyindudebut•r<notlimit<dto•uditory a ndvisual
therontatol•koholu«. Con,·e=ly.alrohot.inductd halluciruotion,,ddU>ioruolthoughtoonlrnt,mdide.o,ofref -
=ldy,functionr«ultsinhypo><><ualfunctioning rnene<. Alooh ol-induc«I psychotic di50rder is utr,cm,ly
(impair<d d«ir<, arou5" l. <rrpsm; er,ctile dysfunction; pon<v, to lr<atmrnt 'th, •il"J 'ofc m«rc,t' n,,
md painful interc om~,) that cm p,nist for month> into •lthough th e actu.al mechanism i, uncle.or. Clinician,""
sobriety " caur · ' to av,>dtheu'mt'p,-, ',ot'cm«rc,t'ondur -
ingp,riodsol acut<alcoholwithdrawol.Conv,ruly,alcohol
si...,oi,orclof> Sl«pproblem, a r,ca common ,ymplomthat
u« di>ord<r i, th, mo,t common co-occurring disorda
help «Lobli>h th, J>T<«n« ol • menl.01 di>order. Th«<
foundi ndient>withschiz ophreni.o ." ' Alroholintoxication
indud, difficulty,Loylng •sl«pnwd l ., <>.rly-morning
orwithdr:nvald,liriumcm•OOpr=1wi1h,ymptom,o/
•w:ak<ning. Akoho l caw.«sl«pprobl,msduetoiapow,r -
p,ycho<i,
ful,uppI<Mionofr.tpidey,mo,,em,nt(REM)slttp . Known
... lrohol-induc,d,l«pdisorda,disruptionofnorm.ol Otmomi.l Th, neurotoxicdf«tsof•lrohol•r<well«l1b-
•l«ppatternscanWtformonth,aft<r a p<r110n>111in• lish«I.A lroh ol•bu,, cancau«•d<m,nWl-lik<,yr,drom,
,tablesobriety.lf a p,=in',sl«pproblemsocrurinth,con - withprominentoognith'eddicit>. Twooonditio...,_alrohol-
t<xtofakoholu,,.theym.oynotindicat<th,pr<«ne<ofan inducedper,istentdem,nti.o•ndalrohol-inducedp<T'5ist -
!nd<p<ndrn tmenald i>ord<r. · namnu ' •· ' . :mm'm' oth, ft'om,uch u
Al,h<imerOdi=,e.lnth<pastth<><disord,nw,redescribro
Mxioty Alooholis a minortr.tnquili,uthatha>mti.onxi<ty ., Wernick<-KorYl<off •yr,drom, . Wernick<\ ,nc,phalopa-
pr<>p<tti«. Wh,n • p,=in O • lrohol ina k, ac«ds th,
thy and KorYl<off\, syndrome, cau«d by • thi.omine (via -
bodyO a bilityto meaboli,e it, th<p<T50n will <>rp<rimc,
min B,) ddiciency , occunin • koholicsdue to metabolic,
•k oholwithd,..waluponcessation . Symptom,of • lrohol
g:,,troint«tinal,•nddi<toryimbolmc«.Symptom,oflhe,,
withdn.Wlll indud, incrns,d pul"' nte, body t<mp,n.•
condition> indud, confusion. d,lirium. memory im pair-
tur, . andbioodpu,wr,Hw,Ua,avarietyoF • nxi<ty,,lik<
m<nt. visual probl<mS, imbai.onc,, :md motor roordin•tion
•ymptoms.Symptom,ola!rohot.indocedmxi<tydisorda
difficulti« . Apati<n twith •lrohot.inductdd,me nt i.oinits
di>oipat<ov<r a p,riodoftwoorthrttdoys. Th,dinician
most«nre<m=r,ga' som,oog 'ti ' ti 'ng'n
mustoon,id<rth,patimt O•lroholu«wh,ndi•gno<ing•n
,obriety.•lthough th<proce55moyak<yar, _ Patirnt>i n
ind<p<ndrnt•nxi<tydisord<r
<>.rlyr,c o,.,ryfrom•koholismwil loft<npr= lwith""'<"
°"PNWOnStudi<>indicat<thatuptoi~oFalroholics m,moryprobl<msthatconint<rl<r<withtr<>.tm<nt,,otr<at -
puKntwithroncurnmtsymptomsofJru1jord<pr<"iv< m<nt•pproach«mustb,modifiro•coordingly.
di>ordu. Aftufourw«ksoFsobri ety, hownu,only6%
wiU rontinu, to hav, th,,;, depu .. iv, •ymptoms. '°' Most
eosn- 1........,..,, SPECT (single -photon emi>oion com -
puterized tomognph)·) ,an bniin imaging hH r,val«! that
up<rirnc:,alrohol,inductdmooddi..,,.du,whichu,ually
• bw.eol a!oohol•ndothadrug,r«ultsin=aalr,gion<of

:!~;::t~:~
r«0h'<Swithcontinued,obri<ty.Am.ojord<pr<»h,ed iso r-
dercanno1b,d i.ogno«duntilthe a koholicha,romp l,t<dat
::::nb~!~~:;i~,!':i'~:,;t:;;e:~
lastfourw«ksolsobri<tyThrnear<conflictingdo Lar,gard -
ruot«lu,e _ D,crencdb.-.inactivityrorr,bt<•toth<high
ingthellSOCi.o tionb,tw«n m.ojor depr=iv,di>ordumd •
d,gruofrognitiveimp,irments(rnention,m,mory, j udg -
historyof•koholism.Som,outhors,ugge,1tha1recov<r:ing
m<nl. word me.oning, proce55ing of time . •nd other prob-
•koholicshave•fourloldriskofdevdopingm.ojord,p=
l,m,) that•"' ap,rirnc«I during the ariy pan of th,
,ivedisorda. "" •lthoughth,m«hanismofthisti>oei.otion
hos not b,,n id,nti/i«i . Tr,atm,nt with antid,pr,sYnt
m«licationisrontraindicat<dinp<opl<whou,activdy
drinking. Stimulant-InducedMental Illness
lffl1HII
M-Control --• Stimul•nt •buli<Crs demonstrat<
impul«-controlprobl,m,. T he,eb,ha,-ior,;•r<notdueto
~n ~nd<p<nd<n~!m _puls~-control di«m:ler ii th<y occur only

Stimulan<-IMU<NSoxu•IOr,funnlonlniti alu,eolcoca ine ,

• mph<12mine. or •nother ,timuW11 drug oft<n result> in
hyperxxualirywithimpul11C-Controlprobl,ms.Prolong«I
high-do,, u,, r<>ult> in ,onul <!;~function ,imibr to that
cau,.,dbyalooholi,m .1'
~• This clinical ')ndrom,i, mnk<d byth< d<velop- Stimulan<-IMucoclflload OilOfHf> A p<T50n who is acut<ly
m<nt of psychotic symptoms ,f t<r many d<cad<> of hn.vy 'ntox · at«! w'th ,t'moi.ont> c•n presen t ·n a n 'd, ti ·
drinking. Th= ,ymptom, <Xist in th, •h«ne< ofintoxic• - Whion H som,on, who is in the acut< manic p~ of•
tion•ndwithdr>wal.Th i,,yndrom,hos•vori<tyoframe,; bipobrdi,orda.Thedinician,houklnot•s,umethatthis
the m0<1currrnt is alcohol-ind uced J>'y<hoticdisorda. mE1ic-lik,b.haviori,soldy • ttribu tobleto•bipobrdi <-
Any • nd • IIJ>')'Chotic,ymptomsC2J1b<«rnwiththisdi<- orderilitoccunonl)·in thecont<xtofstimubnt•bu,e
 10.20 CHAPTER10
If the manic-like symptoms are due solely to the use of
stimulants, they will completely resolve upon cessation of
intoxication. Anti-manic medications such as valproic acid
(Depakote ®) and lithium are not indicated for stimulant-
induced manic disorder ; the syndrome is best treated by
helping the patient achieve stable abstin ence.
Depression Depression is caused by an imbalance of neu-
rotransmitters , like serotonin and norepinephrine . Stimulant
drugs , such as methamphetamine, cause a temporary
imbalance of these neurochemicals. This imbalance can last
up to 10 weeks after a person stops using stimulants.
During this period the person will present with depressed
mood, anhedonia (lack of ability to feel pleasur e), suicidal-
ity, anxiety, and sleep disturbance-symptoms identical to
those of someone suffering from a major depressive disorder .
If the symptoms of depression are caused by stimulant
withdrawal, antidepressants may help with the symptoms
during the initial detoxification phase of treatment and
should not be continued for long-t erm treatment of major
depression . The proper treatment approach for those suffer-
ing from stimulant-induced mood disorders is monitoring
suicidality while engaging the patient in substance-abuse
treatment.
In the early days of the crack cocaine epidemic of the mid-
1980s, there was great enthusiasm for the use of antidepres-
sants to treat stimulant abuse. Although the initial reports
were very promising , when this treatment approach was
studied in a double-blind research design , the initial benefits
could not be replicated. Panic and/or anxiety disorders
resulting from abuse of stimulant drugs are generically
referred to as stimulant-induced anxiety disorder.
Panic Disorder The use of stimulants can induce a panic
attack. The panic focus in the brain increases in size with
each stimulant-induced panic attack. (Panic focus is the part
of the brain from which panic attacks originate. Excess drug
use turn s neighboring cells into panic cells. It is very similar
to what is called a "seizure focus.") At a certain point , which
is unique to the individual , this panic focus can take on a life
of its own-a person can continue to have a chronic panic
disorder without ever again using stimulants .
1\\~ lv~'-NN
I
f~'{C\-\l~l"R'{.._
Cl 2001. WileyMiller. Reprintedby permission. All rights reserved.
NON SEQUITUR
AnxietyStimulant-induced anxiety disorders occur in the
context of both acute intoxication and withdrawal. The
proper treatm ent of stimulant-induced anxiety includes
engaging the individual in substance-abuse treatment.
Psychosis It is a well-known medical fact that stimulants can
cause both short- and long-term psychotic symptoms. Not
everyone who abuses stimulants will experience psychotic
symptoms. Stimulant intoxication delirium and stimulant-
induced psychotic disorder are the two conditions that
result in psychosis in some stimulant abusers. Individuals
who do have psychotic symptoms will almost always re-
experience those symptoms each time they use ; and as
abuse continues , the duration of the psychotic symptoms
can last up to five years after cessation of use . Though
uncommon , there are a few reports of symptoms lasting a
lifetime . The five-year figure represents one end of the spec-
trum; however, it is common for people to experience psy-
chotic symptoms for many months after cessation of
stimulant abuse. Proper treatment includes the use of anti-
psychotic medications . The exact dosing and duration of
treatment with antipsychotic medications depends on the
severity of the stimulant-induced psychotic disorder.
Stimulant-Induced Sleep Disorder This is a prominent mark of
a methamphetamine , cocaine, Adderall,® meph edron e,
Ritalin,® or any other stimulant-abuse problem . Metham-
phetamine addicts have been known to forgo sleep for sev-
eral days while under the influence of the drug . When they
run out of drugs , the stimulant addict "crashes " and experi-
ences hypersomnol ence-sleeping for days and rising only
for short periods to eat or relieve themselves . Animal studies
suggest that after the hypersomnolence stage, amphetamine
depend ence results in a REM sleep phase rebound with rest-
lessness and severe nightmares for several months after
abstinence has been initiated.
Cognitive Impairment With the advent of neuroimaging,
researchers have been able to demonstrate that stimulant
abuse causes both transient and permanent damage to the
brain. Transient damage is the deactivation of many areas of
a person 's brain caused by actively abusing a stimulant. The
damage remains for several months after use is discontinued .

More-permanent brain damage results from the loss of hip-
pocampus and other limbic gray matter (an average of 11.3%
of these neurons are destroyed in methamphetamine abuse),
which also contributes to the cognitive impairment often
seen in stimulant abusers.
Cannabis-InducedMental Illness
In many circles marijuana is believed to be a benign sub-
stance . Upon closer scrutiny it has been shown to be a potent
psychoactive substance . The higher concentration of the
active ingredient THC is thought to be responsible for the
psychiatric syndromes noted in marijuana users .
cannabis Intoxication Delirium The essential element of a
marijuana-induced delirium is a disturbance of conscious-
ness that is accompanied by a change in cognition that can-
not be attributed to a pre-existing or evolving dementia. Most
people suffering from a delirium are not readily noticed by
the general public or identified by a clinician not adept at
diagnosing subtle neurocognitive problems. People who are
delirious are unable to recognize their condition because they
believe that their state of consciousness and perceptions are
normal. Marijuana is thought to be responsible for causing
delirium in some chronic users . People who use marijuana
on a regular basis ("stoners") are spaced out, detached, and
oblivious to the world around them, typifying this delirium.
These individuals often have difficulty with memory, multi-
tasking, and other simple cognitive processes. The current
thinking is that it may take three months or longer for this
delirium to clear after a person stops using marijuana .
cannabis-Induced Psychotic Disorder Due in part to the high
concentrations of THC currently found in marijuana, it is
not uncommon for people intoxicated on the drug to experi-
ence psychotic symptoms, which include but are not limited
to paranoia and auditory and visual hallucinations. These
symptoms tend to be transient and occur only while the
person is high. Reports are surfacing of Cannabis-induced
hallucinogen persisting perceptual disorder (HPPD) occur-
ring in marijuana abusers, with symptoms lasting for several
months or years, without any further exposure to the drug.
Marijuana-induced HPPD as described in the DSM-5 con-
sists of perceptual distortions experienced while intoxicated
(trails of images of moving objects, flashes of light, strange
odors) that persist and cause significant distress and impair-
ment long after use had been discontinued. If psychotic
symptoms persist after cessation of use, the clinician should
be alerted to consider alternative explanations for the psy-
chotic symptoms.
Also, as noted in Chapter 7, there is growing evidence link-
ing high-potency marijuana and its synthetic forms sold as
herbal incense with the precipitation of schizophrenia and
thought disorders that persist after use is discontinued.
Though some think that this may be due solely to marijuana
toxicity, most researchers believe that it occurs only in
those predisposed to have major mental illness whose
onset is hastened by marijuana abuse .
Some Cannabis chemicals
cannabis-Induced Anxiety Disorder
can cause symptoms consistent with generalized anxiety,
Mental Health and Drugs 10.21
panic, phobic (paranoia), or obsessive-compulsive disor-
ders. Marijuana can induce a panic attack with onset of
intoxication or during chronic use. Panic, anxiety, paranoia,
and other symptoms of Cannabis-induced anxiety disorder
disappear within a month after cessation of intoxication or
withdrawal. If symptoms persist for a month or longer, an
alternative diagnosis should be considered.
Amotivational Syndrome There is no scientific evidence to
support the traditional notion that marijuana causes a lack
of motivation in those who use it. Does marijuana make
someone amotivational, or do amotivational people tend
to smoke marijuana? To date no scientific studies explain
the relationship between marijuana and amotivational
syndrome .
Other Drug-InducedMental Illnesses
Most psychoactive substances can induce transitory or more-
enduring psychiatric syndromes, but the incidence of sub-
stance-induced psychiatric symptoms is much greater than
the incidence of pre-existing psychiatric problems (and
symptoms) . For example, during the active phase of alcohol
or drug abuse, many patients present with symptoms of
various neuropsychiatric disorders (known as Axis I clinical
disorders) as well as many different personality disorders
(known as Axis II disorders); but with treatment and stabili-
zation, most symptoms disappear . Of particular concern is
the emergence of psychiatric syndromes secondary to the
psycho-stimulant MDMA (ecstasy) . Although it has not been
rigorously studied to date, it appears that ecstasy can cause
both mood and psychotic problems in susceptible individu-
als. Because many psycho-stimulants release serotonin,
symptoms of serotonin syndrome should be considered
when treating psychoses related to their use.
The close association of unbalanced brain chemistry seen in
mental illness and addiction disorders coupled with the dis-
torting brain effects of heredity, environment, and psychoac-
tive drug use suggests that treatment of mental illness and
addiction should be directed toward rebalancing brain
chemistry.
I
RebalancingBrain Chemistry
Heredityand Treatment
With new understandings of genetic expression (epi-
genetics), we may someday be able to alter the expression of
individual genes in a person 's DNA, but as of yet expression
of specific genetic traits in a person cannot be readily and
reliably obtained. We cannot change the DNA of a person
with alcoholic marker genes that signal a susceptibility to
alcoholism, drug addiction, or other addictive behavior . We
cannot reduce the genetic vulnerability of a teenager whose
mother and grandmother have schizophrenia. We can, how-
ever, alert people that they have a higher risk for a certain
 10.22 CHAPTER10
mental illness, drug addiction , or other compulsive behav-
ior due to their heredity . Current research in gene therapy
or altering gene expression is getting us closer to controlling
inherited mental illnesses. Some researchers are focusing on
the evolving science of pharmacogenomics-the study of
how an individual's genetic inheritance affects the body 's
response to psychoactive drugs, with the goal of someday
being able to choose the treatment and the medication that
are most compatible with the person's genetic profile. m
Only about 40% of patients with depression react favorably
to the first antidepressant medication they are prescribed;
pharmacogenomics aims to lessen the trial-and-error pre-
scribing of such medications by identifying the antidepres-
sant medication that will most favorably address a patient 's
specific genetic vulnerability to developing depression.
Environmentand Treatment
Heredity cannot be altered but environment can . Reducing
everyday and long-term stress is one of the most important
actions anyone can take to improve their mental health. By
improving their environment, human beings can alter brain
chemistry to better handle both mental illness and drug
abuse. People can leave an abusive relationship, avoid drug-
using associates, avoid situations that make them angry, seek
new friends in self-help groups, avoid isolation, and take
care of their health. If people change where and how they
live, they can avoid the stressors and the environmental cues
that keep them in a state of turmoil, continually unbalance
their neurochemistry, and make them more likely to abuse
drugs and intensify their mental illness.
As the science of epigenetics and neuroplasticity continue to
evolve, there is evidence that these strategies along with con-
tinuing abstinence can indeed change protein synthesis in
the brain, lessening a person's vulnerability to relapse over
time. The National Institute of Mental Health has about 100
active studies examining the relationship between epigenetic
markers and behavioral problems like PTSD, substance
abuse, schizophrenia, and bipolar disorder. 112 •113
PsychoactiveDrugsand Treatment
We are in the midst of a psychopharmacologic revolution.
New treatments are available to alleviate a patient's suffering,
and substance-abuse treatment providers must understand
the basics of psychopharmacology, as it is the cornerstone
I
of modern mental health treatment. This notion may be
contrary to the beliefs of many seasoned professionals, but
the success of many of these therapies may allow some to let
go of their prejudices regarding psychopharmacology
Oftentimes patients are tom between which substance to
take to alleviate their condition .
for
"/ took both alcohol and lithium mq manic depression.
The differenceis one worksfaster.The alcohol worksquicklq;
the lithium takes time to get there. But the alcohol caused
other problemsin mq life in addition to mq depression.
I think /'II stick to the lithium."
52-year-old female
The group of drugs called psychotropic or psychiatric med-
ications (e.g., antidepressants, antipsychotics or neuroleptics,
mood stabilizers, and antianxiety drugs) that physicians
prescribe to counteract the neurochemical imbalance caused
by mental illness or addiction help the dual-diagnosis client
lead a less destructive life. The effectiveness and the avail-
ability of these drugs have encouraged various institutions to
recognize mental health issues and implement treatment.
Today more universities and colleges in the United States are
providing mental health treatment for students with such
diagnoses as depression, ADHD, and bipolar disorders_ll 4
(The various psychotropic medications are examined in
detail later in this chapter .)
StartingTreatment
Though formal treatment can proceed only after a thorough
diagnostic assessment, sometimes it is difficult to know
where to start when treating a dually diagnosed client. Do
you first treat the mental illness or the addiction-or do you
treat both simultaneously? The current best practice is to
address both problems simultaneously, that is, stabilize
both the substance abuse and mental health problems in an
attempt to make the most accurate assessment possible .
This includes acute stabilization of the homicidal or suicidal
patient as well as detoxification from tissue dependence.
"It is o~en difficultto know whereto start with a duallq
diagnosedpatient. Upon initialevaluationit is almost
impossibleto know which came first:the substanceabuse
or the mental illness.Mq approach to these verqdifficult
patients is to assume that all psqchiatricsqmptomsare
substanceinduced until provenotherwise."
Pablo Stewart, M.D., psychiatrist
Impaired Cognition
A very common but underappreciated condition of dual-
diagnosis clients is significant cognitive impairment. Many
clinicians involved in treatment mistakenly believe that once
these individuals forgo the booze or drugs, they should be
able to engage in treatment, but that is not always the case.
A study of dual-diagnosis clients at a public hospital found
that most of them were mildly-to-severely cognitively
impaired and had difficulty participating in treatment .
Reviewing screening exams on neurocognitive function at a
VA hospital, researchers found that approximately 50% of
the patients were mildly-to-severely impaired. m
For the treatment provider , this means that the patient often
appears normal but is suffering from significant cognitive
impairment. For example, even if the patient can repeat what
he hears, the information and the therapy do not necessarily
sink in . It may take weeks or months after detoxification for
reasoning , memory, and thinking to return to a point where
the dually diagnosed individual can begin to fully engage in
treatment. Once in treatment, teaching strategies must be tai-
lored to the patient 's ability to process the information .
The most common cognitive impairments associated with
SUDs are problems with attention, memory, understanding,

learning , use and meaning of words, and judgment. Abuse of
drugs also causes temporal-processing problems , which con-
sist of poor time management, inability to work toward goals
over time, and delayed discounting (inability to appreciate
delayed gratification).
DevelopmentalArrest
Drug abuse and mental illness often arrest emotional devel-
opment . Consider an intelligent young man in his late teens
or early twenties who has been using drugs since the age of 12
and has also had emotional and mental problems. This patient
comes to treatment with all kinds of difficulties. One acute
complication stems from the fact that he suffered develop-
mental arrest at age 12, the point at which most people begin
to work through issues and stresses in their lives. Most people
mature through these struggles and go on to become adults;
but those who used drugs, avoided dealing with difficult
emotions, and have not gone through that process of matura-
tion will still experience all the emotions they avoided five
or six years earlier and have no tools to cope with them.
"It'sall thosechildhoodissuesthat I seemedto takeintomq
adulthood-theq comeout. I'd9et mq buttonspressed.
Someone9ets me a littlepissedoff. You know,I reallqthou9ht
whenI 9ot into recoverqI wouldn'tbe ansrqanqmore . Well,
it tookmealmostthreeqearsin treatmentto realizethat an9er
is a le9itimatefeelin9.It's how I dealwithit todaqand how
I usedto dealwithit. That's what I'm learnin9about."
30 -year-old with a dual diagnosis
Many dual-diagnosis clients have character traits that are
normal in children but abnormal in adults, complicating
treatment . Dr. Burt Pepper, a psychiatrist who treats young
dual-diagnosis clients, identified the following such char-
acteristics:
• low frustration tolerance
• inability to work persistently toward a goal without
constant encouragement and guidance, partially because
of the low tolerance for frustration
• tendency to lie to avoid punishment
• harboring mixed feelings about independence and
dependence, with a show of hostility when dependency
is imposed
• constantly testing limits because they have not yet been
learned or have been rejected
• tendency to express feelings as behaviors by crying,
running away, or hitting rather than talking , reasoning,
explaining , or apologizing
• exhibiting a shallow labile affect, which means a shal-
lowness of mood: give a kid a toy, he'll laugh ; take it
away, he'll cry
• fear of rejection-extreme rejection sensitivity can be
expressed as paranoid schizophrenia
• tendency to live in the present or in the past, with no
hope for the future; most dual-diagnosis clients never
focus on the future due to damage from early trauma
Mental Health and Drugs 10.23
• denial, such as refusing to deal with unpleasant but nec-
essary duties or stopping something that is pleasurable
but potentially hazardous , like kids playing roughhouse
• tendency to use a black-and-white approach to every
judgment in life, with no modulation or moderation:
either you 're for me or against me 116
These characteristics are also commonly found in people
being treated solely for chemical dependency. For treatment
providers to appreciate where a person is in his or her
developmental process, and to adapt treatment accord-
ingly, each client should undergo a developmental assess-
ment prior to commencing treatment. A person who is
unable to establish basic trust, a developmental step that is
usually accomplished in early childhood, would benefit from
treatment directed to help establish basic trust before
addressing more-advanced developmental issues . The best
treatment consists of addressing every issue unique to the
client in an individualized manner. These are usually
chronic or sometimes lifelong problems of living, of living
sober , and of living with the symptoms of the mental ill-
ness that cannot be treated with short-term therapy .
Psychotherapy,
IndividualCounseling,and GroupTherapy
"Lookintothe depthsof qourownsouland learnfrst to know
qourself,then qouwillunderstandwhqthisillnesswasboundto
comeuponqou, perhapsqouwillthenceforthavoidfallin9ill."
Sigmund Freud , 19 24
Psychotherapy is very effective in treating both mental ill-
ness and substance-abuse disorders in a group or individual
setting. Group therapy is preferred for both substance-
abuse and mental illness treatments; 117 however, strategies
for employing psychotherapy for mental illness are beyond
the scope of this chapter .
Today the primary treatment for severe mental illness is
psychopharmacology and not psychotherapy, whereas the
opposite may be true for treating SUDs. Because of this
paradox , many substance-abuse or dual-diagnosis clients
may suffer needlessly during the course of psychotherapy
because what they really need is medication. This is not to
imply that the clinician should forgo any engagement with
the patient while he or she is being stabilized on medication.
In the recent past , th e psychotherapeutic approach focused
I
on working through the patient's denial. The consensus was
that a person could not get clean-and-sober without first
addressing the denial. Although this psychotherapeutic
strategy was very appealing to clinicians, it did little for the
substance abuser. Current thinking regarding the proper use
of psychotherapy in SUDs includes a phase model.
The first phase is achieving abstinence. This is a period of
at least six months during which the therapist emphasizes
supportive psychotherapeutic techniques. These techniques
include relapse prevention work, education on stress reduc-
tion and mental illness , and abstinence psychotherapy .
During this phase a therapist should avoid confronting a
patient about his or her denial.
 10.24 CHAPTER10

The next phase is maintaining abstinence, which occurs

after the patient has between six and 24 months of sobriety Cornered by Mike Baldwin
During this phase the therapist begins introducing notions a~23 C 2003 Mike Baldwfn I 01st by Universal Press Syndlca1e www.cornered .com

of denial and other maladaptive defense mechanisms.

The last phase is actual psychotherapy, which is indistin-
guishable from any other psychodynamically oriented
treatment except for the emphasis on education and absti-
nenc e from addictive drugs.118 , 119
Cognitive behavioral therapies (CBTs) have become the
most frequently used evidence-based psychotherapies for
all three phases of co-occurring disorder treatment (e.g.,
dialectic behavioral therapy, rational emotive behavioral
therapy, motivational enhancement therapy, and stress inoc-
ulation behavioral therapy) . These therapies are based on
the idea that feelings and behaviors are caused by a person 's
thoughts and not by external situations or events. People
may not be able to change their external circumstances, but
they can change how they think about them , thereby chang-
ing how they feel and behave . The goal of CBT in addiction
treatment is to help clients recognize situations in which
they are most likely to use so that they can avoid those situ-
ations and learn to cope with every problem that has the
potential to lead them back to drugs. 120,m
"It'sfor panicattacks.Hand them out
Psychopharmacology to peopleyou meet."
© 2003 Mike Balcmn. Reprintedwith permissionof UNIVERSAL
CORNERED Udick.
The field of medicine that addresses the use of medications All rightsreserved.
to help correct or control mental illnesses and drug addic-
tion is called psychopharmacology. The scope of this branch
of medicine has grown rapidly, particularly in the past 20 The various psychiatric medications currently in use affect the
years, producing hundreds of new medications and greatly manner in which neurotransmitters work in different ways:
expanding this approach to mental illness.
• They can increase the presynaptic release of neurotrans-
Quite often the dual-diagnosis patient does need medication mitters (methylphenidate) .
for psychiatric disorders, such as antidepressants and mood • They can block the neurotransmitter from connecting
stabilizers for mood disorders, antipsychotic (neuroleptic) with a given receptor site (antipsychotics) .
medications for thought disorders, and antianxiety medica-
• They can inhibit the reuptake of neurotransmitters by
tions for anxiety disorders. These medications are prescribed
the presynaptic neuron, thus increasing the amount of
only after a thorough assessment. Care should also be taken in
neurotransmitter available in the synapse. (Selective
the use of these medications given the individual's difficulty in
serotonin reuptake inhibitors [SSRis] such as Prozac®
dealing with drugs. The clinician must be sure that the medi-
and Zoloft®work in this way on serotonin.)
cation used for the psychiatric problem does not aggravate or
complicate the substance-abuse problem. • They can inhibit the metabolism of neurotransmitters
(Nardi!® and MAO [monoamine oxidase] inhibitors),

I
Medications are used on a short-term, medium-term, or thereby enhancing the action of norepinephrine or
lifetime basis to try to rebalance brain chemistry that dopamine.
became unbalanced either through hereditary anomalies,
• They can enhance the effect of existing neurotrans-
environmental stress, or the use of psychoactive drugs and
mitters. (Benzodiazepines such as Valium® amplify the
compu lsive behaviors. These medications are used in con-
effects of GABA.)
junction with individual or group therapy and with life-
style changes. In addition to manipulating brain chemistry, some drugs act
directly to control symptoms . Beta blockers (Inderal ®) calm
Previously, one of the biggest debates in treatment circles
the sympathetic nervous system that controls heart rate,
centered around the reliance on psychiatric medications.
blood pressure , and other functions that can go out of con-
Some clinicians looked at medications only as a last resort.
trol in a panic attack or drug withdrawal state.
Others believed that meds should be the first step in treat-
ment. Due to recent advances in the mental health and It is very hard to design a psychiatric medication that will
substance-abuse fields, psychiatric medications are much work only on a certain neurotransmitter in a particular
more acceptable to treatment providers. way. Advances can be seen in the new atypical antipsychotics,

which are designed to work on the specific dopamine recep-
tors involved in psychotic symptoms. Atypical antipsy-
chotics are targeted to be more effective in controlling
negative symptoms of schizophrenia (apathy, lack of emo-
tion , poor social functioning) as well as positive symptoms
(hallucinations, delusions, racing thoughts) that were the
original target of typical antipsychotics .122 Atypical antipsy-
chotics are also said to have fewer extra pyramidal symptom
side effects than typical antipsychotics. Even with these
advanced medications, there is some overlap on dopamine
receptors in other parts of the central nervous system not
involved in the psychotic process. Therefore newer medica-
tions will always have side effects. It is imperative to con-
stantly monitor each patient's reactions to a drug and to
ensure that it is being taken as directed (and not arbitrarily
discontinued without medical advice) and making appro-
priate adjustments when necessary. A careful review of the
purpose of the drug along with possible side effects and a
specific plan of use should be fully explained to each patient.
'The medicationthat we are talkingaboutgivingqou in this
treatmentprogramis reallqdesignedto correctsomeof the
damage that qou did to qourbodq and to qourmind with the
drugsor damagethat had beenhappeningas a resultof some
emotionalor psqchologicalproblem.It does not mean qou're sick,
it does not mean qou'redefective,and it does not mean qou're
weak. It just meansthat qourbiochemistrqsomehowgot out of
balance,and the medicationsthat we're recommending,especiallq
the antidepressantmedications,are to rebalancethose chemicals
and bringqou to a point whereqou can fullqand effectivelq
functionand then beginto workon qourother problems."
Stanley Yantis, M.D., psychiatrist, consulting with a dual-diagnosis client
PsychiatricMedicationsvs. Street Drugs
One of the advantages of physician-prescribed psychiatric
medications over street drugs is, except for the benzodiaze-
pines and stimulants, that they are not addicting. In fact, the
treatment of anxiety, depression, and other mental prob-
lems with psychiatric medications can relieve many of the
causes and the triggers of drug abuse . A study of the risk of
SUDs in boys who were treated with methylphenidate and
other ADHD treatment drugs found a significant reduction
in their risk of drug use problems as adults compared with
patients who were not treated .123
Sometimes a prescription for psychiatric medications can
cause problems for dual-diagnosis clients because they are
often taught to stay away from all drugs during recovery
To counteract that , the treatment profession has developed
and distributed pamphlets to recovery fellowships, explain-
ing the need for psychiatric medications for many dual-
diagnosis patients in recovery. Nevertheless there are
well-meaning members of these fellowships who insist that
a person taking these medications is not really in recovery.
The patient may be talked into flushing his or her medica-
tions down the toilet, leading to potentially adverse psy-
chiatric results. Consequently, it is essential that those
responsible for treating dual-diagnosis clients understand
and support those clients' early recovery .124 -' 25
Mental Health and Drugs 10.25
When using street drugs, patients feel a false sense of con-
trol over which drugs they ingest, inject, or otherwise self-
administer. The same patients, when receiving medication
from a doctor, often express the feeling that they are not in
control of their lives, and many are more apt to rely on street
drugs rather than on prescribed psychiatric medications for
relief of their emotional problems. It is up to the physician to
work with the patient regarding any and all issues raised by
the use of prescription medications.
"BeforeI came to the clinic, I thought that usingantidepressants
was taboo. I wanted to use street drugs but not clinicalones.
There's a stigma to it. I used marijuanato deal with mq
depression,and I could take it when I felt I needed it, not a pill
that I had to take everqdaq as prescribedbq mq psqchiatrist."
35 -year-old with depression and a problem with marijuana
Table 10-2 is a compilation of many of the ideas presented
regarding the relationships among brain chemistry, drug
addiction, and mental illness. Notice how many different
neurotransmitters are affected by a single street drug espe-
cially cocaine or alcohol. Also note the physical and mental
traits that are affected by a neurotransmitter and how a street
drug affects those functions. 126 , 127
The drugs are discussed in depth under the heading of
the mental illness that they are generally used to treat but
are often used to treat other psychiatric disorders as well.
There is some overlap, for example, when a drug used for
depression, such as Prozac, ® is also used to treat obsessive-
compulsive disorder, or when the antipsychotic Seroquel ®is
also used for bipolar disorder. Psychiatric medications that
have been abused to alter states of consciousness are the
stimulants (i.e ., methylphenidate), benzodiazepines, GABA
(Xyrem®), and quetiapine (Seroquel ®).
Drugs Used to Treat Depression
Many in the psychiatric field believe that depression is
caused by an abnormality in the production of the neu-
rotransmitters serotonin and norepinephrine (noradrena-
line) plus a few others. Antidepressants usually increase
the amount of serotonin or norepinephrine available to
correct this imbalance . The number of people receiving out-
patient treatment for depression has more than tripled
since 1987. During that same period, the number of clients
receiving psychotherapy dropped about 15%, so the primary
I
treatment for those suffering from depression is medication
rather than psychotherapy
The most common antidepressants (such as Prozac,® Paxil,®
Zoloft,®Wellbutrin ,®Remeron,®Serzone,®Celexa,®Cymbalta,®
and Effexor®)work through a variety of mechanisms, mostly by
increasing the levels of certain neurotransmitters, including
dopamine, norepinephrine, and especially serotonin.
SelectiveSerotonin Reuptake Inhibitors(SSRls)
Fluoxetine (Prozac ®) was the first and most popular of the
antidepressants; it has received much publicity both pro
and con since its release in 1988 . It is quite effective in the
treatment of depression, and it produces fewer side effects
 10.26 CHAPTER10
than tricyclic antidepressants or the MAO inhibitors . It is
also used to treat obsessive-compulsive disorder, panic dis-
order, and eating disorders.
Fluoxetine (Prozac®), sertraline (Zoloft®), citalopram (Celexa®),
escitalopram (Lexapro ®), paroxetine (Paxil ®) , and fluvox-
amine (Luvox ®) are classified as SSRis-all of which make
more serotonin available to the nervous system. The effec-
tive amount varies widely from patient to patient , so adjust-
ments are usually required . It generally takes two to four
weeks for the patient to feel the full effects. The most com-
mon side effects are insomnia, nausea, diarrhea, headache,
and nervousness. Most of the side effects are mild and dis-
appear after a few weeks.
Recently, the federal Food and Drug Administration (FDA)
warned against the use of paroxetine (Paxil ®) for those under
age 18 due to a slightly increased risk of suicide . The drug is
not approved for pediatric use, but some physicians were
prescribing it for teens. The FDA did approve fluoxetine
(Prozac ®) for pediatric use .128
Problems with SSRis occur when they are used in conjunc-
tion with street drugs that stimulate the release of serotonin
(e.g. , methamphetamine), which can lead to what is called
serotonin syndrome. Caused by excess serotonin, the symp-
toms include elevated body temperature, shivering and
tremors, mental changes, rigidity, autonomic nervous sys-
tem instability, and occasionally death. The use of SSRis by
people who abuse stimulants (e.g., cocaine and amphet-
amine) can result in severe stimulant toxicity and the devel-
opment of a condition called substance-induced delirium.
This condition is the result of a user 's susceptibility to the
medical and psychiatric side effects of the stimulants (e.g.,
convulsions, psychosis, and severe manic-like behavior) .
Depressive mood disorder resistant to SSRI treatment led to
the development of medications that enhance the activity of
other specific neurotransmitters. Serotonin-norepinephrine
reuptake inhibitors (SNRis) specifically inhibit the reup-
take of serotonin and norepinephrine (e.g ., venlafaxine
[Effexor®] and duloxetine ICymbalta ®]). Selective norepi-
nephrine-dopamine reuptake inhibitors (NDRis) include
bupropion (Wellbutrin ®and Zyban ®). Selective norepineph-
rine reuptake inhibitors (NRis) include reboxetine
(Edronax ®and Vestra®). Trazodone (Desyrel ®) is classed as a
serotonin modulator, and mirtazapine (Remeron ®) is consid-
ered an atypical antidepressant medication, as it blocks some
I
serotonin receptors while causing the release of norepineph-
rine and serotonin. Many more are in development.
TricyclicAntidepressants
Tricyclic antidepressants were once the primary medications
used to treat depression, but over the past 15 years the newer
antidepressants have proved to have fewer toxic effects and
side effects. SSRis and others are now the preferred medica-
tions for depression .
Tricyclic antidepressants, such as imipramine (Tofranil ®)
and desipramine (Norpramin ®), are thought to block reab-
sorption of serotonin and norepinephrine by the sending
neuron, thereby increasing the activity of those biochemicals
at the receiving neuron. This blocking effect in tum forces
the synthesis of more of these neurochemicals via eventual
down regulation of their autoreceptors . The delay of autore-
ceptor down regulation and the synthesis of extra serotonin
account for the observed lag time in effecting a change in the
patient 's mood. It usually takes two to six weeks for a
patient to respond to the drug therapy. 129
The tricyclics are very effective in treating patients with
chronic symptoms of depression. People without depres-
sion do not get a lift from tricyclic antidepressants, as most
of these medications cause drowsiness.
'The antidepressantsdid not9et me hi9h. It wasn't likefeelin9
drunkor stoned.You don't}Jetthat sensation.The hi9hI 9ot is
morelikea lift- a moodlift. It's the differencebetweenbein9
lethar9icand sad or activeand happq."
41-year -old male with depression
The tricyclic antidepressants are usually available in pill
form and can be dangerous if taken in overdose . Monitoring
for dosage compliance as well as constant feedback from
the patient about the effects and the side effects are neces-
sary to ensure safety and treatment efficacy. Major side
effects are dry mouth, blurred vision, inhibited urination,
hypotension, cardiac instability, seizures, and sleepiness.U 0
"I wentoff antidepressants.
And aftera month, sixweeks,
I be9an9ettin9depresseda9ain, but I had to be convinced
that I wasdepresseda9ain.And theqsaid, 'Youreallqshould
90 backon medication,' and I didn't wantto admitthat I
didn'twantto be on medication.I wantedto existwithoutit."
35-year -old with major depression
These drugs are dangerous to the heart when mixed with
street drugs or alcohol. Of note, tricyclics are rarely pre-
scribed for depressive disorders due to the overwhelming
superiority of the newer antidepressant medications.
MonoarnineOxidase(MAO) Inhibitors
Monoamine oxidase inhibitors such as phenelzine (Nardi! ®),
tranylcypromine (Parnate ®), and isocarboxazid (Marplan ®)
were fomerly used to treat depression but are rarely used
today because of the severity of their side-effect profile.
These are strong drugs that block an enzyme (MAO) that
metabolizes the neurotransmitters norepinephrine and
serotonin, which in essence raises the level of these neu-
rotransmitters . They do give fairly quick relief from a major
depression or panic disorder, but the user must be on a spe-
cial diet and remain aware of the potential for high blood
pressure, headaches, and several other side effects. Combined
use of MAO inhibitors with stimulants, depressants, and
alcohol can be fatal. Medications have been developed that
specifically block a form of the MAO enzyme known as
MAO-B and are proving to be a safer form of these medica-
tions. MAO-B inhibitors like Eldepryl ® (selegiline) and
Azilect ® (rasaqiline) more selectively block the enzyme that
breaks down dopamine and phenethylamines and are used
more often to treat epilepsy than depression. 131
 Mental Health and Drugs 10.27

have been developed during this time, including carbam-

Cornered by Mike Baldwin azepine (Tegretol ®), valproic acid (Depakene ®), divalproex
8-18 C 2005 Mike Bald win I DlsL by universal Press Syndleate www .cornerea .com sodium (Depakote ®), oxcarbazepine (Trileptal ®), gabapentin
cornerea@com1c.com
(Neurontin ®), and topiramate (Topamax ®). Each of these
5101::. ffffC,S IIJ<Ll/0€" W€(C,I-\T 1..oss, medications is well tolerated by patients and very effective in
C.LEARSK1tJ, Afvl..L~/'\l:>Of t-\A-11<1.., the treatment of the disorder. Each has a very distinct side-
MUL1" If'(£ JO~ OffE'/!.S , A8,S oF S1e:£L 1 effect profile and requires that the patient undergo a thor-
LO~ll\lb GOMf-'AI\JI0'1JS~\~ ough medical evaluation prior to receiving any of these
8
re <,;f'A~IC'.Ut.Jb
!'EltS0AlA1.c-f"V . . .
medications. In 2007 quetiapine (Seroquel ®), an antipsy-
chotic drug, was approved to treat bipolar disorder. It has a
significant sedative effect, and there have been reports of its
'-- abuse for that purpose. 132,m All of these drugs are used as
mood stabilizers, although some were initially designed for
other purposes. Various types of antidepressants are also
used in the treatment of bipolar disorder. Care must be taken
when initiating a patient on antidepressants, however, as
these medications can induce a manic episode in those with
bipolar disorder.

Lithium
Lithium is a naturally occurring mineral that helps stabilize
both the highs and the lows of bipolar disorder. It is more
effective, however, in stabilizing the highs. Although it is
generally safe, it carries some potentially serious side effects,
such as hypothyroidism, and requires close medical moni-
~,.......::~ -2::~ toring. A patient can expect to see clinical improvement in
How antidepressants should work. as soon as two weeks. The use of street drugs and alcohol
CORNERED
O 2005 Mike Baldwin. Reprinted with permission of UNIVER
SAL Udick. is contraindicated in patients taking lithium.
All rights reserve
d.

for
'The wa~ manic depressionworks,at least me, is the medicine
of
can control about 20% it. The other 80% is me. I have
Stimulants to learn how to control m~ moods with m~ mind becausethe
In the past amphetamine or amphetamine congeners, includ- medicationis onl~ a small part."
ing Dexedrine, ® Biphetamine, ® Desoxyn, ® Ritalin, ® and 40-year-old with bipolar disorder
Cylert, ®were used to treat depression. They work by increas-
ing the amount of norepinephrine and epinephrine in the
"Man~of the dru9scurrent/~usedto treatbipolardisorder
central nervous system. They are mood elevators when used
are also antiseizuremedications.These medicationshelp the
in moderation; but because tolerance develops rapidly and
bipolarpatientb~stabilizin9
the mis~rin9neurons
. Eachof
the mood lift is alluring, misuse and addiction develop
fairly quickly. Overuse leads to various physical and mental
of
these medicationshas its own uniqueset medicalside effects,
requiresclose monitorin9,and, like lithium, should not be
problems, such as agitation, aggression, paranoia, and psy-
or
taken with street dru9s alcohol. The antiseizuremedication
chosis. Stimulants are no longer indicated for the treat-
ment of depression. Ritalin ® is prescribed for patients with
valproateacid (Depakote®) is used in conjunctionwith or
attention-deficit/hyperactivity disorder. In the recovering
of
instead lithium becauseman~ clientsdislikethe side effects
of lithium. Complianceamon9dual-dia9nosisbipolarpatients
dual-diagnosis client with ADHD and a substance-abuse
wasbetterwith Depakote ®than with/ithium."
134

problem, stimulants are also contraindicated.
Non-StimulantADHDMedication
Diversion for sale and concerns regarding the use of stimu-
lants to treat ADHD have led to the development and the
promotion of non-stimulant medications to treat this
condition. Psychiatrists now prescribe non-stimulant medi-
cation such as bupropion (Wellbutrin ®) and atomoxetine
(Strattera ®) to treat ADHD, especially for patients who also
suffer from addiction.
Drugs Used to Treat Bipolar Disorder
For the past 30 years, the primary drug prescribed to treat
bipolar disorder has been lithium. Other medications
I
R. D. Weiss, S. F. Greenfield, L. M. Najavits , 1996,
Amrricanjoumal of Psychiatry
Drugs Used to Treat Psychoses
( e.g., schizophrenia-antipsychotics or neuroleptics)
In the early 1950s, a new class of drugs, phenothiazines,
was found to be effective in controlling the symptoms of
schizophrenia. Some of the drugs, such as chlorpromazine
(Thorazine ®), thioridazine (Mellaril ®), fluphenazine (Prolixin ®),
and prochlorperazine (Compazine ®), were initially referred
to as "major tranquilizers" to differentiate them from barbi-
turates and benzodiazepines, which were called "minor
tranquilizers." These traditional antipsychotics block the
dfrru of dopam ine in th< br>in. N<w<r antipsychotics- advant.,,geofthi<,id,df«twh<ntrutingan•gltatedpsy •
non•ph<nothiazin<> likt h.olop<Tidol (Haldol 0), lox,_pin< choticpati<nt.Th<><drug,•r<dang<rou, ifu«dH<l«ping
(Loxiu.n, • ), •nd molindont (Mob•n •)-...., 1.., block th< aid, bypatiml> who>r< not psychotic, •nd th<y shou ld
dfrruofclopamin< nev<rh<used,oldytocontrol • n • gltotedpati<nl
During the past d<ead<, • numbu of atypical ant ipsy• T h<neis•tr<ndtow:ordpr,,cri bing atypical•ntip,ychotic,i
chotk,i,ouchasri,peridon,(Ri•p<ub.l ' ). ol:1IW1pin< ,uch as ri,peri don<(Ri,perdal ' )forth e ocut<lypsychotic
{Zypr,xa • ),do.::apin,(Clo.::aril ' ). <iprasidone(G,odon • ) pati<nt.ll<c,us,monyofth,montroditional•ntip,ychotic
and qu<ti•pin< (S<roqu<l'), rulv< b«om< widdy us<d drug, do not ha,·, •n immed iat< effect on the patimt's
Thcyactliktph<nothiazin<>mdh.ov,,imibr,id,df,ru p,ychotic,ymplom,,it11LOytokt.....,r.t!w«kstoachin<
butworkbyunknownactiomon,p,c!ficr<e<ptorsofdopa • th< full:mtip,ychotic<ffttt. Duringthistimeth<pati<nt
min<, ><rotonin, •nd oth<T nrurotr:m,mill<n . AripiplllOl<
(Abili~) . a r.oth<ratypical•ntip,ychotic
thoughttoh<•dopamin<<y<t=l<tabiliz<r
medication, i,
.1"· 1" 1nl007
!:~ ~n\'.: ~t:t;;•~r:~ ~::: !=,'::~;•
1oin:
1
d~
1

the•mountmoyh<,lowlyincrn«difth< pa timtnetain,
an acti,., m<t>.bolit< of ri<p<ridon< (Ri<p<rdal~) called pal~ intr>ctabl<p,ychotic , ympto,ns _lf af1<rlour10'1xw«ksot
p<ridon< (lnv,ga • ) w• • •pprovci to Uttt <ehizophnen i• thi<higherd0«th<pati<nt ~ •ymplom,r,cmainunch.ong<d
Both block dopamin< •nd «rolonin r«<pton, but th<ir thedinicianu,ua lly,witch<>to•diff<r<nttyp<ofanti •
aact m<eharni,m ol •ction i, <till unknown .'" ·''° By 101 I p,ychotic . The doo,canusu•llyb,,af, lylow<r<d•ft<rlh<
thrtt oth<r atypic•l•ntipsychotic medi cations thought to ,ymplo1M•r<monoged . Thi< approochispanirularlyimpor •
block,pecificdopamin< md«roloninne«ptOT<-lurni• L>nt intruting, ld<rlypa1im1>
don < (Latuda • ), ilop<Tidon< (hnopt • ). and asmopin<
(S..phri, 0 )- wrn,FDA•pprovcitoUttt<ehimphnenia Clo:apin< (Clo.::aril' ) i, u,uall y ,fftttiv< in th e 30% of
patients who do no t re,por.d to ,undard ant ip,ychotk
R<Sarch<nlound t haton,ofth < mojor ca=ofpsychotk drugth<r.opy, a lthoughw«klyb loodt<>1> a nen,ce,,aryto
,ympto,ns in sch imphmri • i, an <><«M of dopamin< . Most monit0Tth<,id , ,ffect,,whichmak< i1>u«v=1<,qxmiv<
of th < ant ip,ychotk me dicat ions work by blocking the Althoughnew<ratypi calrntip,ychotico.,uch • •ri<p<ridon <
dop•min< n«pton in th< br:oin, th<r<by inhibiting th < (Rispen:b.l') ,obnupine(Zypnen • ),>ripipruol<( Abili~).
dfrru of the <X«M dopamin<. G<n<r:tlly. •ntipsychotk andpaliperidon,(ln,.,g,, 0) ,donotmiuineb loodt<<l>, t hcy
1 0 or< still mon, <xp<n5iV< than th< older mtipsychotic•
:::::-t;;:~:.: ::t:~~cl:'r:~:~c f~;m:i: ~ ~tn:I ~~'. Cumenth«tprocti«promot<>th<US<ol • typical•ntip,y •
n<M<>lh.oth>,.,p,ych<>«<associat<dwithth<m . Th<main choticoov<rth<irl<S5apensi,.,prrd«<<SOn
diff<r<n«•mongthediff<r<nlantip,ychot ic drug,i<th<ir
>id<-<ff«tprofil< Th<T<wa,;••ixfoldincr,..., inth<numb<rofch ildr,nu.k•
ini; ant ip,ychotic• from 1\193 10 1002 (from 201,000 to
Themoin>idedfec1>h.ov,todowithth<block>g<oldopa •
m'n<.Dopam "necontro l,mu ' · ,n,andmotorb<h»' ;;.!;.~] ,~"~:-: :.8.:n~~ i~~I ~::• d:,,~~tf:n~
Dyblockingdopamin<,th<drug,cau.,,uch•ymptom,as
medicotion<ff«:tiwcn<>0aprnds,th<m:iu<>1>forp,ychiat •
involu nu.ry mov<m<nt •nd th< inability to sit '1ill ricmedic,tiontrulm<nlfromcoll<g<medicalc,cnt<r<rul,.,
Porkin,on's ,;ndrom< (mainly • t r<mor but •i<o .!owed
h<come mor<lm:iu<nt .' "
mo,.,m<nl>>ndth<l<>Moffacial,xpr<.,ion),•k>thi,ia (ogi•
Lotion, r<stk,on<>,, md jumpine .. , ahibit<d by 7~% of r,uirnts with• pre=i<ting psychotic illn«< ,uch as
pati<nl>l. •kin<>ia (t<mpomy !OM of mov<m<nt a r.d • pa· ochimphllniaorochiroaff«tiv<di<0rderofttnatttmptto
th)·) , andth<mor<«riou,tardiv,dyskin«i•(involuntary ron tr olth<ir , ymptomsu, ing'1rtttdrug,.Thestr<<tdrug,
mo,.,mm1>ofth,j •ws,h<ad , n<ek, t runk,mdutttmitie, ) rommonl)'u«dindud,h<roin•ndoth<ropiot<>.•lcohol
or< th< mo,;t common complication, r«ulting lrom the u« marij u•na, md -tiv< •hypnotic,. lkau« • II of th,.,
of th<« m<dicatiom. Oft<n anticho linergic medicatiom '1n<tdrug,rulv,dangerou,andtoxicdfttts wh,nrom•
,uch • •Cogrntin • •ndAru.r.t. • ormmtihi< L>min<lik< binedwithantip,ychoticdrug,,patim1'ar<<Xhon,dto
ll<nodryl ' •«puscr!bedtoblock.JdedT«1> c,c...,u,ingthemwhileunderpsyc hiatrictr<>tmmt . 1"
Thme•r<oth<rpolrntWly«riou,,id , dfec1>•550Ciated
with•n tip,ychotic .. Th<S<indud<m<u.bolicprob lems,uch · 1"""'IJdrinlolco/,o/w;tlt"""'ofthr,,pdl,thatl"""talJtij
,,,,,1/...,.IJ,,al"j!.<>e(oot,.,,J/wou!Jlo..coruciou>,.,,,-
as dev:ot<db loodgluco« . <l<v.ttedchokst<rol.•nd <l<>coted
pas,ool aoJjt =pr<ttJtl,,,d: o.J I ,..,../Jha..J;if,,,nt
lriglycerid<>.A lthoughth<«cm<dicin<••rereb.tiv<lyW<
a t r<m<cu,<houldb<u.ktnwhrnth<yn,pr,,crib<d tlfp,,of>ith,lf«1>IJ,,b lotd,'l,l;n.andit=l,,,J,,all'I
"a!Lj, 1,,,J·
andth<patim t ,houldb<do,dymonitor<dby
t''1du · n· ' ,urvoftreatm<n t
o p,ychia-
,._ ......,,...
-""""~""""'"".,,..,_. ,........
Anothercommonlyencount<r<d.Jdeeffectof•ntipsychotic
medications i, «dation ; patients on ant ipsychotk,i may DrugsUsedtoTreatAnxietyDisorders
<«mdrugged;thi<i••nun wa nt<d.Jde,ff<etandisnotth< Forg<n<r:tliud:mxietydiso-rda as w<ll a< 50m<ofth,oth<r
primorypurpoo<olpr<<eribing•ntip,ychoticm<dicatiom anxi<tydi<oro<B,theb<modiuq,in,sar,widdyu«d . The
Thme>r<tim<>.how,va , wh<nlh< • stut<dinic ianwilltak< mo>lcommonlypr=:ribed•r<alpruob.m (X.~ ) .clonu •
 Mental Health and Drugs 10.29

TheRelationships
AmongNeurotransmitters , Their Functions,StreetDrugs
,
Menta
l Illness
and chiatric Medications
STREET
DRUGSTHAT
DISRUPT
THE ASSOCIATED
MENTAL SOMEEXAMPLES
OFMEDICATIONS
USEDTO
NEUROTRANSMITTERNORMAL
FUNCTIONS NEUROTRANSMITTER
ILLNESSES REBALANCE
NEUROTRANSMIITTRS
Serotonin Moodstability,appetite, Alcohol,nicotine, Anxietydisorders(e.g., PTSD, SSR ls (e.g., Prozac,®Zoloft, ® Paxil,
® Luvox,®
sleepcontrol,sexual amphetam ine,cocaine, panic disorder,OCD, l exapro, ®Celexa ®); seroton in andSNROs
activity,
aggression, PCP,LSD,MOMA generalized anxietydisorder), (Cymbalta, ® Effexor®); tricyclicandother
self-esteem (ecstasy) mooddisorders(e.g., bipolar antidepressants (e.g., Elavi
l,®Tofranil
®); atypical
disorder, major depressive antidepressants (Desyrel, ® Remeron, ® BuSpa~)
disorder, depression)
Dopamine Musdetonejcontrol, Cocaine,
nicotine,PCP, Psychoticdisorders Dopamine antagonists (e.g.,Risperdal,® Clozaril,®
motor behav ior, energy, amphetam ine,caffeine, (e.g.,schizoph
renia, Zyprexa,®Ability,® lnvega ®); anti-Parkinson'sor
reward mechanisms, LSD,marijuana,alcohol, schizoaffectivedisorder); dopamine agonist(e.g.,L-dopa,amantad ine,
attentionspan,pleasure, opioid Parkinson'sdisease bromocriptine, rasagil
ine,selegiline);some
mental stability,hunger/ antidepressants (Wellbu trin·~)
thirst/sex
ual satiatio
n
Norepinephrine, Energy,motivation, Cocaine,
nicotine, Anxiety,
attention,depression, Buprop ion, desipramine,methylamphetamine,
epinephrine eatin& heartrate,blood marijua
na, MOMA,2CB, arcolepsy,
disorder SNRls, methy lphenidate,clonidine,
betablockers
pressure,dilation of CBR
bronchi,assertiveness,
alertness,
confidence
Endorphin, enkephalin Paincontrol,reward Heroin,Oxy(ontin,
® Psychoticdisorders,
mood Agonist= methado
ne, LAAM,buprenorphine;
mechanisms,stress opioids,PCP,
alcohol, disorders Antagonist=
naltrexone,
nalmefene,
ALKS33
control(physical
and marijua
na,salvino
rinA
emotionaO
GABA(gamma Inhibitor of many Alcohol,marijuana, Anxiety,
sleepdisorders, Benzodiazepines,glutamine,
THC,Neurontin,®
aminobutyricacid) neurotransmitters,muscle barbitura
tes,PCP, narcolepsy,
seizure disorders l yrica,
®Xyrem,
®Topama x®
relaxant,control of benzodiazepines
aggression,arousal
Acetylc
holine Memory,learnin& Marijuana, nicotine, Alzheimer's disease, Vistaril,®Artane,® Cogentin,® Benadryl,®tacrine
muscularreflexes, alcohol,PCP, cocaine, schizophrenia,tremors (Cognex®), donepezi l (Aricep
t®), rivastigmine
aggression,attentio
n, amphetam ine,LSD (Exelon®), galantamine (Reminyl ®),
bloodpressure, heart mecamylam ine(lnversine~)
rate,sexualbehavior,
mental acuity,sleep,
musc le control
Cortisone,
cortico
trophin Immunesystem, Heroin,cocaine Schizophrenia,depression, Corticosteroids
(e.g., Prednisone,
®cortisone),
healing.stress insomnia,anxiety ACTH; cortisol;ketoconazole
inhibitsACTH
Histamine Sleep,inflammat ion of Antihistam
ines,opioids Bipolar depressive
illness Antihistamines(e.g.,Bena
dryl,® Chlortrimeton,
®
tissues,stomachacid, Vista
ril,®Allegra,
® Phenergan,® Claritin®)
secret
ion,allergic
response
Anandamide,
2AG Natural functionis still Marijuana,hashis
h Not known; possible lsive Marijua
compu na antagonis
t rimonabant (Acomplia,®
unknownbutsevera l n& memoryproblems, Zimulti,®kynure
overeati nicacid [a neurotransmitter])
receptors still discovered schizophre
nia

epam (Klonopin ®), diazepam (Valium ®) , chlordiaz epox:ide
(Librium ®) , and cloraz epate (Tranxene®). Developed in the
early 1960s, th e benz odiazepines were consid ered safe subs ti-
tut es for barbiturates and meprobamat e (e.g., Miltown®) .
They act very quickl y, particularl y Valium.® The calming
effects are app arent within 30 minutes . Some of th e ben zodi-
azepines are long acting (diazepam , chlordiaz epoxide, cloraz-
epate, clona zepam, prazepam, and halazepam ) , and som e are
short acting (triazolam, lorazepam , and temazepam ). These
dru gs work by enhancin g th e neurona l inh ibit ory effects of
GABA, the major inhibitory neuro transmitter . Many phys i-
cians avoid prescri b ing any benzodiazepine on a chronic
basis, asserting that th ese sedative-hypnoti c.s should be us ed
I
onl y for a bri ef period of tim e to stabilize anxiety or mitigat e
sleep problems . Almost all benzodiaz ep ines or th eir active
metabolit es tend to accumulat e in th e bod y, which leads to
pot entia l side or toxic effects if th ey are taken over a long
period of time. This is of sp ecial concern with elderly patients
because th e half-lives of ben zodiazepin e chemicals may rise
two to thre e tim es in duration after th e age of 50.
Benzodiaz epines ar e hab it forming, even at clinic al dos es,
and have dangerou s withdra wal symptoms . The y should
never be used to treat a duall y diagnosed pati ent b ecause
th ey can retrigger dru g abus e. The re are man y other medica-
tions that can be safely us ed , includ ing BuSpar ,® tricyclic
 10.30 CHAPTER10

~chiatricMedications
MajorDepression
(antidepressants) Generalized
AnxietyDisorder
(anxiolytic:s)
Selective
serotonin
reuptake citalopram
inhiMors(SSRls): (Celexa
®), fluoxetine short-acting
Benzodiazepines: (2-to4-hourduration
ofadion)-alprazolam
(Prozac,
®Sarafem ®), fluvoxamine
(Luvox
®), paroxetine
(Paxil
®), sertraline (Xanax®),
lorazepam (Ativan
®), oxazepam (Serax®),
temazepam (Restoril
®),
(Zoloft
®), escitalopram (Lexapro
®) triazolam ®); long-acting
(Halcion (6- to24-hourduration ofaction)-
chlordiazepoxide
(Librium®), clonazepam (Klonopin®), clorazepate
(franxene
®),
Tricyclic tertiary
antidepressants: aminetricydics-amitriptyline
(Elavil,
®Endep
®), diazepam (Valium
®), halazepam (Paxipam®), prazepam (Centrax
®)
clomipramine(Anafrani
l®), doxepin(Sinequan,
®Adapin ®), imipramine
(fofranil,
®Janimine
®), trimipramine ®); secondary
(Surmontil amine buspirone
Non-benzodiazepines: (BuSpa
r®), citalopram
(Celexa
®), paroxetine
tricydics-amoxapine
(Asendin ®), maprotiline
(Ludiomil
®) (Paxil
®), venlafaxine
(Effexor®),
imipramine (fofranil
®), isocarboxazid
(Marplan®), metoprolol
(Lopresso
r®), guanfacine
(fenex®)
Norepinephrine-dopamine
reuptake
inhibitors bupropion
(NDRls):
(Wellbutrin
®), bupropion
SR(Wellbutrin
SR,®Zyban
®) Obsessive-Compulsive
Disorder
Serotonin-norepinephrine
reuptake
inhibitors venlafaxine
(SNRls): (Effexor
®), Clomipramine (Anafranil
®), fluoxetine
(Prozac®), fluvoxamine
maleate(Luvox®
),
venlafaxine
XR(Effexor
XR ®), duloxetine(Cymbalta
®) sertraline
(Zoloft®),
venlafaxine
(Effexo
r®)
Serotonin trazodone(Desyre
modulators: l®) PanicDisorder
Norepinephrine
reuptake (NRls):reboxetine
inhibitors (Edronax.
®Vestra
®) drugs(medications
First-line thatshouldbetriedfirstto controlpanic):SSRls
(Zoloft,
®Prozac,
®Paxi
l®), alprazolam
(Xanax®), clonazepam(Klonopin
®),
Norepinephrine-serotonin mirtazapine
modulators: (Remeron
®)
desipramine
(Norpramin,
®Pertofrane®), imipramine(fofranil
®)
Monoamine
oxidase phenelzine
(MAO)inhibitors: (Nardil
®), tranylcypromine
MAOinhibitors,
Others: e.g.,phenelzine
(Nardil
®) andtranylcypromine
(Parnate
®),
(Parnate
®), isocarboxazid
(Marplan
®) isocarboxazid
(Marplan
®)
Monoamine
oxidase selegiline
B(MA0-8)inhibitors: (Eldepryl
®), rasagiline
(Azilect®)
SocialPhobia
Stimulants amphetamine/methamphetamine
usedasantidepressants:
atenolol(fenormin
Betablockers: ®), propranolol
(lnderal
®), metoprolol
(Adderall,
®Dexedrine,
®Biphetamine,
®Desoxyn
®), methylphenidate
(Ritalin,
®
(Lopressor®); SSRls-Paxil,
®Effexor,
®andZoloft
®-havenowbeenFDA
Concerta
®), pemoline(Cyler!®)
approved to treatsocialphobia;benzodiazepines
arethelastlinemedications
BipolarAffectiveDisorder
(moodstabilizers) forthisdisorder
Lithium:
Eskalith,
®Lithobid,®carbamazepine (fegretol®), valproic
acid Post-Traumatic
StressDisorder
(Depakene®), divalproex
sodium(Depakote ®), olanzapine (Zyprexa
®),
First-line SSRls
drugs: (e.g.,Zoloft,
®Paxil
®), tricyclic
antidepressants
(e.g.,Tofranil,
®
oxcarbazepine(frileptal
®), gabapentin
(Neurontin®), topiramate(fopamax
®),
Anafranil
®), atypical
antidepressants
(e.g.,Cymbalta,
®Desyrel
®)
aripiprazole
(Ability
®), Quetiapine
(Seroquel
®), tricyclic
antidepressants
Second-line betablockers
drugs: (atenolol,
pindolo
l [Visken
®], propranolol),
alpha
Thought
Disorders
(antipsychotics)
blockers
(prazosin
[Minipress
®] fornightmares)
haloperidol
Butyrophenones: (Haldol
®)
Last-line MAOinhibitors
drugs: (e.g.,Marplan,
®Parnate
®)
loxapine
Dibenzoxazepines: (Loxitane
®), molindone
(Moban,
®Lidone
®)
SleepDisorder
chlorproth~ene
Heterocydic:s: (faractan
®)
clonazepam
Benzodiazepines: (Klonopin
®), clorazepate
(franxene
®), estazolam
chlorpromazine
Phenothiazines: (fhorazine
®), triflupromazine
(Vesprin
®) (ProSom
®), flurazepam (Dalmane®), oxazepam
(Serax
®), quazepam(Doral
®),
temazepam (Restoril
®), triazolam
(Halcion
®)
acetophenazine
Piperazines: (Tinda
l®), fluphenazine
(Prolixin,
®Penmitil
®),
perphenazine
(frilafon,
®Etrafon
®),trifluoperazine
(Stelazine
®) ramelteon
Non-benzodiazepines: (Rozerem
®), amitriptyline
(Elavil
®), chloral
hydrate,
diphenhydramine (Benadryl
®), doxepin(Sinequan
®), trazodone
mesoridazine
Piperidines: (Serentil
®), pimozide
(Orap
®), piperacetazine
(Guide
®), (Desyre
l®), Z-hypnotics
[verysimilar
to benzodiazepines]:
zaleplon(Sonata
®),
thioridazine
(Mellaril
®) zolpidem(Ambien®), zopiclone
(lmovane ®), eszopiclone
(Lunesta®)
thiothixene
Thioxanthenes: (Navane
®) Attention-Deficit/Hyperactivity
Disorder
Atypical aripiprazole
antipsychotic:s: (Ability®).
clozapine
(Clozaril
®), olanzapine amphetamine
Stimulants: (Adderall,
®Adderall
XR ®), pemoline
(Cyler!
®),
(Zyprexa
®), quetiapine
(Seroquel
®), risperidone
(Risperda
l®), ziprasidone dextroamphetamine
(Dexedrine, ®DextroStat,
®Dexedrine Spansule
®),
(Geodon
®), paliperidone
(lnvega
®), lurasidone
(Latuda®), iloperidone
(Fanapt®), dexmethylphenidate
(Focalin®), methylphenidate
(Ritalin,
®Methylin,
®
asenapine
(Saphris
®)

I
Metadate,
®Concerta
®), lisdexamfetamine
(Vyvanse
®)
usedtotreatextrapyramidal
Drugs sideeffects amantadine
ofantipsychotic:s: : atomoxetine
Non-stimulants (Strattera
®), bupropion
(Wellbutrin
®);
(Symmetrel
®), benztropine(Cogentin
®), diphenhydramine
(Benadryl
®), antihypertensive
medications
(clonidine
[Catapres
®]),guanfacine
[Tenex
®])
propranolol
(lnderal
®), trihexyphenidyl
(Ariane
®)

antidepressants (e.g., Tofranil ®), MAO inhibitor medications

(e.g., Marplan ®), and the beta blockers (e.g., Lopressor®).
"I wentoff Paxil.
® I stopped
immediate/~ insteadof taperin9
off,
Recently, SSRI antidepressants such as Paxil® have been
and I hadheadaches; anda9ainI wasjustreall~an9r~.M~ anxiet~
level-that is whatI wastakirl[j
it for-just shotup to theroof
approved for use in anxiety disorder. 127·143 When stopping
I thoushta coupleof timesI washavin9a heartattack.I wentto
SSR!s and almost all psychiatric medications, there should
be constant feedback to the doctor so that the drug can be
m~doctor,and he toldmenatout that~OU cannotjuststoptakins
® that ~ouwillhavehu9ewithdrawal
the Paxi/. s~mptoms."
stopped or the dose adjusted.
38-year-old with a dual diagnosis

Buspirone (BuSpar®) is one of the few other drugs labeled
for generalized anxiety disorder . It is a serotonin modulator
that blocks the transmission of excess serotonin, one of the
causes of the symptoms of many forms of anxiety. It also
mimics serotonin, so it can substitute for low levels of sero-
tonin, a feature favored by some doctors to treat depression.
It takes one to two weeks before it begins to work, and the
initial results are not nearly as dramatic as those from benzo-
diazepines, so many patients are reluctant to use it. It has the
advantage of minimal side effects and has not been shown to
be habit forming; therefore it is an antianxiety medication
that can be more safely used in dual-diagnosis patients.
The SSR!s such as Paxil ®and Zoloft® are currently indicated
for use in anxiety disorders. These drugs have a direct anti-
anxiety effect and are prescribed for other conditions in
addition to depression with anxiety symptoms.
Drugsfor Obsessive-Compulsive
Disorder(OCD)
Almost every type of psychotropic medication has been
used to treat OCD with relatively poor results. Anafranil ®
(clomipramine), a tricyclic antidepressant, has recently been
used with reasonable results. SSR!s and SNR!s like parox-
etine, senraline, fluoxetine, fluvoxamine, and venlafaxine
have also been used.
Drugsfor PanicDisorder
Several drugs are used to control panic attacks and panic
disorder. Previously, benzodiazepines were the primary drug
of choice for the treatment of panic disorders. Benzodiazepine-
type medication should always be avoided when treating a
patient with a dual diagnosis. Current treatment recommen-
dations include the use of SSRI antidepressant medica-
tions. These are very effective in the treatment of panic and
generally have a favorable side-effect profile . These medica-
tions must be taken daily and are not designed to treat a
person with an acute panic attack.
Other frequently used medications in the treatment of panic
are the beta blockers like propranolol. They help control both
Mental Health and Drugs
Introduction
• The close connection between mental health disor-
ders and psychoactive drug disorders can be found in
the neurotransmitters; those affected by psychoac-
tive drugs are the same ones involved in mental ill-
ness . Many people with mental problems are drawn to
psychoactive drug use in an effort to rebalance their
brain chemistry.
• In the 2013 DSM-5 (Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition), addiction-related
Mental Health and Drugs 1O.l 1
the physical and the psychological symptoms associated with
panic . Care should be taken when using beta blockers, as they
can have serious cardiac side effects in certain patients.
Complianceand Feedback
The most challenging problem with psychiatric medica-
tions (actually, with any prescription medication) is com-
pliance with the physician's instructions . If patients are not
getting the desired effects, they will often alter the dosage
on their own, simply stop taking the medication, or combine
it with other drugs, creating the potential for dangerous
interactions.
"I stoppedtakingit and got so depressedI tookthe remnants
of bothprescriptions
. whichwas1.000 milligrams [mg] of
Seroquel®and 1,500 mg of Zolo~.® I tookthemall at once
becauseI becameso depressed.M~ fianceeand I had a fight,
and I wantedto killm~self"
38-year -old male with a dual diagnosis
When a patient begins taking a psychiatric medication,
feedback is necessary for the greatest success . The physi-
cian and the patient must work in tandem to select the right
drug and adjust the dose when necessary. Because insurance
coverage for office visits can be limited, as are publicly
funded treatment slots, sometimes a patient might see a
physician only once a month during this critical period .
Frequent and regular contact to monitor psychotropic medi-
cation effects and side effects provides the best chance for
positive treatment outcomes.
'This clinichas beena lifesaverfor me. I'm ableto comein ever~
da~and talk to a therapistabouthow I'm feeling,but also
I'm ableto talk to doctorsand a pharmacistabouthow the
medicationsareworking,so the~'reableto makeadjustments,
modifications,changeson a dail~basis,whichhas real/~helped
me stabilizem~moodsand thoughts."
35-year-old at the Haight Ashbury Detox Clinic with schizoaffective disorder
disorders are listed under the heading "Substance-
Related and Addictive Disorders," which permits the
inclusion of gambling as a true addiction. Each sub-
stance and behavioral addiction is divided into mild,
moderate, and severe .
• The determining factors for mental, substance, or
behavioral disorders are heredity, environment, and
the use of psychoactive drugs or practice of compul-
sive behaviors . They affect mental health in the same
way as they affect substance-related and addictive
disorders.
10.32 CHAPTER10
Dual Diagnosis
(co-occurringdisorders)
Definition
• Co-occurring disorders are defined as the existence
of at least one independent major mental disorder as
well as an independent substance-related and addic-
tive disorder .
• The mental problem can be a pre-existing condi-
tion (e.g., thought, mood, or anxiety disorder) or a
substance-induced mental condition (e.g. stimulant-
induced psychotic disorder).
Epidemiology
• It is estimated that about 50% of individuals with
severe mental disorders are affected by substance
abuse.
• Of all people diagnosed as mentally ill, 29% to 34%
also had a problem with either alcohol or other drugs.
• There is a high incidence of mental imbalance in drug
users. Many people with mental/emotional problems
use drugs, often to self-medicate.
• Of the 7 million to 13 million people who do have
co-occurring disorders, about 20% to 23% received
only mental health care and 7% to 9% received only
substance-abuse treatment, leaving just 7% to 8% who
received both and 60% to 72% who received no treat-
ment at all.
Patternsof Dual Diagnosis
• One kind of dual diagnosis involves a person who
has a clearly defined pre-existing mental illness and
becomes involved with drugs (e.g., a teen with major
depression who discovers methamphetamine). The
drugs are often used to alleviate symptoms of the
mental illness .
• The other kind of dual diagnosis is a result of sub-
stance abuse and/or withdrawal , which causes the
user to develop psychiatric problems because of the
toxic effects of the drug and the disruption of brain
chemistry The imbalance in the brain chemistry in
this type of diagnosis is usually temporary, and with
abstinence the mental illness usually disappears
within a few weeks to a year.
Making the Diagnosis
• Because the direct effects as well as the withdrawal
effects of drugs can mimic mental illnesses , initial
diagnoses must be "rule-out " diagnoses . The clini-
cian must wait until the drug user has had time to get
sober before diagnosing .
• The increase in the number of dual diagnoses is the
result of a greater availability of psychoactive sub-
stances, a heightened awareness of the mental effects
of psychoactive drugs, and the lack of sufficient treat-
ment facilities .
• About 25% of the homeless have a pre-existing mental
illness, and of those 70% suffer from substance depen-
dence .
• Homeless people are often shuffled aimlessly back and
forth between the mental health care system and the
substance-abuse treatment system, never receiving
adequate care from either .
Mental Health vs. SubstanceAbuse
• There are at least 12 ideological differences between
the mental health treatment community (MH) and the
substance-abuse treatment community (SA).
• MH believes "control the underlying psychiatric prob-
lem and the drug abuse will disappear "; SA believes
"get the patient clean-and-sober and the mental health
problems will resolve themselves."
• MH believes "partial recovery is more readily accept-
able "; SA believes "lifelong abstinence from all abused
drugs is necessary "
• The dual-diagnosis patient must be treated for both
disorders simultaneously and is best treated in a single
program when appropriate resources are available-
known as the "every door is the right door " strategy.
• The previous distrust between the two treatment
communities has partly given way to cooperation and
recognition of the duality of drug abuse and mental
illness .
PsychiatricDisorders:Pre-Existing
Mental Disorders
These are the major divisions of mental disorders in Axis I:
• Schizophrenia spectrum and other psychotic disor-
ders, which include paranoid schizophrenia, schizoaf-
fective disorder, and substance/medication-induced
psychotic disorder , among others
• Bipolar and related disorders, which include bipolar
I and II, cyclothymic disorder , substance/medication-
induced bipolar disorder , and related disorders
• Depressive disorders, which include major depressive
disorder, dysthymia, substance/medication-induced
depressive disorder, and others
• Anxiety disorders , which include panic disorder,
generalized anxiety disorder, substance/medication-
induced anxiety disorder , and agoraphobia
• Trauma- and stressor-related disorders, which include
post-traumatic stress disorder (PTSD), reactive attach-
ment disorder, disinhibited social engagement dis-
order, acute stress disorder, and others (PTSD was
formerly classified under anxiety disorders)

• Dementias
• Neurodevelopmental disorders, which include men-
tal retardation, autism , communication disorders, and
attention-deficit/hyperactivity disorder
• Somatic symptom and related disorders, which
include hypochondria
• Personality disorders, which are fairly common in
dual diagnoses; the most common are borderline,
paranoid, antisocial, narcissistic , avoidant, schizoid,
obsessive compulsive, and dependent personality
disorders
• Feeding and eating disorders , which include bulimia
nervosa, anorexia nervosa , and binge eating
• Gambling disorder
• Others, including adjustment disorders, sleep dis-
orders , sexual and gender identity disorders , and
factitious disorders that exist independently or in
combination with other mental disorders and drug
use disorders
Substance-InducedMental Disorders
These are the most common substance-induced mental
disorders:
• Alcohol-induced , which include impulse-control
problems, sleep disorders, anxiety, depression, psy-
chosis, dementia, and cognitive impairment
• Stimulant-induced, which can include impulse-
control problems, sexual dysfunction , bipolar disor-
der, depression, panic disorder, anxiety, psychosis,
sleep disorder , and cognitive impairment
• Cannabis-induced, which includes intoxication
delirium, psychotic disorder , hallucinogen persisting
perception disorder (HPPD), anxiety disorder, and a
so-called amotivational syndrome
• The incidence of substance-induced psychiatric
symptoms is much greater than the incidence of pre-
existing psychiatric problems .
Treatment
• Treatment of mental illness and addiction should be
directed toward rebalancing brain chemistry.
• To overcome heredity factors, people should be
informed that they are more at risk for a certain mental
illness, drug addiction, or other compulsive behavior.
The authors are indebted to Pablo Stewart, M.D., clinical professor of psychiatry at the University of California,
San Francisco School of Medicine, for his invaluable guidance and contributions in co-authoring this chapter.
Mental Health and Drugs 10.33
• To overcome environmental factors, reducing stress,
avoiding drugs, and eliminating the practice of com-
pulsive behaviors are positive strategies .
• Treatment can include individual therapy, group
therapy , self-help groups, and psychiatric medica-
tions . There are outpatient and residential treatment
facilities. The "every door is the right door " strategy
provides treatment access and improves outcomes for
mor e people with co-occurring disorders.
• For treatment to be effective, both mental illness and
substance-related and addictive disorders must be
treated simultaneously.
• Impaired cognition and developmental arrest make
dual diagnosis treatment more difficult .
Psychopharmacology
• Antidepressants, antipsychotics, mood stabilizers,
and antianxiety drugs are the principal medications
used to control mental illnesses .
• Psychiatric medications can be used on a short-term,
medium-term, or lifetime basis.
• Medications should be used in conjunction with indi-
vidual or group therapy and with lifestyle changes .
• Psych meds are not designed to work only on selected
neurotransmitters, so side effects are a constant problem.
• Drugs to treat depression are usually designed to
increase serotonin and/or norepinephrine (e.g., tri-
cyclics, SSR!s, MAO inhibitors , stimulants, and non-
stimulant ADHD medications).
• The primary drug used to treat bipolar disorder is lith-
ium . Supplemental drugs include (mostly as mood sta-
bilizers or to control side effects of lithium) Tegretol ,®
Depakene ,® Depakote ,® Neurontin, ® Topamax, ® and
Trileptal. ®
• Drugs used to treat psychoses include phenothiazines.
The first antipsychotics (e.g., Thorazine, ® Mellaril,®
Prolixin,® and Compazine ®) were later joined by non-
phenothiazines such as Haldol ,®Loxitan e,®and Moban .®
Atypical antipsychotics such as Risperdal,® Zyprexa,®
Seroquel,®and Geodon ®have been developed .
• For anxiety , the benzodiazepines are widely used. The
others include BuSpar® and SSR!s, normally used for
depression.
R.O
Chapter 1
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Al-Anon A 12-step self-help organization to aid the friends and
the relatives of alcoholics .
Alateen A 12-step self-help organization for teenagers affected
by an alcoholic parent or friend; it helps them deal with the
pain and the disruption in their lives.
alcohol An organic chemical created naturally by the fermenta-
tion of sugar, starch , or other carbohydrate. It can also be
synthesized from ethylene or acetylene.
alcohol dehydrogenase The principal enzyme in the liver that
metabolizes alcohol.
alcohol-induced disorders (other alcohol induced disorders)
A diagnostic category in DSM-5 under Alcohol-Related
Disorders that describes a group of psychiatric symptoms
caused by alcohol intoxication or withdrawal, including
alcohol-induced: bipolar disorder, depressive disorders,
anxiety disorder , sleep disorder , sexual dysfunction, major or
minor neurocognitive disorder , intoxication or withdrawal
delirium .
alcohol-related birth defects (ARBD) Any number of physical
abnormalities that are caused by excess alcohol drinking
during pregnancy but without the facial deformities seen
with fetal alcohol syndrome.
Alcohol-Related Disorders A diagnostic classification that
includes alcohol use disorders including alcohol intoxica-
tion , other alcohol-induced disorders, alcohol withdrawal as
well as unspecified alcohol-related disorder ..
alcohol-related neurodevelopmental disorder (ARND)
Nervous system abnormalities caused by excess drinking
during pregnancy without the facial deformities seen with
fetal alcohol syndrome.
alcoholic hepatitis Inflammation and impairment of liver func-
tion caused by excess use of alcohol. Also see hepatitis.
Alcoholics Anonymous (AA) The first 12-step self-help recov-
ery group for those with alcoholism , founded in 1934 by Bill
Wilson and Dr. Bob Smith ; 114 ,000 chapters exist worldwide
with approximately 2 million members.
alcoholism Addiction to alcohol; a progressive disease charac-
terized by loss of control over use, obsession with use , con-
tinued use despite adverse consequences, denial that there is
a problem , and a powerful tendency to relapse.
ale A beer with a slightly more bitter taste and a higher alcohol
content than lager beer; uses the top fermentation process.
The alehouse or pub and the use of ale rather than lager are
prominent features of British life.
Aleve®See naproxen
alkaloid Any nitrogen-containing plant compound with phar-
macological (often psychoactive) activity (e.g., morphine,
cocaine , and nicotine).
alkanes A class of hydrocarbons that are gases at room tempera-
ture; includes methane , butane , and propane.
allele gene A paired gene whose difference from a normal
gene may be responsible for one of the 3 ,500 chromosom-
ally linked human diseases . Normall y, the alleles have the
same function (e.g. , two alleles control eye color, but one is
for blue eyes and the other is for brown eyes). In terms of
addiction, one allele may be responsible for normal alcohol
metabolism while the other does the same job but does it
poorl y, so the alcohol has a greater effect.
allergic reaction An abnormal reaction to a substance; severe
reactions such as anaph ylactic shock caused by cocaine can
be fatal.
allergy to drugs A concept to explain the uncontrollable reac-
tion to psychoactive drugs , such as alcohol or methamphet-
amine. It is similar to an allergy to pollen, peanuts, or fish
where the substance causes an intense reaction; with drugs,
GLOSSARY G.1
the reaction is an intense craving in someone who has altered
his brain chemistry and become addicted.
allodynia A painful response to a normally pain free stimulus .
like gentle touch or warmth that results from a neurologi-
cal adaptation to chronic opiate/opioid treatment.
allostasis A process for achieving homeostasis (balance)
I
through a number of physiological or behavioral changes
that occur through synaptic plasticit y, altered genetic func-
tion, and other epigenetic processes . This occurs when the
human bod y is continuall y challenged by stressful events or
the use of drugs rather than through the normal homeostatic
process of small alterations in just a few bod y functions.
alpha alcoholism SeeJellinek , E. M.
alprazolam (Xanax®) A popular benzodiazepine used to relieve
anxiety.
alveoli Tiny sacs at the end of the bronchioles in the lungs ,
where inhaled air or vaporized drugs are transferred to the
blood via the capillaries.
altered state of consciousness A nonordinary state of percep-
tion that can be caused by psychoactive drugs.
Alzheimer 's disease The most widespread form of senile demen-
tia; an organic disease marked by the progressive deteriora-
tion of mental functions.
Amanita muscaria A hallucinogenic mushroom that is often
prepared in liquid form and drunk. Also called fly agaric.
American Indians Refers to indigenous people of North and
South America who predated the colonizing European set-
tlers of the fifteenth through nineteenth centuries (pre-
Columbian). The y are thought to have crossed over the
Bering Strait from Asia 10,000 to 20 ,000 years ago. Also
called Native Americans.
American Society of Addiction Medicine (ASAM) A societ y of
physicians dedicated to increasing access to and improving
the quality of addiction medicine.
Amethyst Initiative An organization comprising U.S. college
presidents and chancellors that in Jul y 2008 launched a
movement calling for the reconsideration of U.S. drinking-
age laws, particularly the minimum age of 21. According to
Greek and Roman legend, amethysts protected their owners
from drunkenness.
amine A nitrogen atomic group attached to a carbon molecule
(e .g., amino acids and amphetamines).
amino acid precursor loading A medical intervention technique
to ingest protein supplements and amino acids to build up
neurotransmitter supplies.
amino acids Organic nitrogen compounds that are the building
blocks of proteins; some serve as neurotransmitters .
amotivational syndrome A lack of desire to complete tasks or
to succeed ; sometimes attributed to the long-term effects of
marijuana .
amphetamine C6H5 CH 2 CH(NH 2) CH 3 ; a nervous system stimu-
lant that is closel y related in structure and action to ephed-
rine and other sympathomimetic amines.
amphetamines A class of powerful stimulants based on the
amphetamine molecule that was first synthesized in 1887
and manufactured in the 1930s; the word is also used to
describe various methamphetamines. Amphetamines are
prescribed for narcolepsy , ADHD , and , until the early 1970s ,
obesit y and depression .
Ample Misuse Prevention Study (AMPS) A prevention pro-
gram similar to DARE that consists of a four-session cur-
riculum for fifth- and sixth-graders; it also develops peer
resistance skills.
AMPS See Ample Misuse Prevention Study
 G.2 GLOSSARY
amygdala Part of the limbic system, the emotional center of
the brain, that coordinates the actions of the autonomic
and endocrine systems and is involved in regulating basic
emotions.
anabolic Anything that builds up the body (e.g., converting
protein from amino acids to help build muscles).
I
anabolic-androgenic steroid A steroid that builds muscles and
strength; pharmacologically similar to testosterone; it also
induces male sexual characteristics.
analeptic Any stimulant drug.
analgesic A painkiller that works by changing the perception of
the pain rather than truly deadening the nerves as an anes-
thetic would.
analogues See designer drugs
anandamide An abundant neurotransmitter with effects similar
to those of the THC in cannabis.
anaphylactic reaction A severe overreaction or even fatal shock
from the effects of a drug.
androstenedione A natural hormone found in all animals and
some plants. It is a metabolite of DHEA, a precursor of tes-
tosterone; used in sports to enhance recovery and muscle
growth from exercise.
androgenic Having a masculinizing effect.
anergia A total lack of energy and motivation often caused by
excess stimulant use.
anesthetic A substance that causes the loss of the ability to feel
pain or other sensory input (e.g., ether and halothane).
"angel dust" See phencyclidine
anhedonia The lack of the ability to feel pleasure, often caused
by overuse of cocaine or amphetamines.
anhydrous ammonia A toxic colorless gas used In agriculture as
a fertilizer and in industry as a refrigerant. it is a key ingre-
dient in the manufacture of Illegeal methamphetamine.
anorectic A person with the eating disorder anorexia nervosa; a
substance that reduces appetite.
anorexia nervosa An eating disorder marked by a refusal to eat
and a fear of maintaining a minimum normal weight.
anorexic See anorectic
Antabuse ® See disulfiram
antagonist A drug that blocks the normal transmission of mes-
sages between nerve cells by blocking the receptor sites that
would normally be attached to certain neurotransmitters.
anterograde amnesia Impairment of memory for events occur-
ring after the onset of amnesia; inability to form new memo-
ries; often caused by the use of drugs such as flunitrazepam
(Rohypnol ®), alcohol, or GHB.
antianxiety drug See anxiolytics
antibody An immunoglobulin molecule that recognizes and
attacks foreign substances in the body such as viruses and
bacteria.
anticholinergics A class of mild deliriant drugs found in certain
hallucinogenic plants (e.g., belladonna, henbane, mandrake,
and datura). The active substances (scopolamine, atropine,
and hyoscyamine) interfere with the action of acetylcholine,
causing psychedelic reactions.
antidepressants A series of psychiatric medications that are
used to treat depression mostly by boosting the levels of
serotonin in the brain (e.g., tricyclic antidepressants and
selective serotonin reuptake inhibitors such as fluoxetine
(Prozac ®) and sertraline (Zoloft ®).
antihistamines Any drug that stops the inflammatory actions of
histamines; used for congestion and allergies.
anti-inflammatories Any substance, such as cortisone, that
reduces inflammation.
antipriming The use of medications to modulate or blunt the
pleasurable reinforcing effects of psychoactive drugs.
antipsychotics Drugs, such as phenothiazines, that are used
to treat schizophrenia and other psychoses. Others include
haloperidol, clozapine, risperidone (Risperdal ®), quetiapine
fumarate (Seroquel ®), aripiprazole (Abilify®), and loxapine.
Also called neuroleptics.
antiretroviral therapy The use of antiretroviral drugs in combi-
nation with others to control the replication of HIV, the virus
responsible for AIDS.
antisocial personality disorder A mental disorder in which the
person disregards the rights and the feelings of others, feels
no remorse, needs instant gratification, cannot learn from
mistakes, cannot form personal relationships, and is often
involved in risk taking, drug abuse, pathological lying, and
criminality.
antitussives Any medication that relieves coughing, such as
hydrocodone and codeine.
anxiety A state of intense fear and apprehension; symptoms
include higher pulse, faster respiration, and excess sweating.
Long-term anxiety can increase one 's susceptibility to drug
use because some drugs (e.g., alcohol, heroin, and prescrip-
tion sedatives) can control the symptoms of anxiety.
anxiety disorders A series of mental disorders marked by exces-
sive anxiety, fear, worry, and avoidance, including panic
attacks, panic disorder, agoraphobia, obsessive-compulsive
disorder, post-traumatic stress disorder, and generalized
anxiety disorder.
anxiolytics Drugs that are prescribed to treat anxiety disorders,
including benzodiazepines, barbiturates, buspirone, and the
Z-hypnotics such as Ambien ®and Lyrica.®
AOD Acronym for alcohol and other drugs; an acronym used in
the drug-abuse prevention field.
aphrodisiac A substance, such as sildenafil citrate (Viagra®),
that increases sexual desire and/or performance .
apoptosis Programmed cell death identified by an orderly series
of biochemical events that often occur with drug use.
aqua vitae A medieval name for distilled liquor-literally
"water of life"-when alcohol was thought to have unique
medicinal and rejuvenation properties.
ARBD See alcohol-related birth defects
ARND See alcohol-related neurodevelopmental disorder
arrhythmia Irregularity of heartbeat (loss of rhythm) that can
be lethal; often caused by drug use.
ARRRT Acronym for acceptance, reduction of stimuli, reassur-
ance, rest, and talk-down-steps for treatment of a bad psy-
chedelic experience.
ASAM See American Society of Addiction Medicine
ASAM PPC-2R A screening test for co-occurring disorders, ado-
lescent criteria, and residential levels of care. It evaluates six
dimensions of problem areas and illness severity to match
patients to four levels of care.
ASI See Addiction Severity Index
asthma medications A series of respiratory medications that
include anti-inflammatory agents, decongestants, and bron-
chodilators to control asthma. Their use is restricted in
sports competitions, but medical use is allowed.
astrocytes Star-shaped glial cells in the brain that support sur-
rounding neurons.
ataxia Inability to coordinate muscular activity, often caused by
brain disorders or drug use.
atherosclerosis Fat and plaque deposits on the lining of blood
vessels caused by high blood pressure, stress, smoking, and
cocaine or methamphetamine use. It is often the cause of
heart attacks, heart failure, and heart disease. Also called
hardening of the arteries.
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toproduc,mor,o, \,.,o''»tnturotr>n<m· tt., shopping,and«xu.a l behavior,l nt<rn<ladd iction<(ga.m<<,
av,rsion th, rapyA!omioftherapylhatinfl ict<pain••th , g,rnbling,andpomogr,iphy), and<at ingdi<ord<r<
, 'i ntu«s><11bstancetoeocoor, 0
abst'ntoce(e.1,,som, behavio ral tol,rar,c, u., of part> of th, br>in tha t >r< not
•moking-« ... tionprogram>gi,·eclientsan,Lectric,hock : i~-;;r,.1;1'.~dru g tooornpensat<fortheorherpansofthe
wh,nth,y,mok<)
axonPanolth , ne"''""llthatroOOuctsth , impul«•wayfrom belwlonuA hallucinogtnicpLantwhoseocti,·eingrulien1<
lh<«llbodytothet<rmin>ls:th,ycanbe~to~crn tim<• (hyo,cy amin, , atropine, •nd scopobmin<) cau« intoxi•
«rslong cation, hallucina tion,, and drugged ,lup. Also alltd
oya!tUd>lo A hallucinogenic -,.g, br<w,d from the niglu,Mde
Bani<t<""P'i<canpibushbyth eP,ruvianCham..al nd Lan, ben:odW<pir><•Agroupolminortr • "'luihurs,,u ch .. don •
ll<pam(Klonop in"l•nd•lp ruoLam (Xarwr" ),lhatcalm
azl:::;mu:i~~:::::i::~i= .~~li~ibi to, m<di• anxiny,r<laxmusdes, aOOindu«,l<<p
AZT Sttoz:idOl!tymidinr ,zNl "' "Udi11< benffluryAph,ythy lamin,drug thathasstrongentxtogrn ic
(psych«klic )dfect> similar to the <ff«l< ofEc.,..y (MD',1,1)
ltcan•nd anprod ue<c>rdiovascuLarprob l<m>ilt h<u«r,
bodygetso,·<rh,,u,dor ifta krnr<putedly.
BACS.,bloodalrol>oloon« ntnt lon benu,yl,qonin<O...,oftheme tabolit<,ofcocai "' thatcanb,
11><
:t.:n':""'angodofwinr:,..,,,.,oiony,us,th<Grttkgod loundinth,urin,longaf tercoc•inri>nolongapr=tin
thebody.
~::~;i";C:" or dang,rou, panic ruction to • P'Y·
beta>looholi>mSttjelllndt,E.M
betablock<r, A c~,oldrug, that calmthebody~h<>nratt
"bagging"Pllu inganinhab.m,mch"'rnod< l •irpb.n,glu,,in• re,piration,andt<n<ionbyblocking<pin<phrin<(>dr<n.a·
li8<)attheh<art>nd inthebnin;olt<nu«dtorontro l panic
bal=i~;':! "::1.i::i.::~~:~~":"~n amount of heroin ,old attocks:us<dill,g,lly insportsmch as rill<ry,diving,and
onthe<trtttthotcanbeswa:tlowrotoavoidd<t<ctloni[th, an::h,ry.
d<•l<r !s•rtt•t< dand -canberetr><v, d aft<ru<r< tion. bet<lnutAnutlromth ear<capal rntr«that isc hewedbylOO
"balloon,andcnc
d,·
k<rs"Th<u«of
topunctur<>canofn·trou
a pinororhercra cking
· ',ororher ·nhalant·
;;;~1;:' prop l<, particularly in Asia, for its mild stimulant

blt<111gAnlndLannam<lorth,l,a,·esandthe<1em,o!C"""'1bu
:o~=i: t1:.
'::: 1:: !~~=i~~~:/m, • nd the ,,.pors (m.ariju.ana)plants;it isamildfonnofm..ariju.anatha1canb,
Nlb itura t«Ac ~,o l«dalive •h)'pnoticdrug,deriv<dfrom pr<par<dforsmoking,drinlting,oringeslion
th<barbituric>Cidmol<ru l<( , .g., phmob>rbital,boitalbit>l, BigBookT h,m..ainbooko!Akohol ic,iAnonymous; itoont.ains
and« coborbit.al(S<oona!0 ) thephilosophyofMandautobiographic>l,tori«o l r<oo••
NWg,ngl LaAgroupofne urons >tth eba,,ofthectr<bralh<mi • <ring•looholic<:u«d ut <n<ivelyinMme<lings.
bindi "ll:sit,.Sttr< «ptorsit«
i-?~=;t~ i:~i;.:n:~u;:.~~\~~-=-':'~e in "bindle "Apiec,ofpaperfoldedlik<•minLatur,envelop,to

:=t;:1~1:"'~:.rik~,
~=:r~.:-1~:C.~,hydrod tlo-
hold•small•rnountof
binge U,ingbrg,amounl<oi>drug
a drug,,u cb .. 1gramolcoain,
in•shonperiodol tim<
NSing The proc,ss of transforming oocaint hydrochloridt (<.g.,ooca intbing<). ltcan>loor<f<rto>behaviora l addic•
~':,o>isn':"':.:r' coc>in, frttba« •nd the practice of smoking lion(,.1,,•g,mblingor<>1ingbing<)
bingedrinkin gDrinking larg<•mountsolalool>o l ato...,,;,.
"basuoo"Abrowni<hpu ttylik<inttrm«li>«productofcoain , ling:>rtiOCLallyd<fined .. fi,·eormor,drinkslorm<nand
re!in,men tth ucanbe<molt<d(uwallyincig,rrt tes):popu· lourormor<drinksforwomeninonedrinking«><ion
b.r incoca •growing countri es bingo..wingdi>«d<rR<runing<pioodesolbinge,atingwith •
bath,.[,.(p,yc~ivebathult ) > ru«u«d tol,g,llym..ar- <Hit r<SOrting"' vomiting orothtr methods.- by th,
k<tnewsynlh<tic<t imub.n«on th, in «m<tor ln •h,a,J buhmkor•noltcticto>voidg,iningwright
•hoJ>5"no tabl,forprominent lydi<pbying"notforhuman bioo.,,.i bblli tyTh<degr,e tow hichadrugb<oomes••aib bl< to
consurnp<ion labelson thepacUfling . Some olth=stirnu• hetarg, tt' , ·~ac1m · U , · n_
b.n1<havebe<nfour>dto beupto trntimesmor<pottnt biorransformatlon Metabolictran<form.ationofdrugsthatrn ta
thancoc>i...,c>using«im =,he artproblrn,s ,highbody thebloodstr<am;th,yar<calledm<tabolit<,
 G.4 GLOSSARY
Biphetamine ®A trade name for a capsule containing two forms
of amphetamines, used mostly in the 1950s, 1960s, and
1970s.
bipolar affective disorder A mental illness characterized by
mood swings between excessive elation and severe depres-
sion with some periods of normal behavior. Also called
I
manic depression.
"black tar" heroin A black or brown form of heroin produced in
Mexico. It varies from hard to sticky, has 20% to 80% purity,
and is water-soluble. It is more popular on the West Coast of
the United States than on the East Coast.
blackout Loss of awareness and recall without unconsciousness
due to intoxication by alcohol or other drugs (amnesia while
under the influence of drugs).
blood alcohol concentration (BAC) The concentration of alco-
hol in the blood; used legally to identify drunk drivers (e.g.,
8 parts alcohol per 10,000 parts blood equals a BAC of 0.08,
which is the legal limit in all states). Most countries have a
lower legal BAC for drivers .
blood-brain barrier Tightly sealed cells lining the blood vessel
walls in the brain; prevents most toxins, bacteria, and patho-
gens from reaching the brain. Psychoactive drugs breach this
barrier.
blood-cerebral spinal fluid barrier Helps prevent unwanted
substances from entering the areas of the central nervous
system where this fluid flows (subarachnoid space, ventri-
cles, and spinal cord).
blood doping Transfusing extra blood before an endurance
sporting event to increase the oxygen-carrying capacity of
the circulatory system.
"blotter acid" A form of LSD; a drop of the drug is absorbed on
a small piece of blotter paper and swallowed or placed on the
tongue and absorbed .
"blow" Street name for cocaine hydrochloride powder that is
snorted.
"blunt" A cigar that has been hollowed out and packed with
marijuana so it can be smoked inconspicuously in public;
also known as a "swisher.,,
bock beer A stronger, darker, and sweeter variety of lager that
has a shelf life of six weeks; a seasonal beer made from the
residue in vats; traditionally ready for consumption with the
coming of spring.
"body packer" A smuggler who swallows balloons or condoms
usually filled with heroin or cocaine and then defecates the
drugs after clearing customs.
boilermaker An alcohol drink consisting of a beer mixed with a
shot of whiskey, vodka, or tequila. The full shot glass is often
dropped into the beer mug.
"bong" A water pipe used to smoke marijuana. The smoke is
cooled and made less harsh as it passes through the water.
borderline personality disorder (BPD) An Axis II mental ill-
ness characterized by sharp shifts in mood, impulsivity
(often self-destructive), anger, alienation, and unstable self-
image; BPD patients are often drawn to drug use and are very
difficult to treat.
BPD See borderline personality disorder
brain-imaging techniques Methods of making images of the
brain and brain functions without dissection or death.
Techniques include CAT, PET, SPECT, MRI, fMRI, and beta
scans.
brainstem Located at the top of the spinal cord and contains
the medulla and reticular formation. This section of the
hindbrain is the sensory switchboard for the mind. It is often
affected by hallucinogens.
brand name See trade name
breathalyzer A machine that can measure blood alcohol con-
centration by analyzing the exhaled breath of a drinker.
bromide Hydrogen bromide salts formerly used (before bar-
biturates) as sedatives, hypnotics (sleeping pills), and
anticonvulsants.
bromocriptine Medication that increases dopamine in the brain;
helps initial detoxification from cocaine or amphetamines.
bromo-dragonFLY (BDF) A recently synthesized hallucino-
genic drug related to the phenethylamine family. Its effects
are similar to mescaline but are much longer acting, some-
times for days.
brownout Similar to an alcohol blackout except the drinker has
partial recall of events.
bruxism Clenching of the teeth that can be caused by stimu-
lants, particularly methamphetamine and MOMA.
Buerger's disease Circulatory disease that can be caused by
smoking; it can result in amputation of a limb.
buccal Having to do with the cheek; absorption site for several
drugs that are used orally (e.g., chewing tobacco and coca
leaD.
bufotenine A hallucinogenic substance found in the skin secre-
tions of several toads and in some plants. Also called toad
secretion.
bulimia nervosa An eating disorder characterized by binge
eating followed by weight-control techniques that include
self-induced vomiting, excessive exercise, laxatives, and
starvation.
buprenorphine A drug that can help block both withdrawal
symptoms and the effects of heroin; it is useful in detoxifica-
tion and maintenance programs; it can be prescribed in a
doctor's office, not just in a drug clinic.
bupropion (Zyban ®) An antidepressant that raises the levels
of norepinephrine and dopamine to reduce craving; used in
smoking-cessation programs.
buspirone (BuSpar®) An antianxiety drug that was created to
avoid parts of the brain that can lead to addiction.
buspironebutanol (butyl alcohol) A synthetic alcohol used in
many industrial processes.
butane hash oil (BHO) also known as honey oil, budder, dabs,
shatter, wax An extract of cannabis using butane or other
chemicals to create an extract of THC approaching 100%
concentration. This extracted can also be vaporized in an
e-cigarette which is known as dabbing.
"button" The round top of a peyote cactus that is harvested
because of its psychoactive ingredient mescaline.
butyl nitrite An inhalant that causes a brief rush by dilating
blood vessels in the heart and the head, followed by dizzi-
ness, headaches, and giddiness.
C
C-boom Also known as 25 C or 25 I NBOMe a psycho stimulant
of the phenethylamine variety that is a hallucinogen with sero-
tonergic receptor activation.
caffeine A stimulant alkaloid of the chemical class called xan-
thines, found in coffee, tea, chocolate, and colas.
caffeinism Intoxication due to caffeine use, characterized by
restlessness, insomnia, nervousness, diuresis (increased
excretion of urine), and gastrointestinal problems.
CAGE Questionnaire A four-question test for problem drinking
used frequently in medical settings. CAGE is an acronym for
cut down, annoyed, guilty, and eye-opener.
CALDATA See California Alcohol and Drug Treatment
Assessment
California Alcohol and Drug Treatment Assessment
(CALDATA) The most comprehensive study of treatment
 d!ectiV<n=conductedinC•lifomoa;it<hov.·edthateach c,r,bnl hemi>ph<n• Th< two hah·es of the e<rebrum that
Slspm1intreatrnenl .. v«>tl<.,tS7 inredue«lrosl<( <.~. m.ak, upth<e<rebralcort<xmdtheba<a l ganglia. E><hh.all
r~~of inancuation , miss«lwork,•ndburgbri«) cornrolsthes,nsocyinputandth,rnotorfunctionsolthe
oppo<iteh.alfoflh<body.
eAMPS«cydicadenosinernooophosph.ot< c,r,brumTh,larg<stpartolth,brain:consi<tsofth,cmbral
CAMPS«C:unp,aignAjainstMariju:uu.Pbnting
C..mp,a;gn Ajainst Marijuana Pbnting (CAMP) A multi • =~x~!';,1' ..~~';,;~':' ~heth~h=ofwJ;!~;:i:t<• that oon•
jurtidictional b wrnforcementcampaigntoS<>rch<Hltand dl4ra,lndianwonllorther<>inoltheC..nnabu(m.ari ju.ana)
destroyi llegalmarijuanafield,andplant<;itsimplernenta • planttha1i,mad< intohashi>h
,·on· 1>,·ngres· l«lbysom,count' <. ch2singContinuingtogambletor<oouppreviou<loss,,;tak es
C4n..,l,i1Th , botania lg<nusolallpbnt<thatrontainm.ari • plac,duringthelo>ingph.as,thatmostoftenocru,.with
j uanaorhemp . C.illdi<Acontain,themo<tTHC (psychox • problem andcompulsivega.mbl,,.;th , fourpha>esmwin •
liveingred ient)olallth<<p<ci es;a,hon<hrub.C.noJ<rali, ning,lo>ing,de<p<ration,andgivingup
~ • lowTHCcontmt . C.>oi!i,·ai,th , mostcommon<p< • "ch .. ing thedrago n"He atinghuoinonapi<e<ofrneta lloi l
:;.,';.';'";t!';t~!!'t:ilhernpfiberrontentorTHCrontrnt: andinhalingthe,mok<through•straw.
chemicol depmd<ncy (CD) Ph)~ia. l and/or psychological
e2nnabidiol(CBD)Acann.abinoidwithm<dicinalmdnonpsy • !i;;";;:'.,;:"'onone or more psychoactive drugo.A!ws«
chNctiveproperlies
cannabinoidsAnyofthepsychNC!ivechemic>lsfoundin chemoth<npyU«olmrdi< ationsorchemicalstorontroldi<-
CanMhi>p lants, includ ingTHC,lh<m.a jorpsychNC!ive u«,u<11allycancer
ingredi , rn,cmn.abino l,anda.nnabidio l chewingtobacooT~l< ,se,thaiar<proc<ss«ltobe
cannabinol(C6:S)Aoon-psychoact iv,cannabinoidloundin ch,wrd , allowingtheni.cotin<•bdmjui.cetobeaboorbedby
lh<CofflMb<,plant;it l<anoxidationproduc t ofTHC apillaryb loodve<><lsinth,mou th,mootlyinth , gums
capilbcy The tiniest blood ,.....,1 in thecinculatocy>ystern: "chillum"Aoon , ..it.podclay,wood , orstonepipeus,dto
aboorb,drug,frornthemouth,gums,in t..i inal wall,oos,, smok<bliang.g,rnj4,or,oarn, (V>riousparuofaC4lWll,;.,
lung, , andotherpo int<ofron<Xt plant);wid , lyU«dinlndia
carbohydn t,.Th , most abundmtbiolo pca lmo leculesandt he "Chin.owhi t<" (l)R<fin,dmdun ... uallypureh,roinlrorn
mainpbn1mergysourc<lor anim.als andhum.an, ; refined South< .. , Asia, mostly from th, Golden Triangle. (2)
carbohy<lrat<<>ctlik,apsychoactivedruginfoododdicts 5yntheticheroin(,. ~ .• lpha•methylfentanyl)
andoompuk overeatus "chlpp<r"On e whou«,drugs , ,ucha,heroin.o«a>ion.ally;
carbonrnoooxid<Apol<onou,g.asthati<on,olth , ioxic oftenapplicdto a spond ic heroinu.,-,
byproductsofsmokingtobacro.ltschemi a lsymbol i,CO "ch·va• 5pan·h,trttln.am,'. Y e · antarhero ·n
inst<adolthenontoxicCO , (carbondioxide)thatw<breat he chWl\y<li.aThe"'°'trommons,xuallytnnsmiueddis,..,in
and,xhale,vecyday. theUnited5tllt,s:thepr<S<nceoltheinlectioni<m.arlt<dby
carcinog,n Any,uhstanc,orpathog<ntha1cancaus,cmcer •fluiddi>charg,lromthegenitalsorrectum
cardiomyopathyAgmera l diagnostict<nnfor a primarynonin • chlonlhydrat<AdruguS<dalterthemid •il!OO,a, •>«l.at iv,,
llammatorydi>u«ofthehea:rtm""'le;mmlarged,llabby, anmtironvulsant, and•hypnoti.c:med ina "Mickey" to
and inefficim1 heart olt<n caus,d by exc,.,iv,, chronic knockootandsh.angha i sail=
drinking cholinergic P<rtainingto recep<orsit esm dothernruronal
cardio'l-'aorubrRe b lingtoh<.art andbloodv,.., J,(,. ~ .thecar- structu=im·oh·edinlh<,ynthesi<,production,<torag<
diovasrubr , ystem) andfuoctionolth,neurotran>mitt er xetykholine
at<choWl\in,Aclas,ofneurotransmiU<r>th.atar<panicularly chrom.otographyDrug •l<>tingprocess:p,chromatography
affected by p<)tloactive drug,, especiallystimubnl< (, .~. andthinlayachrom atography areth,mainU«>
<pinephrine,noltpin,phri..,,anddopami"")
athinon<Theact ive,tirnulant• lbloidingn,dirnt , alongwith ch'::n~ ~::'!i:.'T~n~~~~";i ~6°:h:::-:..::.:;:
caihin , ,inthep b mst imulan1khat 2lpa irs)inonee<llrontainsmoreth.an !,OOOg=(our
CBJ,CBlmariju.,...rtt<pto,.Twoolth,m.ajorcann.abinoid gen, ticcod , )
receptors affected by arumdamid ,, th, body'> own THC, "chronic"(!) 5b ngformarijuan.a. (2) Pot<ntmarijuan.a.(J)
andbyTHCit«II . CB2ru:<ptors s« mtoh<limil«ltoth e Cracksmok<dwith • marijuan.acigar<lt<
imrnun<<)'St<mandafewother <it«,whe=•CBlreceptor< chroni.cobotructi-,Jungdi>us,(CO PD) Progr<.,i,·ed,g<n •
CB~r<~oo.:,i;b7,::1yinthebmn. erationolth eai r,a cs inthelungs(<.g .,emphyS<m.1and
chronicbronch i1i>);olt<ne>U«dby,moltingtobaccoor
CDS«cb<mlcald<p,nd<ncy tobacco andm,rijuana
CDi•«llAnimmu..,e<ll,<11cha, a lpnphOC)1<,thati slound tirm<>Si,As,riou<progressiveliverd is,as,that,a,.the liv,r,
in th e bloodmdh,lpsregulat<imrnun , functions . Also oft<n a U«dbyh ,a vychronic aloohol abus, .. w,U .. by
call«IT •O<lp,rull hepatili>BmdC
cell phon,addict1on0ne olth, new electronic addictions, dona,e~(Klonopin ' )Apopubrbenrodi.aupine>«l.at iv,
spun,:byth,ggrowtholsm.anphone,whichoouldloclud, ~;:1~:i:;~1;:""' m.aint<nane<us, it to incre.., the high

e<ntnl1,erv<H1<>y<t<m(C:SS)Thebrainmdthe,pin.alrord donldin< Anti•hyp<rt<n<iv< medication uS<d to help block

e<1<b<llurnTh<larg<partof th,hindb raintha1alf<ctsmotor withd rawal,ymptomsfromh,ro in,•kohol,>«l.atives,and
ystem,,ooonJ ·n•t' noln,o ornt, >ndmuscl< ton<
cerrbr:alrort<xTh , outerparto l thenewbrain(cerebrum)that dubdrupDrug,U«daimusicparli« , oltencalledm·es , that
enfolds the old brain. Thegraymait<ri> l to~millimet< ,. ~:c~d< J.lDMA (ocsta<y) , k<urnine, GHB, GBL., md nitrous
thick.lt=son, , lhinl<s, proc<>S<<S<It>O')'input,a ndiniti •
atesvoluntacymovement. C1'SS««ntralner,,,u,,ystem
 G.6 GLOSSARY
co-occurring disorders The simultaneous occurrence of an
interrelated mental disorder and a substance use disorder;
also called dual diagnosis.
coca (Erythroxylum coca) The leaves of this shrub contain 0.5%
to 1.5% cocaine and are chewed for a mild stimulation; 95%
of all coca is grown in South America, chiefly in Colombia,
I
Peru, and Bolivia.
coca paste The first extract of the refinement process that con-
verts coca leaf to cocaine; often smoked (mostly in South
America); often contains sulfuric acid and other toxic
impurities.
cocada A wad of coca leaves and soda lime formed into a ball for
chewing by natives of the Andes Mountains.
cocaethylene A toxic metabolite of cocaine formed by the use
of alcohol and cocaine; causes more-severe cardiovascular
effects and often more anger than cocaine alone.
cocaine The active ingredient of the coca bush; this alkaloid,
first extracted by Albert Niemann in 1859, is a powerful,
fast-acting stimulant.
cocaine freebase A smokable form of cocaine made by releasing
the hydrochloride molecule from cocaine hydrochloride; has
a lower vaporization point than snorting cocaine.
cocaine hydrochloride The refined extract from the coca bush.
This white powder is used as a topical anesthetic for surgery
and misused by addicts for snorting or injecting .
cocaine psychosis A drug-induced mental illness; symptoms
include extreme paranoia and hallucinations; similar to
methamphetamine psychosis.
codeine An extract of opium discovered in 1832. Between
0.5% and 2.5% of opium is codeine. This opiate analgesic is
used to control mild pain, coughs, and diarrhea. Also called
methyl morphine.
codependency "A pattern of painful dependence on another
person's compulsive behaviors and on approval from oth-
ers in an attempt to find safety, self-worth, and identity"
(Scottsdale definition) . Codependents judge their self-worth
by relying on others' opinions of them, so they try too hard
to please, have low self-esteem, are very impulsive, and are
in denial.
cognition Accurate appraisal of one's surroundings through per-
ceiving, thinking, and remembering; often disrupted during
drug use, detoxification, and initial abstinence .
"cold turkey" Detoxification from a drug, such as heroin, with-
out the use of lower medications to ease the withdrawal
symptoms.
coke Street name for cocaine.
"coke bugs" Imaginary insects that a long-term cocaine abuser
thinks are crawling under the skin; they often cause abusers
to scratch themselves bloody. This is known as formication.
collapsed vein A blood vessel that collapses on itself due to
repeated injections or other traumas. Injection drug users
will end up using almost every vessel in their body.
comorbidity See dual diagnosis
competency-building program Training in self-esteem, in
socially acceptable behavior, and in decision-making, self-
assertion, problem-solving, and vocational skills .
compulsion An uncontrolled need to perform certain acts, often
repetitively, to forget painful thoughts or unacceptable ideas
(e .g., obsessive-compulsive disorder).
compulsive behaviors These include compulsive gambling,
anorexia, bulimia, overeating, sexual addiction, compulsive
shopping, and codependency. Drug addiction is also a com-
pulsive behavior.
compulsive gambling A progressive impulse-control disorder
characterized by: a preoccupation with and a compulsion
to bet increasing amounts of money on games of chance;
continued gambling despite financial, work-related, and rela-
tionship problems; compulsion to chase losses; use of illegal
acts or lying to get money with which to bet; and extreme
denial that there is a problem. Compulsive gambling is often
divided into problem gambling and the severest form, patho-
logical gambling.
computer games addiction Compulsion to play games both
online and through stand-alone systems.
computer relationship addiction Excessive searching through
the Internet for relationships that can lead to cyber affairs.
Concerta ® See methylphenidate
confabulation Repetition of false memories.
confrontation A counseling technique used individually or in
a group that challenges a client's denial. This technique is
crucial in treatment because most addicts are reluctant or
afraid to change .
congeners (1) A chemical relative of another drug. (2)
By-products of fermentation (organic alcohols and salts) that
add flavor and bite to alcoholic beverages .
congenital abnormalities Birth defects in a newborn infant.
contact high (1) A nondrugged person emotionally experienc-
ing a druglike experience from being around or in contact
with drug users. (2) Getting high from skin absorption of a
drug such as 1.5D. (3) Actually inhaling enough drugs (mari-
juana, cocaine, or heroin) to be affected by being in an envi-
ronment where other people are smoking drugs.
controlled drinking A very controversial harm reduction tech-
nique that permits some drinking rather than abstinence as a
way to limit alcohol abuse.
controlled drugs Psychoactive substances that are strictly regu-
lated (scheduled) according to the Controlled Substances Act
of 1970; Schedule I includes cocaine, heroin, and marijuana.
Controlled Substances Act of 1970 The comprehensive drug
control law passed to reduce the growing availability and use
of psychoactive drugs in the United States .
convulsions Involuntary muscle spasms, often severe, that can
be caused by stimulant overdose or by depressant withdrawal.
COPD See chronic obstructive lung disease
coronary arteries Arteries that directly supply the heart with
blood; blocked coronary arteries are often the cause of heart
attacks.
corpus callosum The group of nerve fibers that connects the
two cerebral hemispheres of the cerebrum.
cortex The outer part of an organ (e.g., cerebral cortex, the
outer part of the brain).
corticosteroids A class of drugs related to cortisol, a hormone
normally produced by the body; helps control allergic reac-
tions; relieves inflammation and pain; and can create a sense
of physical well-being. Different from anabolic steroids.
corticotropin A neurotransmitter involved in the immune sys-
tem, healing, and stress.
cortisone A steroid-like metabolite of hydrocortisone, a com-
pound that reduces inflammation.
cotton fever A blood poisoning or infection caused by inject-
ing cotton fibers, pyrogens, or bacteria when using heroin,
cocaine, or amphetamines intravenously. Symptoms include
chills and fever.
counter -transference When a therapist or counselor lets per-
sonal feelings influence how he or she treats a client.
crack Slang for cocaine that is made into smokable form by
transforming cocaine hydrochloride to freebase cocaine
using baking soda, heat, and water.
"crank" Street name for methamphetamine sulfate but often
applied to any methamphetamine.
crash The comedown from a high (usually a stimulant high) in
which energy is depleted by the drug (e.g., methamphetamine

or cocaine), causing the user to stay awake for days.
Depression, anergia, and anhedonia are common.
craving The powerful desire to use a psychoactive drug or
engage in a compulsive behavior. It is mani fested in physi-
ological changes such as sweating, anxiety, raised heart rate,
a drop in body temperature, pupil dilation, and stomach
muscle movements.
creatine A nutritional supp lement; this compound is synthe-
sized in the body from amino acids or extracted from fish
and meat; helps muscle energy metabolism, allowing some-
one who is working out to recover faster.
critical dose A threshold level of drinking and drug use below
wh ich most neurobehaviora l effects are not seen.
cross-dependence Occurs when an individual becomes
addicted or tissue-dependent on one drug, resulting in bio-
chemical and cellular changes that suppor t an addiction to
other drugs.
cross-tolerance The development of tolerance to other drugs
by the continued exposu re to a similar drug (e.g., tolerance
to heroin translates to tolerance to morphine, alcohol, and
barbiturates) .
"crysta l" Used mostly to denote other amphetamines particu-
larly dextromethamphetamine ("ice"), a smokab le form of
methamphetamine.
cue extinction See desens itizat ion
cybersexual addiction Excessive use of online pornography
or sex-related chat rooms to set up virtual or real sexual
relationships.
cyclic adenosine monophosphate (cAMP) A neurotransmitter
involved in the development of opioid tolerance and tissue
dependence .
cycling Alternating use of different steroids over set periods of
time to minimize side effects and maximize desired strength-
and muscle-enhancing effects.
cystic acne An inflammation of oil glands in the skin, character-
ized by eruptions and scarring; often caused by prolonged
use of anabolic-androgenic steroids.
cytokines Neurochemicals that transmit messages between cells
in the immune system; they can kill neurons.
D symptoms. (2) Psychological need for a psychoact ive drug to
dabs An extraction product of cannabis with 90% plus of THC.
It is also called budder, butane hash oil, honey oil, shatter
or wax.
DARE See Drug Abuse Resistance Education
date rape Sexual assault by a date rather than by a stranger . This
and acquaintance rape are the most common types of rape.
date-rape drug Drugs like flunitrazepam (Rohypnol ®), a strong
sedative-hypnotic that can induce amnesia, and GHB are
slipped into a drink so that a date can be assaulted while in
a stupor and not remember what happened . It is banned in
the United States.
DATOS See Drug Abuse Treatment Outcome Study
datura Hallucinogenic plant used throughout history; it con-
tains the alkaloids hyoscyamine and scopolamine and dis-
rupts the action of acetylcholine .
DAWN See Drug Abuse Warning Network
DEA See Drug Enforcement Administration
decriminalization Eliminating crimina l penalt ies for drug pos-
session or use and replacing them with fines or other civil
penalties.
dehydration A deficiency of water in the body that can be aggra-
vated by some drugs (e.g., GHB, creatine, MOMA, and meth-
amphetamine), part icularly when exercising or dancing.
GLOSSARY G.7
dehydroepiandrosterone (DHEA) A hormone supplement used
by some ath letes to try to increase testosterone levels.
delirium tremens (DTs) Severe withdrawal symptoms from
high-dose chronic alcohol use; symptoms include visual and
auditory hallucinations, trembling, and convulsions; some-
times results in death.
I
deliriants Drugs that cause hallucinations, delusions, and
confusion (e.g., ketamine, nutmeg , datura, belladonna, and
deadly nightshade) .
delta-9 tetrahydrocannabino l The main active ingredient in
marijuana; also called THC.
delta alcoholism SeeJellinek, E. M.
delusion A mistaken idea that is not swayed by reason, often
involving the senses.
demand reduction A strategy to reduce drug use by lessening
people's desire to begin use through prevention, treatment,
and education.
dementia Intellectual impairment found in some older people,
often in those with Alzheimer 's disease; includes loss of
memory and abstract thinking, personality changes, and
impaired social skills.
Demero l®See meperidine
dendrites Tiny fibers that branch out from nerve cells to receive
messages from other nerve cells. Many drugs act on the ends
of the dendrites and affect this message transmission.
dendritic spines Solid bits of protein grown on nerve cells, usu-
ally dendrites, that are a person's memories. It might take
more than 1,000 individual dendrites to make a single sim-
ple memory. There are trillions of dendritic spines in each
person 's brain.
denial The inability or unwillingness to perceive one 's depen-
dence on a drug or a behavior; a defense mechanism mani-
fested by drug abusers and addicts.
deoxyribonucleic acid (DNA) An organic substance found in
the chromosomes of all living cells that stores and replicates
hereditary information. The other type of nucleic acid is
ribonucleic acid (RNA).
dependence (1) Physiological adaptation to a psychoactive
drug to the point where abstinence triggers withdrawal
symptoms and readministration of the drug relieves those
induce desired effects or avoid negative emot ions or feelings.
(3) Reliance on a substance (or a compulsive behavior).
depersonalization A mental state in which there is a loss of the
feeling of reality or of one's self; can be caused by several
psychoactive drugs, particularly hallucinogens.
depressants Psychoactive drugs, such as alcohol, sedative-
hypnotics, opiates, and muscle relaxants, that decrease
the actions in the brain resulting in depressed respiration,
heart rate, muscle strength, and other functions. Also called
downers.
depression A psychological mood disorder characterized by
such symptoms as depressed mood, feelings of hopelessness,
sleep disturbances, and even suicidal thoughts.
depressive symptoms Feelings of sadness caused by grief,
medical conditions, or reactions to stress; they are usually
short-lived compared to depressive disorders, which can last
for months or years.
desensitization A therapy technique that first exposes drug
addicts to drug cues and drug-using situations that increase
craving and then desensitizes them through education, bio-
feedback, or talk-down. Also called cue extinction.
designer drugs Drugs formulated by street chemists that are
similar to controlled drugs. There are designer amphetamines
that act partly like psychedelics (e.g., MOMA and MDA) and
designer heroin (e.g., MPPP); also called analogues.
 G.8 GLOSSARY
detection period The time frame after using a drug in which the
substance can be detected by drug testing .
detoxification A drug therapy technique for eliminating a
drug from the body. It can take a few hours to two weeks or
more depending on the type of drug and the length of use.
Detoxification can also be done without medications. It is
I
the first step in most treatment protocols for addiction.
developmental arrest The slowing or stopping of emotional
developmen t in a drug user, an abused chi ld, or a child with
othe r psychological prob lems.
dextroamphetamine A strong amphetamine stimu lant sold as
Dexedrine ®and Eskatro l.®
dextromethamphe tamine Smokable methamphetamine. Also
called "crystal," "glass," "ice," and "shabu."
dextromethorphan (DXM) A nonprescription opioid cough
suppressant found in more than 140 medications; very high
doses can cause psychede lic effects.
developmental disorders Mental disorders, such as mental
retarda tion and ADHD, first diagnosed in childhood.
DHEA See dehydroepiandrosterone
diac etylmorphine Chemical name for heroin. See heroin.
Diagnostic and Statistical Manual of Mental Disorders (DSM-
N-TR) A publication of th e American Psychiatric Associa tion
that classifies mental illnesses.
diathesis-stress theory of addiction A theory that says a predis-
position to addiction caused by hereditary and environmen-
tal factors such as stress is triggered and later aggravated by
excessive drug use or acting ou t a behavioral addiction.
diazepam (Valium ®) The mos t popular benzodiazepine of the
1960s, 1970s, and 1980s. Itisclassifiedasasedative-hypnotic.
diencephalon An area of th e brain located benea th the cerebral
cortex consisting of the thalamus and the hypothalamus.
diet pills Any substance that reduces appetite; most often
amphetamine congeners, such as dexfenfluramine (Redux ®)
and fenfluram ine (Pondimin ®), or methamphetam ine hydro-
chloride (Desoxyn ®).
diffu sion The tendency of drug molecules to spread from an
area of high concentration to an area of low concentration
once inside the body.
diffu sion tensor imaging See DTI
dilu ent Usually a ph armacologically inactive substance used to
dilut e or bind together potent drug substances. Street drugs
can contain active diluents such as quinine and aspirin.
dimethyl sulfoxide (DMSO) A liquid that is easily absorbed
through the skin and often used to transport other drugs,
such as steroids, through the skin.
dimethyltryptamine (DMT) A short-acting hallucinogenic drug
found in several plants (yopo beans and epena) as well as
in the skin secretions of some frogs; also synthesized in the
laboratory as a white, yellow, or brown powder. Also called
businessman'.'> special because of its short duration of action .
"dirty basing" A process of making smokab le (freebase) cocaine
using baking soda alone, without ether, resulting in a prod-
uct that con tains many diluents and impurities.
dis ease concept This model maintains that add iction is a
chronic, progressive, relapsing, incurable, and potentially
fatal cond ition that is mostly a consequence of genetic irreg-
ularities in brain chemistry. The addiction is set in motion by
drug use in a suscepti ble host in an environment conduc ive
to drug misuse. Loss of control and compuls ive use quickly
follow.
disinhibition The loss of inhibitions that con trol behavior, mak-
ing the person more likely to perform formerly unthinkable
or difficult actions (e.g., drinking alcohol makes a person
more likely to overcome shyness and talk to others).
dispo sitional tolerance Cellular and chemical changes in the
body that speed up the metabolism of foreign substances
(e.g., the creation of extra cytocells and mitochondria in the
liver to hand le larger and larger amounts of alcohol).
distillation A chem ical process that vaporizes th e alcohol in fer-
mented beverages and then collects th e concen trat ed distil-
late. It can raise the percentage of alcohol in a beverage from
12% (in wine) to 40% (in brandy).
distribut ion The transportation of a drug through the circula-
tory system to other tissues and organs.
disulfiram (Antabuse ®) A drug used to help prevent alcohol-
ism relapse by triggering unpleasant side effects if alcohol is
consumed .
"ditch weed" Low-grade mar ijuana that is often found along
the roadside in ditches. It was more plentiful when hemp
was grown all over th e United States. it produces no high
because it con tains little THC though Is does contain CBD.
diuresis Excess excre tion of water due to excess intake or drug
use .
diuretic A drug that decreases the amount of water in the body
by increasing the frequency and the quantity of urination;
often used to make one's competing weight in sports or to
control blood pressure.
diversion (1) Diverting prescription drugs from legal sources
into the illegal market, mostly opiates and sedative-hypnot-
ics. (2) Putting a first-time drug offender in a treatment pro-
gram rather than jail.
DMSO See dimethyl sulfoxide
DMT See dimethyltryptamine
DNA See deoxyribonucleic acid
DOB (2,5-dimethoxy-4-bromoamphetamine) A synthe tic ille-
gal stimulant/hallucinogen.
DOM (2,5-dimethoxy-4-bromo-amphetamine) A long-lasting
synthetic hallucinogen . Also known in the 1960s as STP and
classified as a phenylalkylamine psychedelic.
dopamin e A major neurotransmi tter almos t always affected by
psychoactive drugs; it acts at the nucleus accumbens in the
reward/reinforcement pathway to produce euphoria and a
desire to repeat the drug-using activity; it also helps control
voluntary muscle movement.
dop aminergic reward pathway Sometimes referred to as the
survival/reinforcementpathway, through which a psychoac-
tive drug triggers a rush and euphoria.
dose-res pon se curve A graph that shows the relationship
between the amount of drug taken and the effects observed
in or reported by the user.
double troub le See dual diagnosis
down ers See depressants
down regulation The reduction in the number of receptor sites
for a specific neurotransmitter caused by continued use of a
drug (e.g., ecstasy overuse causes a reduction in the num-
ber of seroton in receptors, inducing the need for greater
amounts of the drug).
dragonfly See bromo-dragonFLY
DRD2 A1 allele gene The first gene discove red that signals a ten-
dency to alcoholism and other addictions; it signals a short-
age of dopam ine receptors in the nucleus accumbens.
driving under th e influence (DUI) Drunk driving or driving
under th e influence of another psychoactive drug.
Driving Under th e Influence of Intoxicants (DUii) A program
in the state of Oregon for resolving a conviction for DUI or
DWI cha rges.
driving while intoxicated (DWI) Drunk driving or driving
under the influence of another psychoactive drug.
dronabinol (Marinol ®) A synthetic THC.
DrugAbu.,ll<sisl.OncrEducation(DARE)Adrug mdviol,oce e-cipr< t t<Sttel<ctroniccijar<tt<
pr,,=.tioncurriculumusual lyl.Oughtinth , fiflhgradeby ecsu.y Asynth ,tic..,.logolth<mrthamp h<wnine mol<cu!,
pohc,olfic,rs._1,i;t,,,n"visingitsrurrirulumtocounte, ~;~~~:oi:rhedellc effect<. Also called MDMA, X,
DrugAbu.,Tru
:';::,!'~w«n
t m<ntOutrom,Study(DATOS)R<><>rch
1991 •nil 1993 to study th , ,!f,ctivm<>• of ~:.Stt ..::-:io-;:u:;v:,t::"~
,;,.u<>olth<body
t<r •r.d other fluid< in th,

DrugAbus<W u l1ing:Setwor1' (DAWN) A ltd.,..ll yfuuded IEGS«dtttro<n«phalography

dal.Oroll<ction~l<mthatgather> inlorm.ationondrug <fl<ctiv,dos,Thedo«ofadrugthatca.,... , il<<ir,defl<<I
f>l.Oliti<>,ERincidtnts,audus,patternsfromm<dica l ,nm • ~ olth<tirne ;l:'i'li.o lth , p,opl<t«tedr,quir,>hightr
intrsand,merg rncyroorns. doug,forth<d«ir,ddle<1,andn'li.r,quir<alow«d0<ag<
drugcoon•Courut hatofle,a lterruti.,,toi ncartt rationlor HAS«<n%)'Tl'< imrnun.,,....y
drugolI,,..,,byfirst • •nilocca<ionally><oond •tirn<olI<ud· "<ightball"Dn<~gh1holmoonc,ol•drug,usu.allyh<r-
,rs·oo,rcedtru1mrnt ·,th<m.a·n•lt<rru·· < ·n,coc ·n,,""ri;orn,orrnethamph<tam· <; •common
drugdlil.ributionS«distribution amountuS<dlor .. l<bystr«til<•lus.
drugdiversionS«div,rsion(l) <l<ctroconvu]sj,,.1hu:apy(ECTITh e u.,ol electric<hocksto
drugdi,·er,ionprog,amo!'rogr>m,uS<db y drugcourutottt at th<brain•pproxim>tdythrutirn<•>w<<kfort..-oto<ix
::·:~~~ US<rsand k<<pthrm from advaocingto>bU>< w«ks totr<>tdtpr<«ion;d<,·elop«linltalyin i931!.Also
called ,~oc~ <~""l'J'
DruginforermrntAdminist<atlon(DIA)Th,f«k <al ag,ncy ,lwroencrphalography(EEG)Atechniq11<thatil<t«t<•nd
charg,edwithpolicingdrugabus<.particilbr lyth<supply ,,,..,u.,,,patl<msol,l<Ctri cal>ctivi ty<manatingfromth,
r,ductionpanolp m·mtion
drug.[r,eworkp~Aled,ra l gov,mm<n tmand.a t<tok<<p
drug,ootolth<..-orkpbce,oltenthtoughdrug1«ting.
drughung,r A,trongcravi ng for • particubrdrug
drugin1<ractionTh< al«rationofth,dl«1olon<drugbyth ,
..
brainbypbcing,l<ctrode,onlhe>e>lp
<loctronlcaddictionsTh,.,induil<t< l<vi<ion, cellphon<, ,
orot h<r,l«tro nicg>m<<,:ar.doth<r
<loctronlcclgarrtteApl a, t>Ccigar,1«look .;alik<thatd,li,·ers
lnt<m<I

P""""'ol aooth<rdru g. At..J<tt,yn<rgism ~ni~~~ •bced liquidm cannabi,oil that 1s, .. porizedand
drugte,tingixamin ingth<blood,brulh,uri n<,,.liva ,or hair
olp<opl<toil<l<rmin< ifthey>r<11<ingdrug,. <liminatlonT h< phy,iologicm el.Oboli<mand,xcr,tionofdrugs
drugthr rapy(l) Th<u.,olmedicationstodrtox ifyadrug andothersub<l.On«,fromth<body .
abus<r, tor,du«c raving,01to,u bstitu teal<>,damaging rmbalmi"ll:OuklS«lormald<hyd<
druj , for~dam.a~ng.;' • /2) Anymedicaltr<atm<ntthat rmbolismBlockage in a bloodv<>s, l c:auS<dbyblood dots,
additivesindrug,,andoth<rfor<ignmatl<r,,uchasootton,
dcydrinli.ingrultur,Acultur,thatr,stric t< th<• vailahility associ>t«lwithintnvenousdrugus,
olakohol and Wl« il mott h<•vily (<.g,Drnm.al1'•nd <mbryog<n<>i>Th<pnx ,..olrmbry<> forrnalioninth,womb
Sw«kn);iti<olt<ncharact<riudbyb ing<drinlting. <1n<rg<ncym«licalt<chnicilln(EMT)Alicen«dmedicalt«h •
dcydrunkAn alro ho lic..-hoha, quitdrinkin gbut i,notin nicianwhog0<>outonambubnceca ll<
r,co.,ry:crav«al<oholroMtllndyandgm,rallyha,•loo- IMITS«,n,:ym,multipliedimmunousayt«chniqu,s
holicp<=nalitytrait<,uch.,;nsm,;tivilytoothus,• rmphy.,maAlungdi><a>< cau...J by,mo kingorby ,nviron •
rigidoudook,di<sati<faction,•nd• lackolinsigh1ors,l1 . m<ntalpollul.Onl<(<.g., .. b«io,)that gradu•l lyd«t royth,
,x.aminationbutha, l<amedtor<>i<tth<impuls<ralh<rthan bronchiol<>olthelung,•ndlheirabilitytotak<inair

Stt
chang,th<lif,,.yl<
D5~:::::, DiagMlt i< and 5toti<l>C al M<lllwafof Mttttal
employ«.,.;.,..,,,. program (EAP)A compan y-provided
counsding«rvi«tohelpwith,ubstllnc<abus<•ndothtr
penon.alprobl<m,_U,ually,th<S<«rvi«>>r<out<ouncedto
DTl(difluslonte,,..,rlmagin&)AnMR l techniq11<thatpro- a prob<ionaltr<>trn rn tgroup
l'iil<,informationaboutcon"'<1ionsamongbrainr,gions IMTS«emergrncym<d\cal t«chnlclan
[t,<>nimag,lhetract<oln,rv,fib<rslhroughth,brain \ <JW>lingActioMbyanyon <, <,p<cially a,poo.,,r,bti ,·,,or
lri<nd,that•llo..-addictsorab=tooontinu,th<iraddic •
DT, Sttil<liriumtr<men, liveb<havior . ltindOO<,il<nial,ood<p<ndrnce,payingoll
dualdlagnosi>Asubstan« abu,., withac0<xi<ting rn<nl.O
""' · Also call<drn .., ,bWit):.\llCA (m<nl.Ollyillch,mical
l ill•
..;!':'.iif.."~~i:•:1:;;:::r
~;:~:~i~l~~nt~, can b<
abus<r),.io..b!,t""'ol<,•nil<<>-<><<•"1i,gdiwrd<n f•cal:ofttninduc,dbyinlect«ln,edl«during in,ravenous
DUIS« drivingund<rthrlnllu,nc, drugus,
D\\-lS«drivingwhil<lntoJ<icat<d rndogrnou,ll< l<rringtonatura li n«ma l chtmicalpnx ,..wi lh
DHIS«dextrom<lhorphan th<body.
dy,phoria A general m.abi« marked by mild•to-mod,rate rndogrnou,cravingCnvingfor adrug caus,dby "'unx h<mi•
dep=<ion,r,st1<,,,.,..,, . nd•nl<i<ty:1<.. .. v,r,thllnmajor calcha npi nth<br ainruc h••il<p lrtionol dopamin<
dep=<ion """llinglromoocai,..•bus, . Theoth<rcraving .=,:""""
dysthymi>Ail<p=<ivemooddi<ord er that i>not ••-ou• as ua,ii,g.i>c:aU><dby,x«ma l rnvironm<nl.Ol trigger,(cued
majoril<pr«Sionbutcanb,tforatl<>,ttwoyears craving)
rndog<nou,opioid•Opioid<t hatoriginateor>r<produced
withinthebody,induding,ndorphirui,,nk<phalin,,•nd
dynorphins:antonyrnolo:ogmoi.,opioids(,. g.,h<roinand
IAPS«employ«.,.istan«prograrn opium)
utingdi«<d<,.lnc lud,anor<xi>nuvosa,bulirnian<T\'O,.,
binge~at ingdi<ord , r, andrompul<iv<"'"'"'' ing
 G.10 GLOSSARY
endorphins Neurotransmitters that resemble opioids. They
naturally suppress pain and induce euphoria. Heroin, mor-
phine, and other opioids mimic the effects of endorphins.
energy drinks A new phenomenon in the stimulant soft-drink
market; they usually contain caffeine, vitamins, miner-
als, sugar, and amino acids. Brands include Red Bull® and
I
Rockstar.®
enkephalins Naturally occurring opioid peptides that are part
of the endorphins relating to pain suppression.
entactogen (or empathogen) Psychoactive substances that pro-
duce emotional and ocial effects (empathy and emotional
closeness) similar to those produced by MOMA or Ecstasy.
A drug usually of the phenethyamine group that likely impacts
serotonin and produces a sense of empathy.
enteric division The third part of the autonomic nervous sys-
tem that controls smooth muscles in the gut.
environment Any external influence on a person, including
relationships, school, work, living arrangement, nutrition,
availability of drugs, advertising, and kinds of friends. One of
the three main factors most influential in forming a suscep-
tibility to drug dependency; the other two factors are hered-
ity and the use of drugs or the acting out of a compulsive
behavior.
enzyme A natural chemical that causes a chemical change in
other substances (catalyst) without changing itself. Enzymes
are often involved in the metabolism of drugs.
enzyme immunoassay (EIA) In drug testing, the use of anti-
bodies to seek out specific drugs.
enzyme multiplied immunoassay techniques (EMIT) A sensi-
tive urine drug test rapidly and easily performed. Specific
antigens are created for drugs that then react to their pres-
ence in a urine or blood sample.
ephedra The active ingredient of the ephedra bush, found
mostly in China; the synthesized version of this stimulant is
called ephedrine; also called ma huang.
ephedrine An alkaloid stimulant extracted from the ephedra
bush. It can also be synthesized in labs. It forces the release
of norepinephrine, dopamine, and epinephrine in the
brain's nerve cells. Because it can be used to manufacture
methamphetamine and methcathinone, its importation is
strictly controlled. Ephedrine is used as a bronchodilator in
the lungs and a vasoconstrictor in the nose, so it is found
in many over-the-counter drugs, such as pseudoephedrine
(Sudafed®).
epigenetics The field of research that studies changes (gene
expressions) that are altered by environmental events and/or
substances taken into the body.
epinephrine The body's own natural stimulant neurotransmitter
(adrenaline); a catecholamine, often released by stimulants.
epsilon alcoholism See Jellinek, E. M.
EPO See erythropoietin
ergogenics Any drug that increases performance and strength in
athletics or bodybuilding.
ergot A toxic fungus that contains lysergic acid; used in the syn-
thesis of LSD; found on rye and wheat.
ergotism Poisoning by ergot, often characterized by gangrene,
numbness, hallucinations, and burning sensations.
erythropoietin (EPO) A synthetic hormone that stimulates the
production of oxygen-laden red blood cells; it has potentially
fatal side effects. It has been widely used in athletic events,
particularly endurance events such as cycling.
Erythroxylum coca The botanical name for the coca bush, the
source of cocaine. It is grown mainly in South America
but also in Indonesia. Other, less prevalent plants include
Erythroxylum ipadu, Erythroxylum novotraterse, and
Erythroxylum truxillense.
estrogen A hormone responsible for most feminine character-
istics. Found in both men and women but in greater con-
centration in women (e.g., estradiol, formed by the ovary,
placenta, testes, and possibly adrenal cortex, can be synthe-
sized). Its production is often affected by drugs.
ethanol (C 2H60) The main psychoactive ingredient in beer,
wine, and distilled liquors; usually made from fermented
grains, fruits, or carbohydrate-based vegetables such as pota-
toes and rice. Also called ethyl alcohol.
ether A volatile liquid, it was the first anesthetic. It was discov-
ered in 1730 and called anodyne. Ether was used as a medi-
cine, a drink, and an inhalant; often used for intoxication
because it was thought to be less harmful than alcohol.
ethyl alcohol See ethanol
etiology The study of the causes of a disease, including
addiction.
euphoria A feeling of well-being, excitement, extreme satiation,
and satisfaction caused by many psychoactive drugs and cer-
tain behaviors, such as gambling and sex.
euphoriant A substance that causes euphoria.
euphoric recall The memory of positive drug experiences that
can encourage a user to try it again and again.
euthymia A temporary elation; mental peace that is less intense
than euphoria; often occurs at the beginning of recovery
from drug abuse. Also called pink cloud.
evolutionary perspective A theory that looks at physiological
changes in the brain as survival adaptations.
excise taxes Taxes on tobacco, alcohol, and some luxury items.
excretion The elimination of water and waste products, includ-
ing drugs and their metabolites, due to metabolism through
urination, sweating, exhalation, defecation, and lactation.
exogenous Produced or originating outside the body (e.g.,
exogenous opioids such as heroin and morphine).
experimentation The first stage of drug use wherein the person
is curious but uses the drug only sporadically without nega-
tive consequences.
F
facilitator A professional intervention specialist or a knowl-
edgeable chemical dependence treatment professional who
arranges and participates in an intervention to break through
an addict's denial and get him or her into treatment.
factitious disorder A mental disorder in which an individual
voluntarily exhibits the signs and the symptoms of diseases
to become a patient in a medical setting (sometimes to obtain
drugs).
FAE See fetal alcohol effects
false negative A negative result on a drug test when the person
should really test positive for drugs. It is often caused by
operator error.
false positive A positive result on a drug test when the per-
son should test negative for drugs. False positives can be
corrected through retesting and examination by a medical
review officer.
family intervention See intervention
Farmville An online social networking game that allows players
to manage a virtual farm by plowing, planting, harvesting
crops, and raising livestock. There are more than 60 million
users.
FAS See fetal alcohol syndrome
fasciculus retroflexus A cluster of neuron fibers that commu-
nicates the "stop" message from the prefrontal circuit to the
"go" circuit via the lateral habenula. Damage to these fibers
can accelerate addiction.
FASO See fetal alcohol spectrum disorders

fat-soluble Capable of being absorbed by fat. Most psychoactive
drugs are absorbed by the brain because the brain has a high
fat content.
fatty liver The accumulation of fatty acids in the liver that
begins to occur after just a few days of heavy drinking.
fen-phen The combination of dexfenfluramine and phenter-
mine when prescribed for weight control ; target of a massive
lawsuit due to heart damage caused by the drug combo. Also
called phen-fen.
fenfluramine A drug that reduces appetite.
fentanyl (1) A powerful synthetic opiate used to control severe
pain and as an anesthetic in surgery. It is 100 times stronger
by weight than morphine; it is often abused in the medical
community. (2) A street drug called China white, used as a
substitute for heroin, that uses the same basic formulation as
pharmaceutical fentanyl.
fermentation A chemical process that uses yeast to convert sugar
(usually found in grains, starches, and fruit) into alcohol.
fetal alcohol effects (FAE) Symptoms and physical defects in
the fetus from the mother's alcohol use during pregnancy that
are not as severe as those found in fetal alcohol syndrome.
fetal alcohol spectrum disorders (FASD) Refers to the full
range of disorders caused by alcohol use during pregnancy:
ARBD, ARND , FAE, and FAS.
fetal alcohol syndrome (FAS) Birth defects caused by a mother's
excessive use of alcohol while pregnant. Signs of FAS include
retarded growth, facial deformities, and delayed mental
development.
fetus A formed yet unborn human (from the eighth week after
conception to birth).
fibrosis The formation of scar tissue that can be caused by alco-
hol and other caustic substances .
fight/flight center An area of the old brain and the peripheral
nervous system that reacts to danger by increasing alertness,
releasing adrenaline , and raising heart rate and respiration . It
is initially triggered by emotional memories and instinctual
drives in the amygdala and the hippocampus. Also called
frightlfightlflightlfomication center.
FIPSE Acronym for Fundfor the Improvement of Post-Secondary
Education.
first-messenger system The process whereby the neurotrans-
mitter directly affects electrical transmission in the receiving
neuron .
first-pass metabolism The processing of a substance as it passes
through the gut and the liver for the first time .
flashback A remembrance of the intense effects of a drug, such
as LSD or PCP, that is triggered by a memory, by encounter-
ing environmental cues, or by a residual amount of the drug
being released, usually from fat cells.
flunitrazepam (Rohypnol ®) A potent sedative-hypnotic , cur-
rently banned in the United States , that can cause relaxation,
sleepiness , and amnesia; sometimes used in cases of date
rape.
fluoxetine (Prozac ®) An extremely popular antidepressant
medication that is classified as a selective serotonin reuptake
inhibitor. It increases the action of serotonin in the brain by
preventing its reabsorption.
fly agaric See Amanita muscaria
IMRI See functional magnetic resonance imaging
formaldehyde A chemical used to preserve dead bodies
(embalming fluid). It has been used as an inhalant; it is also
added to marijuana and then smoked-called "clickers" or
"clickems." This material has also been used to help manu-
facture other illicit drugs such as PCP.
GLOSSARY G.11
formication A cocaine- or methamphetamine-induced sensa-
tion that makes users think that bugs are crawling under
their skin.(coke bugs/meth bugs)
fortified wine Wine whose alcohol concentration is raised to
approximately 20% by adding pure alcohol or brandy.
freebase Cocaine that can be smoked (as opposed to cocaine
I
hydrochloride , which is snorted or injected).
freebase nicotine A way to manufacture nicotine to make it
more readily absorbable by the lungs , giving it a bigger kick
and making it more addictive. Marlboro was supposedly the
first to develop this process , but other manufactures have
followed suit.
freebasing Transforming cocaine hydrochloride into cocaine
freebase using ether or another flammable solvent so that it
can be smoked. This method processes out impurities .
French Connection A French heroin distribution syndicate
headed by JeanJehan; it was the main supplier of refined her-
oin to the United States from the 1930s to 1973, when it was
broken up by an international law enforcement coalition.
fright/fight/flight/fornication center See fight/flight center
functional magnetic resonance imaging (!MRI) A method of
imaging the brain that shows blood flow to provide informa-
tion on motor, sensory , visual, and auditory functions .
G
GABA See gamma-aminobutyric acid
GAD See generalized anxiety disorder
gambler's fallacy An assertion that random events can be used
to predict future events , e.g., that if a coin flip produces 20
heads in a row, the next flip is more likely to be tails. This
is false; the odds in the next flip are still 50-50 . The fallacy
leads compulsive gamblers to believe that they can beat a slot
machine and the laws of chance.
gamma alcoholism See Jellinek, E. M.
gamma-aminobutyric acid (GABA) This inhibitory neurotrans-
mitter is one of the main neurochemicals in the brain.
gamma hydroxybutyrate (GHB) Synthetic version of a natu-
ral metabolite of the neurotransmitter GABA; used as a
sleep inducer. It is popular among bodybuilders because it
improves the muscle-to-fat ratio. It is also touted as a natural
psychedelic and used as a party drug .
ganja Indian word for a preparation of the leaves and the flow-
ering tops of the Cannabis plant; less potent than charas, the
resin , but more potent than bhang, the leaves and the stems.
gas chromatography/mass spectrometry (GC/MS) The most
accurate method of drug testing for both amount and type of
drug. It is supposed to be 99.9% accurate.
gastritis Inflammation of the gastrointestinal system, particu-
larly the stomach, that can be caused by drinking .
gateway drug Any drug whose use supposedly leads to the use
of stronger psychoactive drugs. The three most often men-
tioned are alcohol, tobacco, and marijuana.
GBL A chemical found in paint strippers and other substances
that are transformed into GHB, a sedative that is used as a
club drug.
GC/MS See gas chromatography/mass spectrometry
generalized anxiety disorder (GAD) A mental illness that con-
sists of unrealistic worries about several life situations that
lasts for six months or longer .
generic name The chemical name or description of a drug as
opposed to the brand or trade name (e.g., oxycodone is the
generic name whereas OxyContin®is the trade name).
genetic marker Any gene that makes a person more susceptible
to the effects of a drug if he or she uses that drug (e .g., a
 G.12 GLOSSARY
marker gene for alcoholism that indicates slow metabolism
of alcohol).
genetic predisposition A genetic susceptibility to use drugs
addictively that comes into play when the person starts using
psychoactive drugs. Also called genetic susceptibility.
genotype The genetic makeup of an individual; the totality of
I
his or her inherited traits.
GHB See gamma hydroxybutyrate
Gin Epidemic A period in British history (1710 to 1750) during
which the availability of gin led to widespread public drunk-
enness and health problems.
ginseng A plant whose root has been used in Asian herbal medi-
cine for 4,000 years; advocates say it prolongs endurance;
studies say it doesn't.
"glass" Slang for smokable methamphetamine. See "ice."
glaucoma An eye disease that increases intraocular pressure.
Marijuana is promoted as a medicine that can relieve that
pressure.
glial cells Cells in the brain that surround neurons and hold
them in place, supply nutrients and oxygen, insulate the
neurons from one another, destroy pathogens, and remove
dead neurons.
glucose A simple sugar found in fruits and plants that converts
to alcohol when activated by yeast.
glutamate The most common excitatory neurotransmitter in
the brain; NMDA receptors for glutamate are most densely
concentrated in the cerebral cortex (especially the hippo-
campus), amygdala, and basal ganglia. Also called glutamic
acid.
glutamic acid See glutamate
glutamine One of 20 amino acids encoded by the standard
genetic code; it is used as a nutritional supplement to rebal-
ance neurochemistry and neurotransmitter formation .
glutethimide A short-acting hypnotic that used to be a popular
drug of abuse, usually in combination with codeine. It was
sold as Doriden. ®
"go" circuit (switch) Located in the old brain, this circuit is
centered in the nucleus accumbens. Its three main functions
are to tell us that what we are doing is necessary for survival,
to remember what we did, and to do it again, and again, and
again.
Golden Crescent An area of the Middle East that produces large
amounts of opium; includes parts of Pakistan, Iran, and
especially Afghanistan.
Golden Triangle Formerly the major illicit opium-producing
area in the world, now a distant second to the Golden
Crescent; includes parts of Myanmar (Burma), Thailand,
and Laos.
gonorrhea A common sexually transmitted infection usually
marked by discharge from the genitals or rectum and painful
urination.
"goof balls" (1) Street name for glutethimide (Doriden ®), a
popular drug of abuse in the 1960s, 1970s, and 1980s. (2)
The combination of speed and heroin.
gram (gm) A metric unit of weight often used to measure drugs;
28.35 grams equals 1 ounce; 1,000 grams equals a kilogram,
or 2.2 pounds.
"grass" Slang for marijuana.
gray matter The outer surface of the cerebral cortex and parts
of the base of the cerebral hemispheres that consist mostly of
dendrites and cell bodies.
group therapy The use of several clients in a group setting to
help one another break the isolation of addiction, increase
knowledge, and practice recovery skills. There are different
types of group therapy: facilitated, peer, 12-step, educational,
topic-specific , and targeted.
growth hormone See human growth hormone
gutka A mixture of betel nut, tobacco, lime, and flavorings
sold mostly in India; it's chewed, and the stimulant juice is
absorbed by the mucosa.
gynecomastia Enlargement of male breasts, often from the
excess use of androgenic steroids that metabolize to an estro-
gen; steroid-using athletes often report this effect.
gyrus (gyri) Ridges of convoluted rounded brain tissue of the
cerebral hemispheres.
H
HAART See highly active anti-retroviral therapy
habenula See lateral habenula
habit A term for addiction (i.e ., "he has a habit n).
habituation A level of drug use just before abuse, where the
substance (or behavior) is used on a regular, habitual basis
but does not yet have regular serious consequences though
there is some loss of control.
half-life The time it takes for a substance to lose half of its phar-
macologic or physiologic activity through metabolism and
excretion.
halfway house A residential treatment facility where the addict
is allowed to work and have outside contacts while enrolled
in a treatment program.
hallucination A sensory experience that doesn't relate to reality,
such as seeing a creature or an object that doesn 't exist; a
common effect of mescaline, psilocybin, PCP, and occasion-
ally LSD (illusions are more common with LSD).
hallucinogen A substance that produces hallucinations (e.g.,
LSD, mescaline , peyote, DMT, psilocybin, and potent mari-
juana); a term often used interchangeably with psychedelic,
psychotomimetic, and psychotogenic.
hallucinogen persisting perception disorder (HPPD) A mental
condition triggered by memories or environmentally cued
remembrances of a past intense experience with a drug that
is similar to post traumatic stress.
HALT Acronym for hungry, angry, lonely, and tired; it helps
addicts in recovery to remember these triggers that often
lead to relapse .
hangover Alcohol withdrawal symptoms that occur eight to 12
hours after stopping drinking. They include headache , diz-
ziness, nausea, thirst, and dry mouth. The causes are usually
the direct effects of alcohol and its additives. Hangover is
distinguished from withdrawal, which is more severe and
more long-term.
hardening of the arteries See atherosclerosis
harm reduction A tertiary prevention and treatment technique
that tries to minimize the medical and social problems
associated with drug use rather than making abstinence
the primary goal (e.g., needle exchange and methadone
maintenance).
Harrison Narcotics Act One of the first U.S. laws that con-
trolled the importation, manufacture, distribution, and sale
of narcotics; enacted in 1914.
hash oil An extract of marijuana (made using solvents) that is
added to food or to marijuana cigarettes. Its THC content
can be as high as 80%.
hashish The potent sticky resin of the marijuana plant that is
often pressed into cakes and smuggled . The THC content is
anywhere from 8% to 40%.
HCG See human chorionic gonadotropin
HCV Acronym for hepatitis C virus. See hepatitis C.
heavy drinking Defined as drinking five or more drinks in one
sitting at least five times a month.

"head shop" A store that sells drug paraphernalia such as roll-
ing papers, roach clips, water pipes, and crack pipes.
hemp A generic term often used to describe Cannabis plants
that are high in fiber content and low in THC content.
henbane (Hyoscyamus niger) A hallucinogenic plant containing
the alkaloids scopolamine, hyoscyamine, and atropine.
hepatitis Liver disease that can inflame or kill liver cells. It is
caused by a virus or by a toxic substance, such as alcohol.
The most common strains of viral hepatitis are A, B, C, D,
and E. Depending on the strain, they can be transmitted
through contaminated needles, exchange of body fluids,
or feces. Hepatitis B and C are the most common strains in
injection drug users. Also see alcoholic hepatitis.
hepatitis B A common form of hepatitis that is transmitted by
contaminated blood, semen, vaginal secretions, and saliva.
It is the ninth-leading killer in the world. Often transmitted
by high-risk sex and contaminated needles; 75% of IV drug
users have been infected with hepatitis B.
hepatitis C A form of viral hepatitis found, in some studies,
in 70% to 80% of injection drug users. It is a major cause
of liver failure and liver cancer. Four million Americans are
infected.
heredity The transmission of physical and even mental charac-
teristics through genes, chromosomes, and DNA.
heroin (diacetylmorphine) A powerful opiate analgesic derived
from morphine. It was discovered in 1874 and soon became
the object of abuse and addiction.
herpes simplex Common sexually transmitted disease usually
marked by intermittent painful blisters or sores on the geni-
tals and/or mouth.
"hexing herbs" Members of the nightshade family of plants
(e.g., belladonna, henbane, mandrake, and datura) that con-
tain scopolamine, hyoscyamine, and atropine.
HGH See human growth hormone
highly active anti-retroviral therapy (HAART) HIV treatment
regimen that targets viral enzymes; uses three medications
that must be taken according to a strict schedule.
high-risk behavior Dangerous behavior (e.g., unprotected sex,
violence, and risk taking) that can lead to injury or infection .
It is often caused when drugs lower inhibitions or impair
reasoning.
hippocampus An area of the primitive midbrain in the temporal
lobe that is responsible for emotional memories and conver-
sion of short-term memories to long-term ones. It compares
sensory input with experience to decide how to react.
histamine A natural amine in the body that stimulates gastric
secretions, constricts bronchi, and dilates capillaries, usually
to bring healing to an injured area of the body. Antihistamines
control the inflammation.
"hit" A dose of a drug.
HIV See human immunodeficiency virus
homeostasis The balance of functions and chemicals in the body
as well as the process by which that balance is maintained;
responsible for the development of tissue dependence, toler-
ance, and subsequent withdrawal from psychoactive drugs.
hops An aromatic herb that comes from the dried cones of the
Humulus lupulus vine, used in the brewing of virtually all
beers; provides the bitter "hoppy n taste of beer.
hormone A biochemical manufactured by an organ that can
alter body function (e.g., pituitary gland).
HPPD See hallucinogen persisting perception disorder
"huffer" Slang for an inhalant abuser.
"huffing" Putting a solvent-soaked rag, sock, or other material
over or in one's mouth or nose and inhaling.
GLOSSARY G. ll
human chorionic gonadotropin (HCG) A drug used to restart
testosterone production in the body after long-term or high-
dose anabolic steroid use; it can be toxic.
human growth hormone (HGH) A substance produced by the
body that stimulates body growth and muscle size. It is used
illicitly in sports but can have dangerous side effects; it can
I
now be synthesized rather than extracted from cadavers.
human immunodeficiency virus (HIV) The virus that causes
AIDS.
hychocodone (Lortab, ®Vicodin ®) The most widely abused opi-
ate-based painkiller; prescribed for moderate-to-severe pain.
hychomorphone (Dilaudid ®) A synthetic opiate analgesic pre-
scribed for moderate-to-severe pain.
hydrophilic The property of attracting or interacting with water
molecules; alcohol is hydrophilic.
hyoscyamine See atropine
hyperalgesia A temporary increase in the sensitivity to pain-
ful stimuli experienced during the long-term use of opiate/
opiods to treat pain.
hyperemesis Uncontrollable vomiting which can be brought on
by the use of highly potent cannabis, synthetic marijuana, or
from highly concentrated extracts (dabs). Only the cessation
of use brings relief from what is theorized as an overstimula-
tion of the CBl receptors as traditional anti nausea medica-
tions fail to control this reaction.
hyperkatifeia Opiate use In the context of pain management
which produces a hypersensitivity to emotional distress.
hyperpathia An abnormal Increase to pain as a result of long-
term opiate/opioid pain treatment that persists even though
the original painful stimulus has been corrected or healed.
hyperplasia Precancerous changes in the bronchial tubes of the
lungs characterized by abnormal and increased cell growth;
often caused by smoking tobacco.
hypertension High blood pressure; can be caused by stimulant
use (and sometimes psychedelics) or by withdrawal from
depressants.
hyperthermia Abnormally high body temperature; can be
caused by MOMA, methamphetamines, and other party
drugs especially when coupled with dancing or exercise.
hypnotic A drug that induces sleep (e.g., some benzodiazepines,
barbiturates, bromides, Z-hypnotics, and large amounts of
alcohol).
hypodermic needle A device consisting of a hollow needle
attached to a syringe that is used for injecting a fluid into
the body intramuscularly (in a muscle), intravenously (in a
vein), or subcutaneously (under the skin).
hypoglycemia A condition of extremely low glucose level in the
blood; often found in people with eating disorders. It causes
symptoms of lethargy, lightheadedness, and hunger.
hypothalamus Part of the brain that controls the autonomic
nervous system and maintains the body's balance. It also
controls the hormonal system and is located near the top of
the brainstem.
hypoxia Very low level of oxygen in the blood or tissues; can be
caused by inhalant abuse.
iatrogenic addiction Addiction caused by medical treatment
(e.g., liberal use of opiate analgesics in a hospital setting or
prescribed by a physician which leads to opiate addiction).
ibogaine A long-acting psychedelic from the iboga shrub that
when used in high doses acts like a hallucinogen; in low
doses it acts as a stimulant; it is currently being researched as
a treatment for heroin addiction.
 G.14 GLOSSARY
ibuprofen A non-opiate pain reliever or nonsteroidal anti-inflam-
matory drug that controls pain, fever, and inflammation.
"ice" Street name for dextromethamphetamine (actually dex-
tro isomer methamphetamine base); also called "crystal"
meth, a crystalline form of amphetamine that is smokable. It
has slightly milder physical effects than methamphetamine
I
hydrochloride but more-severe mental effects.
illusion A mistaken perception of a real stimulus (e .g., a rope is
mistaken for a snake; the colors on a wall seem to be flowing).
immune system A complex system of white blood cells, mac-
rophages, and other cellular and genetic components that
defend the body against foreign organisms.
immunosuppression A decrease in the effectiveness of the
body's disease-fighting mechanisms; can be caused by the
use of certain drugs, by the HIV virus, or by other infectious
agents.
immunoassay Testing for drugs using drug antigens. See
enzyme multiplied immunoassay techniques .
impairment Physical and mental dysfunction due to psychoac-
tive drug use or other addictive behaviors.
imprinting A process whereby memories, such as survival
memories, are impressed onto nerve cells in the brain.
indica A species of Cannabis that is high in THC content. See
Cannabis.
indicated prevention Targets dependent drug users and also
focuses more broadly on groups or individuals who exhibit
early signs of substance abuse or other problems.
individual counseling One-on-one interaction between a
therapist, counselor, or other treatment specialist and a cli-
ent with emotional or mental problems, to help him or her
understand and cope with the illness .
in dole psychedelics A class of hallucinogens that includes LSD,
psilocybin mushrooms, ibogaine, DMT, and yage.
information addiction A form of Internet addiction that
involves excessive surfing of the Web, looking for data and
information.
ingestion Taking food, liquid, drugs, or medications into the
stomach via the mouth.
inhalant Any vaporized, misted, or gaseous substance that is
inhaled and absorbed through the capillaries in the alveoli of
the lungs; smoked drugs are classified differently.
inhibition Controlling and restraining instinctual, unconscious,
or conscious drives especially if they conflict with society's
rules.
inhibitory neurotransmitter A neurotransmitter, such as GABA
or serotonin, that prevents a neurotransmitter from relaying
a message.
inpatient treatment A treatment program in a hospital or other
residential facility that focuses on detoxification, therapy,
and education; usually seven to 30 days but can be much
longer.
insufflation A term for snorting a drug, such as cocaine, heroin,
or methamphetamine .
insulin A hormone secreted by the pancreas to help control
blood-sugar levels; diabetics need to use oral medications
to force the pancreas to release more insulin or use it more
efficiently; insulin itself is injected.
interdiction A supply reduction technique of intercepting drugs
before they are distributed to dealers or users.
interferons A class of proteins that increase cells' resistance to
infection . Interferon is the main treatment for hepatitis C.
Internet A global system of computer networks serving billions
of public, private, academic, business, and government users
worldwide . Development began in the 1960s between the
U.S. government and private interests. The system uses the
Internet Protocol Suite to serve users.
Internet addiction A compulsion to overuse various services
available on the Internet; it includes cybersexual addiction,
computer relationship addiction, net compulsions, infor-
mation addiction, online gambling, and computer games
addiction.
intervention A planned attempt to break through addicts' or
abusers ' denial and get them into treatment. Interventions
most often occur when legal, workplace, health, relation-
ship, or financial problems have become intolerable. Also
called family intervention.
intoxication Functional impairment; loss of physical and men-
tal processes due to substance use . It can be acute due to
high-dose use or chronic due to continuous lower-dose use.
In both cases it is most often caused by the drug 's effect on
the central nervous system.
intramuscular injection Injecting a drug into a muscle . It takes
three to five minutes for the drug to reach the brain and have
an effect.
intravenous injection Injecting a drug directly into a vein . It
takes 15 to 30 seconds for the drug to reach the brain.
inverse tolerance Continuous use changes brain chemistry to
the point that the same dose suddenly starts causing a more
intense reaction. The user becomes more sensitive to the drug 's
effects as use continues. Also called kindling and sensitization.
ion An electrically charged atom .
isopropyl alcohol See propanol.
Jellinek. E. M. (1890-1963) Famed researcher of alcoholism,
founder of the Center of Alcohol Studies, and co-founder of
the National Council on Alcoholism. His well-known The
Disease Concept of Alcoholism delineated five levels of alco-
holism: alpha (problem drinking), beta (problem drinking
with health problems), gamma (loss of control with severe
health and social consequences), delta (long-term heavy
drinking), and epsilon (periodic) alcoholism. These terms
are not used nowadays, but the categorical descriptions are.
jimsonweed A hallucinogenic plant of the Datura family; con-
tains the anticholinergic substances hyoscyamine, scopol-
amine, and atropine .
Joe Camel The advertising icon for Camel cigarettes for 10 years
(1987 to 1997) . It was widely decried by health professionals
because it appealed to adolescents and seemed to prime them
to become smokers. Secret documents of R. J . Reynolds, the
maker of Camels, seemed to contradict the assertion that the
company was not targeting the 14-to-24-year-old age group .
joint Slang for a marijuana cigarette .
''Jones" (1) Withdrawal from chronic heroin use; symptoms
include chills, sweating, and body agony. (2) Term for any
compulsive or addictive behavior (e.g., "Internet Jones").
"juice" Street name for methadone, PCP, or steroids.
"junk" street name for heroin
junkie Someone who is addicted to a psychoactive drug, espe-
cially heroin.
K
K-2® A trade name for one form of synthetic marijuana often
sold as incense .
Kaposi's sarcoma A form of cancer that usually erupts as purple
splotches on the skin . It is considered an opportunistic dis-
ease that is one of the signs of AIDS..
Keeley Institute A series of 118 treatment centers in the United
States that treated alcoholics, drug addicts, and tobacco
smokers between 1880 and 1920.

ketamine An anesthetic that produces catatonia and deep anal-
gesia; side effects include excess saliva , dysphoria , and hal-
lucinations. Its chemistry and effects are very similar to PCP;
used as a recreational club drug.
khat A 10- to 20-foot shrub whose active ingredient is cathi-
none, a mild-to-medium stimulant. It is brewed in a tea , or
the leaves can be chewed and the active ingredient absorbed.
It is popular in Somalia , East Africa, Yemen, and other
Middle Eastern countries.
kilogram (kg) A metric unit of weight that equals 2.2 pounds.
kindling See inverse tolerance
Klonopin®See clonazepam
"knockout drops" Old street name for chloral hydrate , a
sedative-hypnotic.
kola nut The seeds of the Cola nitida tree found in Africa; they
contain a high concentration of caffeine.
Korsakoff's syndrome A disease that most often affects heavy,
long-term drinkers , partly due to a thiamine (Bi) deficiency;
symptoms include short-term memory failure, confusion,
emotional apathy , and disorientation. Also called Korsakoffs
psychosis.
kratom The leaves of the Mitragyna Speciosa (coffee family
tree) grows in Indochina and Malaysia. It is brewed as a tea
or chewed. In high doses it is a painkiller and can also pro-
duce opiate like dependence and withdrawal symptoms In
heavy users.
krokodil A semi synthetic opiate (desomorphine) made from
codeine , iodine, lighter fluid and red phosphorus. This
injected concoction can give the users skin a green scaly
appearance , hence the name krokodil.
"krystal" Street name for PCP; not to be confused with the
street names "crystal" and "crystal meth " that denote
methamphetamine.
L loss of control The point in drug use where the user becomes
LAAM See levomethadyl acetate
lag phase The time between the first use of a drug and the
development of problematic use.
latency The delay between the time a person uses a drug and
the time it appears in urine , blood , saliva, or other fluid and
can be tested.
lateral habenula Embedded in the old brain, it receives signals
through the fasciculus retroflexus from the left prefrontal
cortex , the "stop " switch for the survival/control pathway
that is activated by psychoactive drugs. It normally stops
the release of dopamine in the nucleus accumbens and other
areas of the circuit , but this function is disrupted by the
drugs .
laudanum A popular opium preparation , first compounded by
Paracelsus in the sixteenth century and popularized at the
end of the nineteenth century, mostly in patent medicines;
used to relieve pain, produce sleep , and allay irritation.
laughing gas Nitrous oxide; an anesthetic that was originally
used and abused in the nineteenth century for its intoxicat-
ing effect. It is often used at raves or other parties.
legal high Intoxication by a legal drug , such as alcohol or a
prescribed medication; tobacco and caffeine use are also con-
sidered legal highs .
legalization A prevention concept that decrim inalizes the cul-
tivation , manufacture , distribution , possession, and use of
drugs to reduce crime, drug dealing , and disease .
lethal dose (LD)The amount of a drug that will kill the user .
It can vary radically , depending on purity , sensitivit y of the
user, tolerance , and other factors.
GLOSSARY G.15
leukoplakia White oral mucous that persists in the mouth and
is sometimes a sign of HIV disease or tobacco use.
levomethadyl acetate (LAAM) A long-acting opiate used as an
alternative to met h adone for heroin addiction treatment ;
now used only experimentally in the United States.
LGBT Acronym for lesbian,gay, bisexual, and transgender.
I
"lid" Traditionall y an ounce of marijuana; now any amount in a
baggie is often called a "lid. "
LifeSkills Training (LST) A prevention program for grades 7 to
10 that focuses on increasing social skills and reducing peer
pressure to drink.
ligand A compound that binds to a receptor; the part of a neu-
rotransmitter or peptide that slots into a receptor on a nerve
cell's receiving dendrite.
limbic system The emotional center in the central nervous
system's midbrain. It includes the amygdala , hippocampus ,
thalamus, fornix, mammillary body, olfactory bulb , and
supracallosal gyms. It sets the emotional tone of the mind ,
stores intense emotional memories, alters moods and emo-
tions, controls sleep, processes smells , and modulates the
libido.
"line" A thin line of cocaine hydrochloride that is snorted.
lipid solubility The ability of a substance to be dissolved in a
fatty substance. Many psychoactive drugs ha ve a high lipid
(fat) solubility.
lipophilic Having a high lipid (fat) solubilit y.
lithium (carbonate) The main drug used to treat bipolar affec-
tive disorder.
liver The largest gland in the body (2 to 4 pounds) ; metabolizes
protein and carboh ydrates and most psychoactive drugs that
pass through the blood , especiall y alcohol.
look-alikes Legal drugs made with caffeine, ephedrine, or other
legal substances to look like hard-to-get sedatives or illegal
stimulants.
unable to limit or stop use.
lost child The child of an alcoholic or addict who is extremely
shy and deals with problems by avoidance.
LSD See lysergic acid diethylamide
LST See LifeSkills Training
lysergic acid diethylamide (LSD) An extremel y potent psy-
chedelic (hallucinogen) synthesized in 1938 that causes
illusions , delusions , hallucinations , and stimulation. It was
originally made from rye mold.
M
ma huang An ancient Chinese tea that contains ephedra, a plant
stimulant. Also see ephedra.
mace The outer shell of nutmeg ; has psychedelic qualities.
macrophage See phagocyte
"magic mushrooms" Hallucinogenic mushrooms , usuall y con-
taining psilocybin or psilocin.
magical thinking An irrational way of thinking used by prob-
lem and pathological gamblers to rationalize their excessive
gambling , i.e., the idea that one can control totally random
events , leading gamblers to believe that they can figure out a
slot machine 's patterns .
magnetic resonance imaging (MRI) scan A technique of imag-
ing the brain that relies on magnetic waves rather than
X-rays. Its three-dimensional images have been used to visu-
alize the neurological effects of psychoactive drugs.
"mainlining " Using a drug , usuall y heroin , intravenously.
major depression A mental illness characterized by a depressed
mood and sleep disturbances without a life situation
causing it.
 G.16 GLOSSARY
major tranquilizer An antipsychotic drug.
malt A grain, usually barley, that is sprouted in water, then dried
and crushed; the resulting malt is used to brew beer; also
used in whiskeys as well as in cereals.
malt liquor A beerlike beverage with a slightly higher alcohol
content (6% to 9%) than normal lager beer (4% to 5%).
I
mandrake (Mandragora) A bush found in Europe and Africa
that contains anticholinergic psychedelics; popular in
ancient and medieval times with shamans, witches, and
medicine men.
mania A period of hyperactivity, poor judgment, rapid thoughts,
and quick speech; it can lead to a diagnosis of bipolar affec-
tive disorder (manic-depressive illness).
manic depression See bipolar affective disorder
MAO inhibitor See monoamine oxidase (MAO) inhibitors
marijuana The common name for Cannabis plants that have
high levels of psychoactive ingredients, especially THC. Also
refers to the psychoactive portions of the Cannabis plant
such as the resin and the flowering tops.
Marino!® See dronabinol
mascot child/family clown The child of an alcoholic or addict
who tries to ease tension by being funny; this child has trou-
ble maturing.
MAST See Michigan Alcoholism Screening Test
MDA (3 ,4-methylenedioxyamphetamine) A synthetic halluci-
nogen that became popular in the 1960s.
MDMA (3 ,4-methylenedioxymethamphetamine) Commonly
called X or ecstasy, a psycho-stimulant first synthesized in
the early 1900s and popularized in the 1980s and 1990s.
medial forebrain bundle A nerve pathway involved in reward
and satiation. It extends through the ventral tegmental area ,
the lateral hypothalamus , the nucleus accumbens , and the
frontal cor tex.
medibles Cannabinol-laced cakes , cookies , candy, brownies ,
and other food items that are legally used by medical-mar-
ijuana card holders as well as illicit-marijuana users who
don't want to smoke.
medical intervention The use of medications to treat a sub-
stance-related or mental disorder. This is usually done in
combination with group/individual therapy or other treat-
ment techniques.
medical marijuana Marijuana that is used for medical rather
than recreational purposes. It is the focus of much of the
current debate about legalizing marijuana.
medical model (1) Using medications to treat addiction because
addiction is caused by irregularities of brain cells and brain
chemis try. (2) In mental health, the concept that mental
illnesses are caused by a disease process and by changes in
brain chemistry.
medical model detoxification program Use of medications and
other medical therapies for detoxification under the direc-
tion of medical professionals.
medical review officer (MRO) A physician who reviews posi-
tive drug test results to see if there is any other explanation
or mitigating circumstances.
medulla The part of the brain that controls heart rate , breath-
ing, and other involuntary functions.
mentally ill chemical abuser (MICA) See dual diagnosis
meperidine (Demerol ®) An opioid analgesic, like morphine ,
prescribed for moderate-to-severe pain.
mephedrone See methcathinone
meprobamate (Miltown ®) A long-acting sedative developed in
the 1950s to replace long-acting barbiturates. Commonly
called "mother'slittle helper."
mescal Toxic seed from the mescal tree that at nonpoisonous
doses can cause hallucinations.
mescaline The hallucinogenic alkaloid of the peyote cactus; has
been found in other cacti (e.g. , the San Pedro cactus) and has
also been synthesized.
mesocortex A subdivision of the cerebral cortex, sometimes
called the midbrain , that contains the limbic system.
mesolimbic dopaminergic reward pathway A nerve pathway in
the limbic system of the brain that carries reward messages
to the nucleus accumbens and the frontal cortex; thought to
play a crucial role in addiction.
metabolism The body 's mechanism for processing, using , inac-
tivating , and eventually eliminating foreign substances, such
as food or drugs , from the body.
metabolism modulation The technique of using medica-
tions that alter me tabolism of an abused drug to render it
ineffective.
metabolite The byproduct of drug metabolism that can also
have psychoactive effects on the brain ; often used as a
marker in drug tests.
meth See methamphetamine hydrochloride
methadone A long-acting synthetic opiate used orally to treat
heroin addiction; also used to treat pain.
methadone maintenance A treatment and harm reduction tech-
nique that keeps a heroin addict on methadone for long peri-
ods of time, even a lifetime. It helps addicts avoid infec tions
from needle use , the need to break the law to support their
habit, and the desire to return to the heroin lifestyle.
methamphetamine freebase An altered form of methamphet-
amine called "snot." When methamphetamine is altered to
the dextro isomer , methamphetamine base is called "glass,"
"batu," and "shabu." Both forms of methamphetamine base
are smoked.
methamphetamine hydrochloride An intense psychoactive
stimulant based on the amphetamine molecule; used for
injecting , ingesting , and snorting. Also called meth and
"crystal."
methamphetamine sulfate A methamphetamine compound
that is supposedly slightly harsher than methamphetamine
hydrochloride. Also called "crank."
methanol Wood alcohol; used as a toxic industrial solvent; it
can be synthesized. Also called methyl alcohol.
methaqualone ( Quaalude ®) A sedative that was widely abused
in the 1960s, 1970s, and early 1980s for its disinhibitory
and intoxicating effects. It is now available only illegally
and is usually counterfeited with a benzodiazepine or an
antihistamine.
methcathinone A synthetic stimulant that is chemically rela ted
to the natural stimulant cathinone found in the khat bush.
It is one of the many drugs sold as psychoactive "bath salts".
methyl alcohol See methanol
methyl morphine See codeine
methylphenidate (Ritalin, ® Attenta, ® Concerta ®) An amphe t-
amine congener stimulant used to treat attention-deficit/
hyperactivity disorder and narcolepsy. It has been abused on
the street. Also called "pellets."
"Mexican brown " Heroin processed from poppies grown in
Mexico; it is brown due to crude refining techniques.
mic See microgram
MICA Acronym for mentally ill chemical abuser. See dual
diagnosis
Michigan Alcoholism Screening Test (MAST) An assessment
test of 25 questions that are primarily directed at the negative
life effects of alcohol on the user.
microgram (mic) One millionth of a gram; a dose of LSD is 25
to 300 micrograms or mies.
Miltown ®See meprobamate

Mini Thins ® Small, thin tablets that contain pseudoephed-
rine; used by street chemists to make methamphetamine or
methcathinone.
minor tranquilizers Antianxiety medications .
misuse (1) An unusual or illegal use of a prescription, usually
for drug diversion purposes. (2) Any nonmedical use of a
drug or substance.
mitochondria Membrane-enclosed organelles found in many
cells. They supply the chemical energy that helps the cell
function .
mixed drinking culture A mixed wet and dry drinking culture
in which binge drinking is common; much drinking is done
away from a dining table (e.g. , England, Canada , and the
United States).
MMORPG ( Massively multiplayer online role-playing game), a
genre of video games in which a very large group of players
interact online , with each other, within a virtual game world .
Among the most popular is World of Warcraft.
mobile phone addiction A reliance on cell phones for all com-
munications , game playing, and other activities. It can con-
sume four or more hours a day, especially when coupled with
computer addiction .
MODCRIT One of the National Council on Alcoholism's assess-
ment tests for alcoholism.
model child The hardworking child of an alcoholic or addict
who often takes over the duties of the dysfunctional parent
or parents.
monoamine oxidase (MAO) inhibitors Psychiatric drugs used
to treat depression by raising the levels of norepinephrine
and serotonin ; can have severe side effects. They have very
dangerous cross-reactions with other drugs and even foods.
morning glory A common garden plant that contains lysergic
acid amide. The seeds are soaked and the liquid drunk,
sometimes causing mild hallucinations.
morphine A powerful analgesic extracted from opium sap that
contains 10% morphine. Extracted and isolated in 1803 , it
set the stage for the refinement of other psychoactive sub-
stances present in many plant and even animal secretions.
"mother's little helper " See meprobamate (Miltown ®)
motivational interviewing A nonconfrontational style of treat-
ment to involve clients in their own recovery process and
help them convert ambivalence about drug use or behavioral
addictions into motivation to make changes.
MPPP A chemical found in the designer drug meperidine
(Demerol ®). Also see MPTP.
MPTP The residue of the chemical used to make MPPP; it causes
brain damage to dopamine-producing neurons and produces
the "frozen addict ," who can 't move muscles voluntarily,
similar to the effects of Parkinson's disease . Also see MPPP.
MRI See magnetic resonance imaging
MRO See medical review officer
mucous membranes Moist tissues lining various structures of
the body, including the bronchi, esophagus , stomach, gums,
larynx, tongue, nasal passages, small intestine , vagina, and
rectum. Drugs can be absorbed via these tissues.
"mule" Someone who smuggles drugs in their luggage , cloth-
ing , or body. Also see "body packer ."
multiple diagnosis The presence of drug addiction in combina-
tion with two or more other ailments (e .g., polydrug diagno-
ses and diabetes) .
"munchies " A strong desire to eat excessively that is caused by
Cannabisuse.
muscarine A neurological toxin found in the Amanita muscaria
mushroom that acts as a parasympathetic nervous system
stimulant.
GLOSSARY G.17
muscle relaxants Central nervous system depressants pre-
scribed to treat muscle tension and pain; also called skeletal
muscle relaxants.
muscling Injecting a drug into a muscle. It takes three to five
minutes for the drug to reach the central nervous system.
Muslims Followers of Islam who are forbidden alcohol and
I
most other psychoactive drugs by their religion.
mutation An alteration in a gene caused by radiation, chemi-
cals , or medications .
Myanmar The modern name for Burma in Southeast Asia, one
of the main growing areas for the opium poppy and more
recently , the production of "ya ba ," or speed.
mycology The science of the study of fungi, especially
mushrooms.
N
N-SSATS See National Survey of Substance Abuse Treatment
Services
NA See Narcotics Anonymous
naloxone (Narcan ®) Opioid antagonist that blocks the effects of
heroin or other opiates ; used to treat overdoses and to help
prevent relapse during treatment.
naltrexone (Revia, ® Vivitrol ®) Opioid antagonist that blocks
the effects of heroin or other opiates; used to treat overdoses
and to help prevent relapse during treatment.
naproxen (Aleve ®) A pain reliever (analgesic); also relieves
fever.
"narc" Narcotics control officer who sometimes works
undercover.
Narcan ® See naloxone
narcolepsy A sleep disorder characterized by sudden periods of
sleep during the day and sleep paralysis or interrupted sleep
at night ; sometimes treated with amphetamines.
narcotic From the Greek narkotikos, meaning "benumbing ";
originally used to describe any derivative of opium but came
to refer to any drug that induced sleep or stupor. In 1914
it became a legal term for those drugs that had high abuse
potential , such as cocaine and opiates.
Narcotics Anonymous (NA) A 12-step self-help program cre-
ated in 194 7 and developed along the lines of Alcoholics
Anonymous but focusing on people addicted to drugs.
National Survey of Substance Abuse Treatment Services
(N-SSATS) An annual survey of all drug treatment facilities
in the United States, public and private.
Native American Church A religious sect of about 250,000
American Indians that uses the hallucinogenic peyote cac-
tus as a sacrament for its rites that combine elements of
Christianity and vision-quest rituals .
Native Americans See American Indians
natural high A feeling of elation and satisfaction that is induced
without the use of psychoactive drugs (e.g. , parachuting ,
sexual activity, or running).
NCA CRIT One of the National Council on Alcoholism's assess-
ment tests for alcoholism.
NCADD Acronym for National Council on Alcoholism and Drug
Dependence.
necrosis Cell death or tissue death , often caused by drinking.
It is a less orderly process than apoptosis , which is pro-
grammed cell death.
needle exchange A harm reduction technique in which out-
reach workers supply addicts with clean hypodermic needles
to prevent the spread of disease .
"needle freak" An injection drug user who prefers the use of
a syringe as a method of drug delivery ; someone who has
become addicted to using a needle to inject drugs.
 G.18 GLOSSARY
negative reinforcement A hypothesis about learning that says
we learn an action when the response lets us avoid a nega-
tive stimulus or removes the negative circumstance (e.g., the
threat of severe withdrawal from heroin reinforces the con-
tinued use of the drug).
neocortex Processes information from the rest of the brain and
I
from the senses. Also called new brain.
neonatal Refers to the period immediately after birth through
the first 28 days of life. Also called newborn.
neonatal abstinence syndrome Withdrawal symptoms in a
drug-exposed infant that appear when he or she is born and
becomes free of the mother's drug-laden blood.
nerve cell See neuron
neuroleptics See antipsychotics
neuron The basic building block of the nervous system, consist-
ing of the cell body, the axon, the dendrites, and the termi-
nals. Also called nerve cell.
neurosis An older term that refers to any mental imbalance that
causes distress; it hinders a person's ability to adapt to his or
her environment, although the person can still function and
think rationally. This is in contrast to a psychosis, which is
marked by a loss of touch with reality.
neuropathy Any condition that affects any segment of the ner-
vous system. The most common form of peripheral neuropa-
thy usually affects the feet and the legs; often a numbness
caused by diabetes.
neurotransmitters Chemicals that are synthesized within the
body that transmit messages between nerve cells. The activ-
ity of these chemicals is strongly affected by psychoactive
drugs.
newborn See neonatal
new brain See neocortex
"nexus" (1) Street name for 2CB, a hallucinogenic drug. (2)
Street name for methcathinone, a synthetic stimulant.
NIAAA National Institute on Alcohol Abuse and Alcoholism.
"nickel bag" Five dollars' worth of a drug, such as heroin; infla-
tion has made it hard to find.
Nicotiana tabacum The most widely used genus and species of
plant that produces smoking and smokeless tobacco.
nicotine The active stimulant alkaloid of the tobacco plant; it
mainly affects the natural neurotransmitter acetylcholine.
nicotine replacement therapy A treatment technique that
supplies a smoker with lower and lower doses of nicotine
(through patches, inhalers, and gum) to alleviate withdrawal
symptoms.
nicotinic receptors A type of cholinergic receptor that is affected
by nicotine.
NIDA National Institute on Drug Abuse.
nightshade See belladonna
NIH National Institutes of Health.
nitrites Synthetic drugs (butyl, amyl, and isobutyl nitrite) that
are used as inhalants; originally used to treat heart pain
(angina); the effects include a rush and mild euphoria fol-
lowed by headaches, dizziness, and giddiness. Also called
volatile nitrites.
nitrous oxide See laughing gas
nitrosamines Chemicals produced from nitrites and second-
ary amines when heated or subjected to highly acidic con-
ditions. Nitrites are found in tobacco and food products,
especially beer, fish, or meat and cheese products preserved
with nitrite pickling salt. Many nitrosamines are considered
carcinogenic. Tobacco smoke is considered one of the major
causes of lung and other cancers.
NMDA receptors A subtype of glutamate receptors; they play a
key role in many physiologic processes.
nociceptive Pain that is caused by external stimuli (eg bofy
truma, injury, bum).
non-nocioceptive Pain that is caused by nerve cell dysfunction
(eg. pinched nerve, nerve disease, multiple scerosis, stroke).
nonpurposive withdrawal Consists of objective physical signs
that are directly observable during withdrawal (e.g., seizures,
sweating, goose bumps, vomiting, diarrhea, and tremors).
nonsteroidal anti-inflammatory drugs (NSAIDs) Drugs used
to control inflammation and lessen pain (e.g., Motrin ® and
Advi l®).
nootropic drugs So-called smart drugs that are supposed to
improve mental ability, particularly for the elderly. They are
often composed of mild over-the-counter stimulants (e.g.,
ephedrine and protein neurotransmitter precursors like leci-
thin and d,l phenylalanine).
norepinephrine A neurotransmitter that prepares the body for
physical activity; it affects energy release, appetite, motiva-
tion, attention span, heart rate, blood pressure, dilation of
bronchi, assertiveness, alertness, and confidence.
normative assessment A prevention technique that teaches
people that the true extent of drug use is less than they think;
the idea is to lessen the pressure they might feel to use.
NORML National Organizationfor the Reformof MarijuanaLaws,
the major political organization trying to legalize marijuana.
"nose candy" Street name for cocaine hydrochloride that is
snorted.
novelty center An area of the brain that signals when something
is new and makes the person pay attention to what is happen-
ing. This area is stimulated by marijuana, which makes the
user pay close attention even to familiar or mundane things.
NSAIDs See nonsteroidal anti-inflammatory drugs
nucleus accumbens septi A nerve pathway in the limbic sys-
tem of the brain that carries reward messages to the nucleus
accumbens and the frontal cortex; it produces a surge of
pleasure and a message to repeat the action when activated.
It is activated by most psychoactive drugs and is thought to
play a crucial role in addiction. Also called survival/reinforce-
ment pathway.
nutmeg A spice that contains MDA and can therefore cause
psychedelic and stimulant effects; when abused, it causes a
profound hangover
nutritional supplements Substances that include food extracts,
vitamins, and minerals; used in treatment to build strength,
facilitate synthesis of neurotransmitters within the body, and
encourage better athletic performance.
nystagmus Involuntary tics of the eye pupils as they move or
even when they are not moving; often caused by drug use,
especially PCP and alcohol. Eye movements are used by law
enforcement personnel to determine if a driver is intoxicated.
0
O-BOAT See office-based opiate addiction treatment
OA See Overeaters Anonymous
obsessive-compulsive disorder (OCD) An anxiety disorder
characterized by disturbing obsessive thoughts that can be
resolved only by acting out some compulsive behavior, such
as hand washing.
obsessive-compulsive personality disorder A personality dis-
order marked by excessive neatness, rigid ways of relating to
others, perfectionism, and a lack of spontaneity.
occipital lobe Part of the cerebrum involved in vision; found at
the rear of each hemisphere .
OCD See obsessive-compulsive disorder
office-based opiate addiction treatment (O-BOAT) A new
treatment protocol that allows certain licensed physicians to

prescribe buprenorphine in their offices rather than only in
a drug clinic setting.
Office of National Drug Control Policy (ONDCP) The cabinet-
level coordinating agency for drug control activities in the
United States.
old brain See primitive brain
ololiqui A variety of the morning glory plant whose seeds con-
tain lysergic acid amide, a weak psychedelic.
ONDCP See Office of National Drug Control Policy
online A state of connectivity to the Internet.
online gambling Gambling on the Internet, which includes :
card games such as Omaha and Texas Holdem in tournament
and ring game structures; online casinos with a variety of
games ; sports betting; bingo; and lotteries.
opiates (1) Any refined extract of the opium poppy (e.g., codeine
and morphine) or semisynthetic derivatives of opium (e.g .,
heroin and hydromorphone). (2) A generic term that refers
to any natural refinement , semisynthetic derivative, or syn-
thetic drug that resembles the actions of opium extracts .
opioids Synthetic opiates (e.g., fentanyl , meperidine
[Demerol ®], methadone , and propoxyphene [Darvon®]);
sometimes used as a generic term for all opiates and opioids.
opium A drug that consists of the sap of the opium poppy; used
legally for analgesia, cough suppression, and diarrhea con-
trol and illegally for euphoria and pain suppression .
Opium Wars Two wars in the 1800s, mostly between England
and China, fought for the British right to sell opium in China .
opportunistic infection An infection that causes illness in a per-
son with a damaged immune system ; often found in AIDS
patients (e.g., Kaposi's sarcoma).
oral gratification Satisfaction or pleasure obtained by placing
something (e.g., tobacco or food) in the mouth.
organic mental disorders Mental illnesses caused by physical
changes in the brain due to injury, diseases , or drugs and
chemicals .
organic solvents Hydrocarbon-based compounds refined from
petroleum that are used as fuels, aerosols , and solvents . Often
inhaled for their psychoactive effects, they include gasoline,
paints, paint thinners, nail polish remover, and acetone.
OTC over-the-counter.See over-the-counter drugs .
outpatient treatment Programs in which the client lives at
home but receives therapy and support from a facility (such
as a drug-treatment center), therapist , or therapy group .
outreach Programs in which therapists or treatment workers go
into the community to identify and assist drug abusers and
addicts rather than wait for them to come into a treatment
facility.
over-the-counter (OTC) drugs Drugs and medications that can
be obtained without a prescription and are legally sold in
retail stores.
overdose The accidental or deliberate use of more drug than
the body can handle; causes severe medical consequences
including coma and death .
Overeaters Anonymous (OA) A 12-step self-help group for
compulsive overeaters.
oxidado (also known as basay, pasta,or rust) An intermediate
substance formed during the extraction of cocaine from
its leaves paste containing solvents . It is smoked. Its use is
mostly confined to South America but Is gaining more popu-
larity in the US. "Oxi " contains other cocaine alkaloids and
other chemicals. It is felt to be more powerful than cocaine.
oxycodone (Percodan ®) A semisynthetic derivative of codeine
that is often abused in a time-release formulation called
OxyContin. ®
GLOSSARY Ci.19
OxyContin ®This time-release version of oxycodone that gives a
heroin-like high when the time-release granules are chewed
or crushed to make the does available at one time.
p
pancreatitis Inflammation of the pancreas , often caused by
heavy drinking.
panic attacks Short episodes (10 to 20 minutes) of intense anxi-
ety, nervousness, heart palpitations, sweating , and shortness
of breath due to anxiety, certain prescription medications,
and the use of stimulant drugs, including cocaine and any
amphetamine ; withdrawal from depressant drugs can also
induce an attack.
panic disorder An anxiety disorder characterized by multiple
panic attacks (sudden repeated episodes of intense anxiety,
panic , and confusion).
Papaver somniferum The botanical name for the opium poppy.
paraldehyde A sedative developed in 1882 that was used to
control symptoms of alcohol withdrawal.
paranoia Irrational suspicions that someone or something is
out to harm you; often induced by psychoactive drugs.
paranoid psychosis Irrational fears that someone or something
is out to get you; the condition can be mimicked by drug use,
particularly cocaine or amphetamine use .
paraphernalia Drug-using equipment such as syringes, glass
pipes, and water pipes .
paraquat An herbicide that has been used to destroy illegal
marijuana crops.
parasympathetic nervous system Part of the autonomic nervous
system that acts to balance the sympathetic nervous system
(i.e. , the sympathetic system speeds up heart rate and breath-
ing while the parasympathetic system slows it down) ; the
parasympathetic system mostly uses acetylcholine , whereas
the sympathetic system mostly uses norepinephrine .
paregoric A tincture of opium and alcohol used since th e early
eighteenth century, mainly for diarrhea.
parenteral drug use Injecting a substance into a vein or muscle
or under the skin.
paresthesias One of the symptoms of panic attacks; it refers to
numbness.
parietal lobe The area of the cerebral cortex that receives infor-
mation from surface body receptors; found in the middle of
the cerebral hemispheres.
Parkinson's disease A disease caused by the destruction of one
of the dopamine-producing areas of the brain , the basal gan-
glia; symptoms include tremors, rigidity, and a masklike face.
paroxetine (Paxil®) An antidepressant that is a selective sero-
tonin reuptake inhibitor.
passive smoking Inhaling exhaled smoke from nearby smokers .
Also see secondhand smoke.
passive transport Movement of a drug from an area of high con-
centration to an area of low concentration.
"pasta" Spanish slang for cocaine paste.
paste An intermediate product of cocaine refinement that con-
tains impurities , such as kerosene and sulfuric acid. This
light-brown doughy substance can be smoked, often in
countries that grow or refine the coca leaf.
patent medicines Medicines that were very popular in the
eighteenth , nineteenth, and early twentieth centuries that
promised cures for almost any ailment. They often contained
opium, cocaine , Cannabis, and alcohol. Their unregulated
distribution was responsible for the creation of thousands of
opium , morphine , and cocaine abusers and addicts.
P'-thologlal gambler A problem gambltr with th< odd<d de - phenothW.ine,Aclassofp,ychiatricmedic>1ionsd"·elop<din
ment o/ 00«,.sive persi<trnc,, which c•US<><ontinwol and the ,a rlyl9~•ndus,dtotreatS<hirophren ia.A lsocalled
<ignifican1di<ruptionolmo>1depanmen1>olhisorh<r life =rolq,tio:1aOOOJ11ip,)·,lioti<1
PAWSS«post--arut<withdrawalsyndrome phenotyp,Theto Lohryof•p<=na,determinedbygenetic
P2Xil0 S«puoxetine andenvironmentalfacto,..,of'!>O"'dtogeootyp<,which
PCPS«ph<nc)"'lid ine focus<>onlyongenetics
p«rlaciliLotorAr<oo,·eringaddictandlorakohol ic who•ct< phen)·lalkylaminepsychedelicsAcl.as,olps)"' hed,licsth.at
.,,memor,advis<r,orcon!idantetohelp,drug•buser , rechemicallyrel.at<dtoadreruolineand,mphetam ine (, .g.,
r<oover. Alsocalkd,po= p<yot<>ndMD'>IA)
p«rgro upAgroupofp<op lewith , imilarinter<<t>:p<<rpr<> · phenylethylamin .. Sttpsych-tim ul anl>
,ur<e>neru:ouragedrugme phen)·lprop,mol.arnineAdeoong,<tllntandmild .app<tit<,up-
"p<llet>"Stt methylph<nklo.t<(Rlulin ,• Au enl.O," Con«rl.0 °) p,....rbat ·,us,d· rryov.,.the-eounterm<'= ·ons
p<lvlcinllammatorydli<..,(l'ID)Acomrnon,,xu.allytrans - totr<a1the sympt omsofooldsandallugie, . Thisi, alsoan
~:~.~:'": •n infection of the uterus, f.allopi.antube,, xtiveingredient inlook •alike stimul.ants
pheromones Natural human hormones louOO in swe>l th.at
p<~tid". A compound of two or mor< amino xili lhat can iru:rea,e,exu.a l d<si?<>nd11timul.ationbyth rirod01
physicaldep,ndrnceStttissuedep,ndrnce
p,rforma-nh.ancingdrugsAbro>dcategoryoldrugs and l'IDSttpelvlcinllammatoryd~..,
<11bsuru:esus,dtoincr<.aseenergy,enduraoc,,andstrrngth pilsr>eTbeerAnylightl.ag,rbttr,originatedinPil<en,C,ech -
(, .g.,,t<roids,humangrowihhormone,anderythropoietin) "'l<"'•kia . lthasahighwhe.atcontentlromthemaltedbarley
p<ri.aqueduculgrayareaAn aruatthebas,ofthebrainth.at pinkcloudS«euthym ia
block>orinhibil>inoomingpainm,s,ages pinpointpupil,Con,trictedpupil,c,US<dbythe....,ofopi -
p<":.~:;1Pert>iningtotheti mebefone ,during,orjust alt<r oid,,panicularlyheroin
plattboAnonac<ive>Ub< Lonce(e.g.,,ugarpill)tha t i,givrnto
p<riphenlr,ervou,sy,t<mOne olthetwom.a jordil'l<»n,ol • :;ient to let ~im thin~ !!!"'tii;ii • real med!;"tion . !t'>
thehum.annervou,,yst<m(whichcomprt.e, the aut onomic
,nd11orn.uic , y,terru):theo therpartolthecomplete<y<tem plattboelfect A,ympt omatic"'!"' nseto a oonacti,·esub-
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plattntalbamerThemembrane betweenth , mother'<aOOthe
p<l'50"'-litydis«de,.Abnormal andrtgidbeh.aviorpatturu letu, ·,bloodsuppli«thatallowsthe•bsorptionolnutn<nt>
thatb<gininchildhood,olt<n l., t•lifetime, andareoften bytheembryowhiletryingtokeeptoxic<11hst.aru:,sout:
s,lf-defealing.They includepar aooid,antilioci.al,narcissistic, psycho>ctivedrugocros,thi<barrt<r
borderline ,andoboess ive..oompul<ivep,=nalitydisordus polydrugabmeTheuseols,,·eraldrug,rith<rin<11cces,ionor
"p<pp ill, "O ld lilrtttn.ameforamphel.Om in<> >10: ti e« • · ~e a «na ·n , orct•mOlildrugabuserure
PH«anSttpo,itronemis,»ntomography(P H )«an polydrug abus,n
poppers Str<et name for the nitrite inhalant>: amyl, butyl,
p<~=~=:.:ut;.. ~;~~=~l~~'.;.,::~,i~o~ : cycloh,xyl,i<opropyl,andi<obutyl
lucinogrnme,;calin , po, itronemi<siontomography(PIT)sanAbrain-imaging
p<yotlTheN,ti,·eAmeric•nn.amefor p<yot< :;:::;~uethatUS<>the>ctionofgluros,toshowbrain
ph.agOC)"t<An immune «ll th.at 11<eksout and destl'O)~ for-
eign microorg.ani<m<,virus<s,>nd de>d«ll< . Also called po,t.-:utewit hd rawalsyn drorne(PAW S)Thep<rsistrn«ol
=ropl,ag,. <11btle),ct•ignificant emolionalandp,ychologie> l problem>
ph.ant.,ticanl>Atermonceus,dlor hallucinogen, tha1c,nl.a>1forth ,ee to>ixmonthsin tor<c0\'"')'•ndcan
"phurnp.anles"A partywh<r<youngp<oplebringpr<ocription triggarel.ap,,
drug,theyh.avet.alcrnfromthrirparents'rn«licin,cab inet> po,tsynapticTh<rndofthedeOOrit<olanen~«llth.at~onthe
orbooghtlromillicit,oun:,s ru:,iving,id,olaneura l m,ssage
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org,n ismsandth,meclunismsofthe iractions. eru:ingolthememoryol•<tr<>slu l eventou1>ideolusual
ph.a;:"""'ynamic toler:u;: Adei;:,s, rnedw,i<m.o;~;rai; hum,n experience(e .g.,comb, t ,s,XIWmolestation . physi-
cal alou«,or a a.rcrash)
psychoactive drug, "pot"Strtttn.ameformar\juaruo
ph.armaooklneticsThe li<.iencetha1 examinesthemov,ment ol potrnti.otionAnex:aggtrat«l,lfectc•u.<dbyu<ingtwodrug,

drug,withinthebody,includingupt.alce,•boorption,tram
; tat' ,d-~ · ,,and,rm ·nafon
ph.armaoologyThe,cirn«ofdrug•c<ion inthebodylt
includesph.arm.aoodyn.amics,pharmarokinetics,pharmaoo-
thenp<uti cs,md toxioology
phencydidine(PCl')Apsychedelicdru gfirlilus,d.,.,,an,s-
theticforp<opleandt hen forutim.als,butthesiderlf<ct<
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- together ; •,yntrgi>tic,lfect
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"pot he>d"5tr<etnameforamar\ju anaabu.,, oraddicL
p<NUrsorAn yphy<iologicallyinoctive>Ub<Lonceth.ati<ron-
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pttdispo,itionAWS<eptibilitytoo vmnc<to theus,of,drug

itw .. smoked,snorted,..,.llow,d,andinj<ct«l:itdi<loned
s,nsoryrnes,ages,d~nedpain,andsupp,essed inhibition,
Exce ·v,us,cmcaus,cat>ton·,roma,•ndoonvul<ion,
phen-fenS«[rn -phen
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hued ityandenvironmentalongwithdrugusecanactivate
thi<tendencyto abusiveandaddict ivemeolp,ychoactiv,
pn[rontalcort<xThelron tpartofthebra inth.at is involvedin
executiv,[unctions,includ ingp lanningoomplexrognitiv,

behaviors, moderating social behavior, determining good
and bad, and expressing personality.
prevention A group of social, medical, psychological, economic,
or legal measures used to lessen the actual impact of drug
abuse and addiction.
primary prevention A series of prevention techniques aimed
at nonusers to promote abstinence, delay drug use, increase
drug education, and promote healthy alternatives.
primitive brain The area surrounded by the reasoning cere-
brum: brainstem, cerebellum, and mesocortex. It handles
instincts, automatic body functions, and basic emotions and
cravings. A version of it is found in all animals. Also called
old brain.
"primo" Marijuana and crack smoked together.
problem child The child of an alcoholic or addict who experi-
ences multiple personal problems.
problem drinking A pattern of drinking, similar to abuse, in
which the drinker is experiencing serious life problems due
to drinking but has not yet had a definitive diagnosis of
alcoholism.
problem gambler One whose gambling behavior causes prob-
lems in any department of his or her life-psychological,
physical, sociological, or vocational.
prodrug Any drug that becomes active when metabolized by the
body (e.g., the amino acid tyrosine is converted to the active
neurotransmitter dopamine in the brain).
prohibition A supply reduction technique that prohibits the
importation, sale, or use of a drug. It is carried out through
laws and interdiction.
Prohibition A specific period in American history (1920 to
1933) when the sale and the manufacture of alcohol were
prohibited by the Eighteenth Amendment.
proof A measure of the amount of pure alcohol in an alcoholic
beverage. In America 100% pure alcohol generally equals
200 proof, so 50% alcohol equals 100 proof.
propanol Used in shaving lotion, shellac , antifreeze , and lac-
quer. Also called isopropylalcohol and rubbing alcohol.
protease inhibitors Drugs that help repress HIV reproduction
by inhibiting an HIV enzyme (protease). Drugs such as indi-
navir , nelfinavir, and ritonavir are used in combination with
other drugs for antiretroviral therapy.
proteins large molecules comprising long chains of amino
acids. They are involved in metabolic reactions and other
biological functions. They also help maintain the cell's
structure.
protracted withdrawal Experiencing craving, side effects , and
withdrawal symptoms long after being detoxified from a
psychoactive drug; usually due to environmental cues that
stimulate memories of use. It can also be caused by with-
drawal , release of small amounts of the drug from fat storage,
or release of accumulated toxic metabolites in the body.
Prozac ®See lluoxetine
pseudoephedrine An isomer of ephedrine that is used in the
illicit manufacture of methamphetamines; found in many
over-the-counter products such as bronchodilators.
psilocin An active hallucinogenic ingredient of the Psilocybe
mushroom.
Psilocybe A genus of mushrooms that contain the hallucino-
genic substances psilocybin and psilocin (e.g., Psilocybe
cubensis and Psilocybecyanescens).
psilocybin An active hallucinogenic substance found in
Psilocybemushrooms. It is converted to psilocin in the body.
psyche The psychological makeup of a person; the soul.
psychedelic A common term for any drug that can induce illu-
sions, delusions , and/or hallucinations (e.g. , 1.5D, MDMA,
psilocybin , ketamine , PCP, and, for some, marijuana).
GLOSSARY G.21
psychic dependence See psychological dependence
psycho-stimulants laboratory variations of the amphetamine
molecule (e.g. , MDA and MDMA) that cause stimulatory and
psychedelic effects. Also called phenylethylamines.
psychoactive drug Any substance that directly alters the normal
functioning of the central nervous system when it is injected ,
I
ingested, smoked , snorted , or absorbed into the blood.
psychological dependence Drug-caused altered state of con-
sciousness that reinforces dependence on the drug. This
is different from tissue dependence. Also called psychic
dependence.
psychopharmacology The field of medicine that addresses the
use of medications to help correct or control mental illnesses
and drug addiction.
psychosis A psychiatric disorder that grossly distorts a person 's
thinking and behavior, making it difficult to recognize real-
ity and cope with life. Schizophrenia , bipolar affective disor-
der, and organic brain disorders are the main causes of this
disorder.
psychotherapy A technique of treatment for emotional , behav-
ioral , personality , and psychiatric disorders based principally
on verbal communication and interventions with a patient as
opposed to physical and chemical interventions.
psychotic Of or relating to psychosis or the behavior associated
with psychosis.
psychotomimetic A drug that can induce behavioral and psy-
chological changes that mimic psychosis.
psychotropic drugs Drugs used to treat mental illnesses (e.g. ,
antidepressants , antipsychotics, and anxiolytics).
P-300 waves A brain wave involved in information processing
that has been shown to be less active in alcoholics and in
sons of alcoholics who have not begun to drink; the lack of
it results in impulse control issues and greater impulsivity
including drinking behavior.
PTSD See post-traumatic stress disorder
P2 P Acronym for phenyl-2-propanol, a chemical used to make
methamphetamine.
public health model A model for prevention that holds that
there is an interaction among a host (the user) , the envi-
ronment , and the agent (the drug); the model is designed
to understand and alter the relationships among these three
factors to control addiction.
pupilometer A device for measuring the size of the pupil , a
technique used to detect drug use.
Pure Food and Drug Act One of the first laws (1906) that pro-
hibited interstate commerce in misbranded food and drugs
and required accurate labeling.
purging Self-induced vomiting; often used by those with buli-
mia to maintain weight.
Purkinje cell Nerve cells located in the cerebellar cortex; some
of the largest in the human brain. One cell can contain thou-
sands of dendrites.
purity A measure of the freedom from contaminants in a sample
of a drug.
purposive withdrawal Withdrawal symptoms falsely reported by
the addict to get drugs from a doctor; psychosomatic symp-
toms triggered by the expectation that symptoms will occur.
Q
Quaalude®See methaqualone
"quick drunk" A description of the instant effects of volatile
solvents.
quid A ball of chewed drug (coca leaf or tobacco) that is kept in
the mouth to allow the active ingredient to be absorbed by
the capillaries in the mouth . Also called chaw or plug.
 G.22 GLOSSARY

R resistance skills training A prevention technique that involves

training an individual to resist peer pressure and the use of
psychoactive drugs.
radio immunoassay (RIA) A method of drug testing that uses
restoration of homeostasis The technique of using medications
antibodies to seek out drugs in biofluids.
and nutrients to restore brain chemical imbalances.
random testing A method of drug testing with short or no noti-
reticular activating system The part of the brainstem involved

I
fication; used by many sports organizations.
in maintaining consciousness; it can be blocked by several
rapid eye movement (REM) sleep A natural part of the sleep
drugs, including anesthetics.
cycle. REM sleep is interrupted by the use of some psychoac-
reuptake ports Sites on the axon terminals of neurons that reab-
tive drugs such as alcohol.
sorb neurotransmitters that have been released into the syn-
rapid_ o_pioid detoxification A technique of rapidly inducing
aptic gap. These sites can be blocked to increase the amount
opioid withdrawal using naloxone or naltrexone and then
of neurotransmitter available to the receptor sites.
mitigating the wit hdra wal symptoms with other medications.
reverse tolerance A turnaround in the body's ability to handle
Rational Recovery A self-help recovery group that uses a cogni-
greater and greater amounts of a drug (e.g., aging or exces-
tive-behavioral approach to treatment and recovery.
sive alcohol abuse reduces the liver's ability to handle alco-
rave A music party-held in a nightclub, in a rented warehouse,
hol, so a chronic alcoholic in his forties or fifties might be
or even outdoors in a field-where drugs, particularly psy-
able to handle only a few drinks instead of the case of beer
chedelics (e.g., LSD, ecstasy [MDMA], GHB, and ketamine),
he could consume 20 years earlier).
are readily available.
Revia ® See naltrexone
receptor A protein found on the dendrites or cell body of neu-
reward deficiency syndrome A theory of addiction that pro-
rons and other cells that receives and then binds specific
poses a common biological substrate and pathway for drug
neurotransmitters; this process of "slotting in" to the recep-
and behavioral addictions. It further proposes that a person's
tor transmits neural messages.
hereditary mabihty to experience reward due to a scarcity of
receptor sites Structural protein molecules on the receiving
dopamme receptor sites in the reward/reinforcement path-
neuron that receive messages from terminals on the sending
way makes the person more likely to search for more-intense
neuron by way of neurotransmitters that slot into the recep-
experiences to trigger this pathway.
tor sites. Also called binding sites.
reward/control pathway
recovery The final step in drug treatment following absten-
reward/reinforcement pathway See nucleus accumbens septi
tion, initial abstinence, and long-term abstinence. Clients
rhabdomyolysis Muscle damage.
have_ changed their lifestyle and ha ve overcome their major
RIA See radio immunoassay
physirnl and mental dependence on psychoactive drugs or
RID Acronym for restless, irritable, and discontent; reminds
addictive behaviors. They are committed to abstinence, have
addicts of the triggers that lead them into relapse.
accepted their addictive disease, and are committed to a con-
"rig" Syringe or hypodermic needle.
tinued drug-free lifestyle .
risk factors Hereditary and environmental factors that put ado-
recreational drug use A level of drug use after experimentation;
lescents and adults at risk to abuse drugs (e.g., physical and
people seek out the drug to experience certain effects but
mental abuse, a family history of drug abuse, living in pov-
there is no established pattern of use and it has a relatively
erty, and a lack of self-esteem).
small impact on their lives; use is sporadic, infrequent, and
risk-focused prevention Programs that identify a person's risks
unplanned. Also called social drug use.
to use drugs (e.g., physical or sexual abuse) and teach the
"reefer" An antiquated term for a marijuana cigarette.
person to deal with them.
rehabilitation Restoring an abuser or addict to an optimum
Ritalin ® See methylphenidate
stat_e of physical and psychological health through therapy,
"rock" (1) A piece of crack cocaine. (2) Slang for crack.
social support, and medical care.
Rohypnol ® See flunitrazepam
reinforcement A learning process whereby a person receives a
"roid" Street name for an anabolic steroid.
reward for a certain action. That reward, in turn , increases the
"roid_rage" Sudden outbursts of anger caused by excessive ste-
likelihood that the person will repeat that action. Negative
roid use. The rage goes away when the drug is stopped.
remforcement uses the concept that a person will learn to
"rolling" The Generation X term referring to the practice of
avoid an action if the consequences are painful.
concealmg an ecstasy tablet in the middle of a Tootsie Roll. ®
relapse Reoccurrence of drug use and addictive behavior after a
rubbing alcohol See propanol
period of abstinence or recovery.
rush A sense_ of elation or intense satisfaction caused by some
relapse_ prevention A treatment technique that focuses on pre-
psychoactive drugs. The sensations can be mimicked by
ventmg the recovering addict from using again.
natural highs, such as thrill-seeking, meditation, and fasting.
relationship addiction A desire to have a compulsive relation-
ship with one or more persons.
REM See rapid eye movement (REM) sleep
s
repressed memories A Freudian term for a memory that is in
SA See Sexaholics Anonymous
the unconscious and not available to the conscious mind· a
favorite target for psychotherapy. ' sacrament_ A visib_lesign of an inward grace; a rite or ceremony
resiliency The ability of an individual to resist drug use and drug with a spmtual context. Historically, a number of psy-
abuse; the resistance qualities are formed by hereditary and choactive drugs have been used sacramentally in religious
services.
environmental influences at home, in school, and in the
saliency The importance of a substance or compulsive behav-
community.
resiliency program A prevention technique that involves build-
ior, i.e., "Dopamine release increases the saliency of the drug
that caused it."
ing on natural strengths that people already have available
within themselves. Salvia divinorum A psychedelic plant whose effects have been
resin The psychoactive secretions of the Cannabis plant on the
likened to_PCP. Salvinorin A is thought to be the key psy-
outer portions of the plant and on the flowering buds. choactive mgredient, although how this extract works in the

brain is not understood and no receptor sites have yet been
identified as the site of action.
SAMHSA Acronym for Substance Abuse and Mental Health
Services Administration.
satiation centers Parts of the brain that tell us when a craving of
the old brain, such as thirst or hunger, is satisfied. Also called
on/off switch or "stop" switch .
Sativex A cannabis based oral medication used for the treat-
ment of spasticity in patients with multiple sclerosis. It con-
tains equal concentrations of THC and CBD whereas most
smokeable marijuana hashas a much greater THC to CBD
ratio. Also known by the chemical name nabiximois , Sativex
has been available In Europe for many years and just recently
begin FDA trial in the US.
scheduled drugs Drugs that are controlled by the Controlled
Substances Act of 1970. Illegal drugs such as cocaine, her-
oin , and methamphetamine are Schedule I. Strong drugs
used medicinally are Schedule II (e.g., morphine, meperi-
dine [Demero l®], and methylphenidate [Ritalin ®]).
schizophrenia A mental illness (psychosis) characterized by
hallucinations , delusional and inappropriate behavior,
poor contact with reality, and an inability to cope with life .
Excessive use of strong stimulants, especially methamphet-
amine , can mimic the symptoms of schizophrenia.
scopolamine An alkaloid found in certain plants (e.g. , deadly
nightshade) that can induce sleep. Also called truth serum.
second messenger system A process whereby a neurotransmit-
ter attaches itself to another neuron to limit or increase the
release of other neurotransmitters (e.g., the release of endor-
phins to inhibit the release of substance P, a pain transmitter) .
secondhand drinking The effect of heavy drinking on non-
drinkers (e .g., loud or obnoxious behavior while some want
to study,unwanted sexual advances or vomit in the dormi-
tory hallway).
secondhand smoke Cigarette or cigar smoke that is inhaled by a
nonsmoker while in the presence of smokers. About 50 ,000
premature deaths each year are attributed to secondhand
smoke.
secondary prevention A strategy to identify those who are
beginning to experiment with drugs and prevent them from
using or having problems with drugs.
Secular Organization for Sobriety (SOS) A 12-step self-help
group for agnostics and atheists.
sedative A drug that eases anxiety and relaxes the body and the
mind. Also called tranquilizers and muscle relaxants.
sedative-hypnotic Any drug that relaxes and soothes the body
and the mind, eases anxiety, or induces sleep. The main cat-
egories are benzodiazepines (e.g., alprazolam [Xanax ®] and
clonazepam [Klonopin ®]) and barbiturates (e.g. , phenobar-
bital). More recently , the Z-hypnotics have become popular .
select tolerance The variable development of tolerance for dif-
ferent effects of a drug (i.e. , as the user develops a tolerance
for desired mental effects, he or she may be developing less
tolerance to other lethal effects of that drug , thus making
overdose more likely).
selective prevention Targets groups or individuals whose risk
of developing substance abuse or dependence is above aver-
age . Groups could be defined by age, gender , socioeconomic
status , or other defining factors.
selective serotonin reuptake inhibitors (SSRis) A group of
antidepressants that increase the levels of serotonin in the
central nervous system (e.g. , paroxetine [Paxil ®] and sertra-
line [Zoloft ®]).
Selective Severity Assessment Test One of the main diagnos-
tic tests for addiction; evaluates 11 physiological signs of
addiction.
GLOSSARY G.23
sensitization See inverse tolerance
serotonin An inhibitory neurotransmitter involved in mood
stability, especially depression , anxiety , sleep control, self-
esteem , aggression, and sexual activity.
sertraline (Zoloft ®) An SSRI antidepressant.
set A person 's mood and mental state when taking a drug.
I
setting The location at which a drug is taken; ambience is
important in determining the overall effect of a psychoactive
drug such Ecstasy
Sexaholics Anonymous (SA) A 12-step self-help group for sex
addicts.
sexual addiction Sexual behavior over which the addict has
lost control; includes masturbation, serial affairs, phone sex ,
excessive use of pornography, and the use of prostitutes.
sexually transmitted diseases (STDs) Infections transmitted as
the result of sexual contact with an infected person (e.g. ,
chlamydia, gonorrhea , syphilis , trichomonas , HIV disease ,
genital herpes , and hepatitis B and C). Also called venereal
disease.
"shabu" Slang for smokable methamphetamine. See "ice ."
shaman A medicine man , curandera, or pries/priestesst who
uses magic or spiritual forces to cure illness, communicate
with spirits, and control the future. Shamans often use psy-
choactive drugs to help them reach the desired mental state
or trance.
shamanic Any religion that believes that only a shaman is capa-
ble of communicating with the supernatural and influencing
those forces.
shock therapy See electroconvulsive therapy
"shoot up" To inject oneself with a drug.
"shooting gallery " A building or room where illicit drugs are
sold and injected.
SIDS See sudden infant death syndrome
sildenafil citrate (Viagra®) A medication to treat erectile
dysfunction.
Silver Spice One of the brands of synthetic marijuana.
simple phobia Irrational fear of a specific thing or place.
single-photon emission computer tomography (SPECT) scan
A brain-imaging technique that measures cerebral blood flow
and brain metabolism; enables clinicians and researchers to
study how a brain functions before, during, and after drug
use; can also image brain function of people with neurologi-
cal diseases or syndromes, such as Alzheimer's or ADHD.
sinsemilla A technique for growing high-potency marijuana
that consists of keeping female marijuana plants from being
pollinated by male ones, thus greatly increasing the THC
content to as high as 30% or more.
skeletal muscle relaxants See muscle relaxants
skin patch A drug-soaked adhesive patch that releases drugs
slowly (over a period of days) through contact absorption
(e .g., nicotine patch).
"skin popping " Injecting a drug under the skin rather than into
a vein or muscle.
"skittles " Slang for dextromethorphan tablets.
"smack " Slang for heroin.
small intestine The portion of the digesti ve tract between the
stomach and the large intestine that absorbs ingested food ,
liquids, and drugs through the capillaries lining its walls .
smokeless tobacco Chewing tobacco or snuff; any tobacco that
is not smoked.
"sniffing " Breathing in an inhalant through the nose directly
from the container .
"snorting " Inhaling a drug through the nose to be absorbed by
the capillaries in the mu cos al membranes ; it takes five to 10
minutes for a drug to reach the brain when it is snorted.
"snot" See methamphetamine freebase
 G.24 GLOSSARY
snuff ( 1) Powdered tobacco that is absorbed through nasal
membranes when snorted. (2) A term for finely chopped
tobacco leaves that are put into the buccal membrane of the
mouth for absorption (e.g., Copenhagen ® and Skoal ®).
sobriety A term for abstinence from drugs or alcohol (being
sober); the concept is used mostly in Alcoholics Anonymous
I
and other 12-step groups.
social drinking A level of drinking between experimentation
and habituation; drinking is sporadic, infrequent , and not
patterned (e .g., moderate drinking at social occasions rather
than by oneselO.
social drugs See recreational drugs
social drug use See recreational drug use
social model recovery program A nonmedical outpatient drug
treatment program that uses a number of therapies .
social phobia Fear of being seen by others as acting in a humili-
ating or embarrassing way (e.g ., fear of eating in public).
soda doping Ingesting sodium bicarbonate 30 minutes prior to
exercise to supposedly delay fatigue.
sodium ion channel blockers A class of medications that inter-
fere with neuron transmission to mute cocaine ,s or another
drug 's effects .
soma Ancient term for Amanita muscaria, a hallucinogenic
mushroom.
Soma®Trade name for carisoprodol, a skeletal muscle relaxant.
somatic system Part of the peripheral nervous system that
transmits sensory messages to the central nervous system
and then transmits responses to muscles , organs, and other
tissues.
somatoform disorders Mental illnesses in which psychological
conflicts manifest themselves as physical symptoms.
somatotype A person's body type; particularly influenced by
genetics. The three somatotypes are endomorphic, meso-
morphic , and ectomorphic.
SOS See Secular Organization for Sobriety
SPECT See single-photon emission computer tomography
(SPECT) scan
speed Street name for any amphetamine or methamphetamine.
speedball A drug combination of an upper and a downer (usu-
ally heroin and cocaine , or heroin and methamphetamine)
that is injected, snorted, eaten , or smoked.
"speed freaks" the street name for methamphetamine abusers.
spirituality An individual's personal relationship with his or her
higher power; awareness or acceptance that one is part of a
greater purpose or existence than just his or her own worldl y
existence; a crucial aspect of 12-step groups.
spit tobacco A term for smokeless tobacco , including chewing
tobacco and snuff.
sponsor See peer facilitator
"spraying" Slang for spraying an inhalant directly into the nose
or mouth.
SSRis See selective serotonin reuptake inhibitors
Saint Anthony's Fire A name for ergot poisoning. Ergot is a
rye or wheat fungus that contains lysergic acid amine , a hal-
lucinogen. One of the symptoms is a burning sensation of
the skin.
stacking Using two or more steroids at one time to increase
effectiveness.
stages-of-change model This model used in treatment delineates
five predictable and identifiable stages one goes through in
the process of making life changes: precontemplation, con-
templation, determination (or preparation), action, and
maintenance.
stash (1) A hiding place for an illegal drug supply. (2) A supply
of illegal drugs .
stay-stopped circuit A postulated system that can indicate the
likelihood that an addict can stay abstinent after initial treat-
ment for an addiction.
STDs See sexually transmitted diseases
stellate cell A star-shaped liver cell that stores vitamin A com-
pounds and fat molecules; alcohol and biochemicals released
from other liver cells can cause scar tissue .
"step on " Adulterating a drug with the addition of cheap or
inactive substances to increase the amount available for sale.
steroid See anabolic-androgenic steroid
stimulant Any substance-including cocaine, amphetamines,
diet pills , coffee , khat, betel nuts, ephedra , and tobacco--
that forces the release of epinephrine and norepinephrine,
the body 's own stimulants.
"stop" circuit (switch) The areas of the brain that can stop an
action after it has begun. The main part of this circuit is in the
left-orbita l prefrontal cortex. The "stop" switch is impaired
by continued drug use or practice of compulsive behaviors .
stout A top-fermented variety of ale that is very dark and sweet,
mostly associated with Ireland.
STP See DOM (2,5-dimethoxy-4-bromo-amphetamine)
stress The body's reaction to illness and environmental forces.
It produces psychological strain and physiological changes,
including the release of cortisol, rapid respiration and heart
rate , constricted blood vessels, and the release of hormones.
subcutaneous Under the skin; a route of drug administration.
sublingual Under the tongue ; a route of drug administration
where the drug is absorbed by mucous membranes .
substance abuse Continued use of a psychoactive drug despite
adverse consequences.
substance dependence Maladaptive pattern of substance use
(e.g. , addiction).
substance P The neurotransmitter that transmits pain from
neuron to neuron.
substance-induced disorders Disorders caused by the actual use
of psychoactive drugs (e.g ., methamphetamine psychosis).
substance-related disorders The overall classification for drug
disorders that is divided into substance use disorders and
substance-induced disorders.
substance use disorder A category of substance-related disor-
ders defined by the pattern of drug use , including substance
dependence and substance abuse.
substantia nigra Part of the extrapyramidal system in the brain
that helps control muscle movements.
substitution therapy Using a drug that is cross-tolerant with
another to detoxify a user who has become physically
dependent.
sudden infant death syndrome (SIDS) A sudden and often
unexplainable death of an otherwise health y infant; often
connected to drug use during pregnancy.
Summer of Love A period in 1967 when the hippie movement
flourished; characterized by drug use, mostly marijuana,
other psychedelics , amphetamines , and free love.
supply reduction A prevention approach that uses such tech-
niques as interdiction of illegal drugs, drug use laws, legal
penalties, and crop eradication to reduce the supply of drugs
available to users , abusers, and addicts.
suppository A drug-infused device used for introduction of a
substance into the rectum for absorption .
supraphysiological Relating to a dose of any substance (neu-
rotransmitter , hormone, or other naturally occurring agent)
that is more potent than would normally occur.
susceptibility A person 's individual vulnerability to use drugs
addictively or engage in compulsive behaviors; it is based on
heredity, environment , and drug use. These factors make one
more likely to use and another to resist use.

Sustiva (lefavirenz) A prescription medication used in the treat-
ment of HIV/AIDS which is diverted or stolen from patients
smoked for its psychedelic effects.
sympathetic nervous system Part of the autonomic nervous
system; it helps control involuntary body functions, includ-
ing digestion, blood circulation, and respiration; it works
with the parasympathetic nervous system to balance body
functions .
synapse The process of nerve cell communication through the
release of neurotransmitter chemicals that cross the synaptic
gap to transmit a message from one nerve cell to another.
synaptic gap The tiny gap between the terminal of the sending
nerve cell and the dendrite or body of the receiving cell.
synaptic plasticity The ability of the synapse to change in
strength and function when that pathway is overused or
underused, often by the intake of drugs or by constant
stress. It helps the brain adapt to the toxicity of psychoactive
substances.
synergism An exaggerated effect that occurs when two or more
drugs are used at the same time. One reason why this effect
occurs is because the liver or another area of the body is
busy metabolizing one drug, so the other slips through
unchanged.
synesthesia An effect of hallucinogens that converts one sen-
sory input to another (e.g., colors are heard and sounds are
seen).
synthesis The process of making drugs in the laboratory from
chemicals rather than extracting them from plants or ani-
mals. Biochemicals can also be synthesized internally by the
body.
synthetic marijuana Marino! ® and Cesamet ® are prescription
synthetic marijuana used to treat health conditions. Gold or
Silver Spice® and Kl ® are sold as incense and used recre-
ationally; they have many of the properties of marijuana but
are stronger and with more side effects .
syphilis A sexually transmitted disease with three levels of
infection severity; less common since the discovery of peni-
cillin and other antibiotics.
T testing method for the urine of a suspected drug user.
T-cells A type of white blood cell (lymphocyte) that helps
fight infection. Low numbers of T-cells signal an impaired
immune system, possibly caused by an HIV infection.
T-helper cell See CD4+ cell
tachycardia Rapid beating of the heart caused by cardiovascular
disease or drugs, especially stimulants .
tachyphylaxis See acute tolerance
tar A by-product of smoking that is carcinogenic.
tar heroin A black or dark brown heroin originally grown and
processed in Mexico. It contains many impurities but can
be 20% to 80% pure. It is water-soluble . Tar heroin is now
processed in Africa and South America as well.
tardive dyskinesia A nerve disorder caused by antipsychotic
drugs; symp toms include invo luntary facial tics and tongue
movements.
TCE See trichloroethylene
TEDS See Treatment Episode Data Sets
temperance A philosophy of light-to-moderate drinking that is
an alternative to abstinence or prohibition.
temporal lobe The part of the cerebral cortex involved in emo-
tions, language, sensory processing, and memory.
teratogen A drug that produces a birth defect when taken dur-
ing pregnancy.
terminals Small buttons at the ends of nerve cells that release
neurotransmitters .
GLOSSARY G.25
tertiary prevention A prevention strategy aimed at drug abus-
ers and addicts to reduce harm to themselves and to society.
Intervention, treatment, and harm reduction techniques are
used.
testosterone The most potent male hormone, formed mainly
in the male testes; the major naturally occurring anabolic
I
steroid.
tetrahydrocannabinol (THC) The main psychoactive ingre-
dient of marijuana; mimics the natural neurotransmitter
anandamide.
"Texas shoeshine" Spray paint containing toluene and abused
as an inhalant.
Thai sticks Marijuana buds skewered to bamboo shoots; a
potent packaging of marijuana.
thalamus Part of the diencephalon deep inside the brain that
helps relay information to the cerebral cortex.
THC See tetrahydrocannabinol
theobromine An alkaloid from the cacao plant that is similar to
caffeine; used as a diuretic, heart stimulant, muscle relaxant,
and vasodilator.
theophylline An active alkaloid found in tea leaves along with
caffeine; used as a diuretic, heart stimulant, muscle relaxant,
and vasodilator.
therapeutic community Any long-term (one- to three-year)
residential inpatient program that provides full rehabilitative
and social services for addicts and alcoholics.
therapeutic drugs Drugs, including anti-inflammatories, pain-
killers, and muscle relaxants, that are used for specific medi-
cal problems .
therapeutic index The effective dose of a drug vs. the lethal
or dangerous side effects of that drug; the ratio of the lethal
dose to the effective dose.
therapy The treatment of addiction or other problem through a
variety of methods, including counseling and group therapy,
that is conducted by a licensed or credentialed professional.
theriac An opium-based cure-all that was developed almost
2,000 years ago. It has undergone many changes in formula-
tion, but the opium remains.
thin-layer chromatography (TLC) A moderately precise drug-
threshold dose The minimum amount of a drug that produces
a desired effect.
tissue dependence The biological adaptation of body cells and
functions due to excessive drug use. Also called physical
dependence.
titration Adjusting the dose of a drug to achieve a desired effect.
TLC See thin-layer chromatography
toad secretion See bufotenine
tobacco The cured leaves of Nicotinia tabacum or other tobacco
plant. It is the source of nicotine and can be smoked, chewed,
or used as snuff.
tolerance The increasing ability of the body to metabolize or
consume greater and greater amounts of a drug or other for-
eign substance.
toluene A liquid hydrocarbon solvent that is used as an intoxi-
cating inhalant. It is found in many household products and
glues .
topical anesthetic A solution, ointment, or gel containing
a substance that deadens sensations in the skin, mucous
membranes, or conjunctiva (e.g., cocaine, lidocaine, and
procaine).
TOUGHLOVE® A treatment approach that requires an addict's
family to set strict limits on behavior to break through denial
and change behavior.
toxic substance A substance that is poisonous when given in
certain amounts. Many toxins are poisonous at low doses.
 G.26 GLOSSARY

toxicology The study of toxic substances. V

tracking The ability of the eyes to follow a moving object.
tracks Needle scars on an injection drug user's body, especially
Valium ® See diazepam
the arms.
vaporization technique A way to aerosolize a liquid without
trade name A drug company's name for its patented medication.
combustion so that it can be inhaled and absorbed by the
Also called brand name.

I
lungs.
trailing phenomenon A drug-induced visual distortion (usually
vasoconstriction Constriction of blood vessels, often due to drugs,
from marijuana or 1.5D) in which the user sees a trail follow-
especially stimulants like cocaine and methamphetamine.
ing a moving object.
vasodilation Dilation of blood vessels; can be caused by alcohol
tranquilizers Drugs that have antianxiety or antipsychotic
or other drugs.
properties but don't induce sleep; also prescribed as muscle
venereal disease See sexually transmitted diseases (STDs)
relaxants.
ventral tegmental area (VTA) The origin of a prominent dopa-
transdermal A method of drug delivery whereby a drug-infused
mme pathway that ascends to various parts of the limbic
patch is adhered to the skin so that the drug can be absorbed
system, particularly the nucleus accumbens; it is part of the
through the skin.
reward/reinforcement pathway.
treatment The use of various techniques and therapies to
ventricle A natural cavity in the brain, heart, or other organ.
change maladaptive patterns of behavior and restore a client
The brain's ventricles are filled with cerebrospinal fluid.
to full health.
vesicle The microscopic sacs in the terminals of nerve cells that
Treatment Episode Data Sets (TEDS) A federal survey that
store neurotransmitters until they are released into the syn-
supplies descriptive information about admissions to sub-
aptic gap.
stance-abuse treatment providers.
Viagra® See sildenafil citrate
trichloroethylene (TCE) A common organic solvent found in
Vicodin ® See hydrocodone
correction fluids, paints, and spot removers.
Vitas vinifera The most common species of grape used to make
tricyclic antidepressants A class of psychiatric medications that
wine; comes in more than 5,000 varieties.
increase the activity of serotonin to elevate mood and coun-
Vivitrol ® See naltrexone
ter depression (e.g., amitriptyline).
volatile nitrites See nitrites
triggers Any object or action that activates craving in a recov-
volatile solvents Petroleum distillates (e.g., toluene and gaso-
ering drug user (e.g., the sight of white powder, money, a
lme) that are abused as inhalants.
syringe, or a former neighborhood or drug-using partner).
Volstead Act The 1920 law that prohibited the sale and the pub-
triple diagnosis The coexistence of drug addiction, a major
he consumption of alcohol. See Prohibition.
mental illness, and AIDS or other physical illness.
VTA See ventral tegmental area
trismusJaw muscle spasm.
truth serum See scopolamine
tryptophan An amino acid that is a precursor of serotonin.
w
tuberculosis A bacterial disease that can affect and damage any
organ but most often the lungs. WADA See World Anti-Doping Agency
"tweak" (1) Street name for methamphetamine. (2) Unusual "War on Drugs" The term was popularized by President Richard
hyperactive behavior and emotions caused by excess Nixon in 1971 even though efforts to prohibit drug use go
amphetamine use. back another 57 years to the implementation of the Harrison
12-step programs Self-help groups based on Alcoholics Narcotics Act. The War on Drugs is a combination of leg-
Anonymous and the 12 steps of recovery. Their purpose is islallon, pohce and military actions, prevention efforts, and
to change addicts' thinking and behavior and enhance their drug policies to stem the use of drugs. The Obama admin-
spirituality. istration decided to avoid the use of the term, feeling it is
twin studies Long-term studies of adopted twins either raised counterproductive.
together or separately to determine the influence of heredity WCTU See Women's Christian Temperance Union
"weed" Street name for marijuana.
on a person.
Wernicke's encephalopathy A central nervous system disease
u caused by excessive long-term drinking and linked to thia-
min deficiency; symptoms include delirium, loss of balance,
tremors, and visual impairment; often seen in combination
universal prevention This type of prevention is aimed at an
with Korsakoff's syndrome.
entire population, providing information and skills neces-
wet drinking culture A culture where daily drinking is sanc-
sary to prevent drug abuse.
tioned and is integrated into everyday life, often with meals
uppers Stimulants.
(e.g., France and Italy).
urethritis Inflammation of the urinary tract, often caused by
Wets Anti-Prohibitionists active in the United States in the
excessive use of steroids.
1920s and 1930s working toward the repeal of the Volstead
urinalysis Analysis of urine to test for drug use.
Act.
U.S. Household Survey A survey of drug use and attitudes
WFS See Women for Sobriety
in the United States compiled by the Substance Abuse and
Whippets ® Small metal canisters containing nitrous oxide
Mental Health Services Administration, Office of Applied
(laughing gas). They are sold as whipped cream propellants
Studies.
but abused as an inhalant.
whiskey A distilled alcoholic beverage made from a mash of fer-
mented grains, including rye, barley, corn, oats, and wheat;
usually contains about 40% alcohol (80 proof).
white matter Brain matter composed mostly of axons, glial
cells, and myelin.

"whites" Street name for amphetamine sulfate (Benzedrine ®)
tablets originally prescribed for weight control.
WHO See World Health Organization
wine An alcohol beverage made from the fermented juice of
grapes; can be made from other fruits and vegetables (e.g.,
rice wine , plum wine, and apple wine). Alcohol content of
wine is usually 10% to 14% but can go as high as 16%.
"wired " Intoxicated by a stimulant (e.g. cocaine or meth-
amphetamine).
withdrawal The body's attempt to rebalance itself after pro-
longed use of a psychoactive drug. The symptoms range from
mild (caffeine withdrawal) to severe (heroin withdrawal) to
life-threatening (benzodiazepine withdrawal). The onset and
the duration of symptoms are generally predictable.
Women for Sobriety (WFS) A self-help group therapy organiza-
tion for female alcoholics.
Women's Christian Temperance Union (WCTU) Women 's cru-
sade to close saloons and promote temperance; founded in
1874, it had a peak membership of 500 ,000 .
"works" Syringe, cotton , and other paraphernalia used to inject
heroin and other drugs.
World Anti-Doping Agency (WADA) A drug-testing and regu-
latory agency founded in 1999 with a mission to promote,
coordinate, and monitor the fight against doping in sport
in all its forms . It does thousands of tests each year, mostly
of Olympic athletes . It also provides a list of banned drugs
every year.
World Health Organization (WHO) The directing and coordi-
nating authority for health within the United Nations system;
provides leadership on global health matters (e.g., research,
setting standards , providing policy options, and providing
technical support to member nations) .
World of WarCraft One of the most popular MMORPGs (mas-
sively multiplayer online role-playing games) that involves
more than 12 million players. It was released in 2004.
GLOSSARY Ci.27
X
X See ecstasy
Xanax®See alprazolam
xanthines A class of alkaloids found in 60 plants (e.g., Coffea
arabica, Thea sinensis, Theobroma cacao, and Cola nitida).
The most prominent xanthine is caffeine.
XTC See ecstasy
y
yage A hallucinogenic psychedelic drink made from the aya-
huasca vine of South America .
yeast A fungus that exists in soil, fruits , some vegetables , and
animal excreta; used to ferment carbohydrat es, especially
sugars , into alcohol and to make bread rise.
yohimbe tree The source of yohimbine , a stimulant brewed
in water as a tea or used in tablet or liquid form as an
aphrodisiac.
z
zero tolerance A prevention philosophy that allows no toler-
ance or second chances for drug use; often used in schools.
Z-hypnotics Benzodiazepine-like medications , including
zopiclone (Imovane ®), zolpidem (Ambien ®), and zaleplon
(Sonata ®). Eszopiclone (Lunesta ®) is also considered a
Z-hypnotic .
Zoloft®See sertraline
Zyban® See bupropion
1.0
Note: This is a selective index. Any entry in qum.ation marks is usually a street name for
a drug. In addition, all trade names of drugs are signified with a~. More comple te citations
for drugs are at the chemica l names, with cross-references from the trade names.
A accidents. See automobile accidents
A-Rod (Alex Rodriguiz ) 7.11
AA. SeeAlcoholics Anonymo us
AAS (ana bolic -aindrogenic steroids).
Seesteroids
Abilify.111Seearipiprazole 10.28 ,
10.29 , 10.30
abruptio plac enta , 8.22 , 8.23
abscess, 1.32, 2.4, 3.16, 4.12, 4.15,
4.19 - 20, 4.43, 8.43--44
absinthe, 5.8
absorption of drugs, 3.8 , 3.10, 3.36,
See also adhes ive pat ches;
contact absorption; mucous
membrane absorptio n
alcohol, 1.38, 5. 45
coca/cocaine, 1.8, 1.15, 1.20-1.23
factors in speed of, 5.9
inha lants, 1.4, 1.38
lungs , 1.4, 1.20, 1.38
pregnancy, 8. 25
skin, 1.13
smoking, 1.20
techniques , 1.4, 1.8, 1.15,
1.20-1.21
testing , 8.53
abstinence, 2.33-3 4, 2.37 , 2.47,
5.4, 5.19. See also anorexia
nervosa; detoxification;
initia l abstinence; pro hibi tion
vs. temperance; relapse;
temperance; 12-step
programs; wit hdrawa l
alcoho l, 5.4, 5. 17, 5.28,
5.31, 5.44
cognitive skills, 9.64, 10.5
dua l diagnosis 10.32
initia l phase, 9.21, 9.36 , 9.38--39,
9.42, 9.46, 9.67, 10.7
Internet addiction, 9.54
liver disease, 5.17, 5.22, 5.26, 5.36
long -term , 1.28, 9.21-22, 9.37,
9.39--40, 9.42, 9.46, 10.24
medications, 1.28
Native Americans , 5.44
nicotin e addiction, 9.40
recovery, 9.6, 10.9
sedatives, 9.44
self-help groups, 9.28--31
as socia l goal, 8.4-5, 10.22
treatment, 9.10, 10.9, 10.20, 10.23
abuse history (emotiona l, physica l,
sexual), 2.12, 2.14, 2.31,
2.40 , 2.41 , 2.47, 9.52, 9.53.
See also domestic violence
alcoho l, 5.12, 5.22, 5.38. 10.16
behavioral compulsions, 7 .32
children of addi cted parents , 8.32
drug abuse by victim, 8.42
as environmenta l factor , 5.22,
5.24, 5.34
mothers of FAS babies, 8.2 1
academic model of addiction,
acamprosate, 9.9, 9.2 1, 9.46, 9.66
ADDICTION, 5.1, 7.2-7.60
Accutrim. ®See pheny lpropano lamine
acetaldehyde , 5.8, 5.16, 5. 19,
5.25, 5.44
acetaldehyde dehydrogenase (ALDH),
5.8, 5.8--9, 5. 19, 5.25, 5.44
acetaminophen (Tylenol *) 4.7,
7.15, 8.55
drug combinations, 4.10 ,
4.24, 4.25
emergency rooms, 4.33
pain control, 4.23
acetic acid, 5.8, 5.9
acetone, 3.7, 3.25, 7.3, 7.4
acetophenazine (Tindal*), 10.30
acetylcholine (ACh), 2.20-22, 2.25,
2.46, 3.12, 3.45, 7.56, 9.36
Alzh eimer's, 2.22 , 2.38
cocaine, 3 .12
function of, 6.20
n icotine, 3.46, 3.48, 3.50
"acid" (LSD), 6.6--10
"acidheads, .. 6.8
acne 5.21 , 7.18, 7.19, 7.60
ACoA. See Adult Ch ildren of
Alcoholics
Acomp lia. * See rimonabant 10.29
acquaintance rap e, 7.24.
See also date rap e
acquired immune deficiency
syndrome. See AIDS and HIV
10.13
ACTH. See corticotrophin 10.29
Actifed, ®4.3
action potential, 2.20, 2.23.
See also neurochemistry
action-seeking gambler, 7.39,
7.39, 7.40
action stage, 9.27
Actiq.®See fentan yl
active transport , 2.6, 2.23
acupuncture , 7.29, 9.36, 9 .36,
9.39, 9.41
acute anxiety reaction (bad trip), 6.9,
9.46--47
"B-FLY," 6.21
dextromethorphan (DM), 6.21
marijuana , 6.34
MOMA, 6.15-16
acute tolerance (tachyphylaxis), 2.27,
5.24--25
acute withdrawal, 4 .17, 4.29, 4.42,
6.33, 6.39--40, 9.12, 10.14,
10.17 , 10.19 See also post-
acute withdrawa l syndrome
Acutrim, ®3.3
ADAM (Arrestee Drug Abuse
Monitoring Program) , 9.8
"Adam" (MOMA), 1.33, 6.4, 6.15
Adanon. ®See methadone
Adapin. * See doxepin
ADAPT (Air Force Alcohol and Drug
Abuse Program), 8. 49
Addams, Jane, 4.10
Adderall. ®See d,l amphetamine
See also levels of use;
treatment
ADHD, 3.30--3 1, 10.6. 10.13,
10.22 , 10.25 , 10.27
(attention deficit
disorder)
alcohol, 1.34, 3.20, 3.22, 5.22-26,
5.45, 7.32, 7.38
amphetamines , 3.6, 3.24
brain changes, 2.17
caffeine, 3.42, 10.16 , 10.29
cocaine 3.19, 3.20, 10.2, 10.5,
10.8, 10.14, 10.17 , 10.20,
10.29
comp ulsive behaviors, 3.14, 3.20,
7.30-34, 10.4,10.13- 14,
10.16, 10.18. 10.21- 22,
10.24 , 10.26 , 10.29 ,
10.31 , 10.33
crite ria for, 2.35-36 , 2.45, 2.47
curability, 9.22
development of, 4.21-2 2,
4.35 , 10.10
as disease , 8.8 , 8.59, 9.8 (See also
disease concept)
dopamine, 3 .6, 7.32, 10.4
enabling, 9.34
as family disease, 9.32-35
hallmarks of, 7.3 1
healthcare cost, 4.20
hero in , 4.6, 4.10, 4.21-22, 4.25-
26, 10.6, 10.12, 10.28--29
hittin g bottom, 9.16-17
khat , 3.33-34
levels of use, 2.32-33, 2.47
lifetim e costs,3.26-28, 8.12
long-term abstinence, 9.21-22
LSD, 2.15, 2.25 , 2.33 , 2.35, 2.40 ,
6.9, 10.2-3, 10.6, 10.14,
10.16--17, 10.21 , 10.25,
10.28--29
marijuana , 6.40
memory , 2.1 , 2.10, 2.12-16 ,
2.21-22 , 2.30 , 2.3 1-32,
2.37 , 2.38 , 2.40-41, 2.45,
10.21-22
methadone, 4.26, 10 .10
mil itary personnel, 4.2 1- 22, 5.41,
8.49
MRI/fMRI scans, 7.30
neurotransmitters, 2.1, 2.2, 2. 19-
26, 2.20, 2.25, 2.29, 2.41,
2.44, 2.46, 3.25-26
nicotine, 3.46, 3.48-450, 3.55-56,
10.29
opio ids, 1.22 , 4.5--6, 4.8, 4.9 , 4. 10,
4.21 , 7.28, 10.16, 10.29
pain control , 4 .22-23, 7.15, 7.28 ,
7.43, 7.56, 10.2
physician-induced (iatrogenic) ,
4.4 , 4.9, 4.10, 4.16, 4.27
pr escription drug abuse, 4 .3---4
psychological, 1.3, 3 .15, 3.28 , 4.17
recognition and acceptance ,
9. 16--19
risk factors for, 3.26, 3.57, 4.22 - 25
sedative- h ypnotics, 4.33--35, 10.5,
10.28--29
simu ltaneous ,3.12 , 3. 15, 5.27
stimu lants , 3.1 , 3.7, 3.56 , 10.8,
10.14--15, 10.1~21 ,
10.25-27 , 10.30
theories of, 2.1, 2.36--37, 2.47
tissue dependence, 4.19, 10.22
Addiction/Alcoho l Severity Index
(AS!), 9.4, 9.11
addictio n and related disorders (DSM
category), 9.11, 10.1-3, 10.5,
10.13, 10.17, 10.21
Addiction Pathway; 2.13-18,
3.12. See also "gon circuit ;
"stop,., circuit
alcoholism, 5.28
compulsive behaviors , 2.15
dopami ne, 2. 14
imaging, 9.3
marijuana , 6.29-30
morality , 2. 18
nucleus accumbens , 2.13, 2.13,
2. 15, 2.46
opioid peptides, 2.21 , 2.22
opioids, 4 .17
stim u lants, 3.1, 3.6, 3.12,
3.45, 3.56
tobacco, 3.46--4 7
addictio nology, 2.25, 2.38
add ictive disease model, 2.36.
See also disease concep
adenosine, 2.21, 2.22
ADH. See alcohol dehydrogenase
ADH4 (gene), 2.39
ADHD. See attention deficit
h yperactivity disorder , 10.6,
10.13, 10.22 , 10.25 , 10.27
adhesive (skin) patches, 2.4.
See also contact absorption
absorp tion, 2.2 , 2.4
fentanyl, 4.30-31
morphine, 4.26
nicotine, 2.4, 9.9, 9.21 , 9.40, 9.41,
9.66, 9.68, 10.29
steroid, 7 .18
AdipexP.®See phentermine
Adipost. ® See phendim etrazine
Adler, Alfred , 6.14
adolescents, 3.50, 8.29--34. See also
high school; youth
ADHD, 3.2~30, 10.6, 10.13,
10.22, 10.25 , 10.2
adult role model, 8.30
AIDS and HlV,3.14, 3.16--17, 3.24
8.45 , 10.13
alcohol , 5.24 , 5.37-38, 8 .37
anorexia , 7.50-7.51, 9.51 , 10.14,
10.18
antidepressants, 10. 7, 10.20 ,
10.24--27, 10.29 , 10.30
brain development, 2.34 , 2.40--41

crime, 8.30
diagnosis, 9.11, 9.12
drug information programs, 8.5
eating disorde rs, 7.45-7.51, 10.18,
10.26
emotional maturity, 8.29
energy drinks, 1.38, 3.42,
7.20-7.21
gambling, 7.37- 7.38
inhalants, 1.38, 7.2- 7.7, 7.8, 7.9,
7.11, 9.48, 9.49, 10.8
Internet use, 7.57 - 7.58, 7.59, 9.54
mari j uana, 8.32, 10.12, 10.14,
10.21, 10.28-29
menta l health, 10.11, 10.14,
10.17 - 18, 10.22- 25,
10.27 - 29
obesity, 7.32, 7.45- 7.47, 7.49- 7.50
pee r groups for, 9.29, 9.33, 9 .50
pee r pressure, 8.31, 8.32
polydrug abuse, 5.27
pregnancy, 8.26
prescription drugs, 1.3 7
p reven tion, 8.30-32
primary p revention, 8.11- 12
risk factors, 8.30
sense of in vu ln erability, 4 .33
sexual behavior, 5.14, 8.37
sexual explo itation of, 7.55, 7.56
signs of drug use in, 8.32
smoking, 1.35, 1.36, 3.50
sports use, 7.15
steroi ds , 7.15, 10.14
stimulants, 9.38, 10.8, 10.14-16,
10.19, 10.25 - 27
television addic tion, 7.57
therapeutic communi ti es for, 9.15
tobacco, 3.50, 5.27, 5.38, 8.37- 38
treatment, 9.34-35, 9.55- 56
adrenaline . See epinephrine
Adult Children of Alcoholics
(ACoA) , 1.25
adult en terta in ment industry, 7.55
adultera tion/contamination,
cocaine, 3.16, 3
herbal products, 7.28-29
heroin, 4.20, 4.43
mari j uana, 7.27, 7.28
needle use , 8. 4 3
(See also needle use)
adultery, 7.55, 7.55
Advanced Research Projects Agency
Ne twork, 7.55
adve rt ising. See also marketing;
TV advertising
alcohol, 1.33, 1.38
am p hetam in es, 3.22
antismoking ads, 1.35 3.57
direcMo -consumer, 4 .41
legal drugs, 8.15 - 16
patent medicine, 4 .15, 4.30
prescription drugs, 1.22
prevention,3.57, 8.12, 8.58
rave parties, 1.33
sedative -hypnotics, 4.32
tobacco, 1.22, 1.23, 1.35- 36
3.55 - 58
Adv il.® See ibupro fen
Aeschylus, 1.10
affective disorders. See bipolar
affective disorde r ; major
dep ressive disorder; mood
disor d ers
Afghan heroin. See Afghanistan
Afghan istan, 6.24, 6.29, 6.31
anti-drug efforts, 8.8
opi u m/op iates, 1.30-1.32, 4.11,
4.13, 4.41, 4.42, 4.43
U.S. soldiers in, 1.30
Africa
alcoho l, 1.9, 1.15
HIV/AIDS, 1.33
marijuana, 1.10-
op ium, 1.71.10
psychedelics, 6.2, 6.3, 6.10, 6.11,
6.17, 6.22, 6.23, 6.24,
6.27, 6.36, 6.42
stimu lant plants, 1.14 , 3.33, 3.36,
3.39
AFRICAN AMERICANS AIDS and
HIV,8.46
alcoho l use, 1.15, 5.1630, 5.3942 -
430
conspiracy th eory, 9.59
diabetes, 7.49 - 7.50
discriminatory legislation, 8.9
epidemiology, 9.15, 9.57- 58
homelessness, 5.4 2
pregnancy, 8.26
prison, 8.9, 8.17
treatment, 9.57 - 59, 9.59
women dri nkers, 5.42-43
"African LSD" (ibogaine), 6.11 - 12
agave plant, 5.5, 5.7
agent (drug ), 2.37
Age of Discovery, 1.14-17
Age of En lightenment, 1.17- 1.22
age of first use, 8.12.
See also first -time u se
abstinence, 2.33
alcoho l, 5.39
anorex ia nervosa, 7.50-7.52,
10.14, 10.18
memory, 2.11
primary preven tion, 8.12
stimu lants, 3.23, 3.4 7
treatment, 9.55
aggression, 8.35, 10.27, 10.29
acetylcholine, 3.46, 6.17
alcoho l, 5.27- 32, 7.26
amphetamines, 3.6, 3 .12, 3.28,
7.20
cocae thylene, 3.12 - 13
cocaine, 3.12 - 13
marijuana, 6.40
neuro transmitters, 10.26
nico tin e, 3.46
PCP,6.18
prison, 8.10
stero ids, 7. 18, 7.19, 7.19, 7.20
stimu lants, 3.28, 10.28
substance abuse, 8 .40
aging. See elderly
agonis t , antagonis t mixed
medications, 9.67, 9.69
agonis t maintenance trea tmen t , 9.15,
9.67
agonists, 2.24-25, 4.28-30 See also
methadone
beta2, 7.14, 7.16
bu p renorphine, 4 .30, 9.59
dopam in e, 9.39, 9.66
op ioid 4.28-30, 7.56, 9.39, 9.69,
10.26, 10.29 (See also
buprenorphine; LAAM;
methadone)
tobacco, 3.36
agoraphob ia, 10.13-14, 10.16, 10.17,
10.32- 33
AHMD. See alcoholic hear t mus cle
disease
AI/AN popula tions. See Alaskan
Natives; Native Americans
AIDS and HIV, 1.33, 4.22 - 234.22 - 23,
10.13
AIDS and HIV, 1.33, See also needle
use; sex and drugs
adulterated drugs, 3.16
amphetamines 3.24
AZT, 8.47
cocaine/c rack, 3.16
conspiracy theory, 9.59
contamination, 3.16, 4 .22- 23,
9.38, 9.63
dirty nee dles, 4.22 - 23, 8.42--44,
9.38, 9.63
epidemio logy, 1.32, 1.33, 4.22 - 23,
8.41
community, 9.63
efavirenz (Sus tiva) 6.21
history, 1.33
homeless, 5.42
IV drug use rs, 9.42-43
marijuana, 3.44
medicat ions, 6.22, 7.19, 8.45
meth abuse, metha d one, 1.29
pregnancy, 3.14, 8.20
preven tion, 1.29, 4 .29, 8.45, 8.63,
9.10
sex, 1.33, 8.35 - 38, 8.43, 8.44
societal costs, 4 .5, 4.20, 4.4 1
steroid abuse, 7.18
treatmen t pl an, 9.9, 9.10
triple diagnosis, 10.12, 10.13
Air Force Alcohol and Drug Abu se
Pr evention Program, 8.51
Air Force Drug Abuse Prevention and
Treatment (ADAPT), 8.51
air freshener. See room odorizers
airplane glue, 7.2, 7.3
Aj ax, ®8.44
Al-Anon, 9.29
Alaska, 1.34, 6.44
Alaskan Na tives
alcohol, 5.44
inhalan t abuse, 7.5
treatmen t , 9.61-62
Alateen, 8.31, 9.29
albuterol, 7.16
ALCOHOL , 5.7-8. See also
alcoholism; cirrhosis
absorption, 1.38, 5.1, 5.8-10,
5.45, 9.52
addiction, 1.29, 1.38, 3.46---47,
5.21- 27
ADHD,3.30
advertising, 1.38, 8.16
African American, 5 .30, 5.42-43
age of initiation, 8.18
alcoholic b everages, 5.5-83.25,
3.27
alcoholism (addiction,
dependence), 5.21 - 27
an tagonists, 9.2 1
an tidep ressants, 10.27
approved medications, 9.66
ARBD, 5.26-29, 8.21
ARND, 5.26, 5.27, 5.28, 5.29,
5.44, 8.21, 822
assessmen t, 8.8, 8.12, 8.23, 8.3 1,
8.33, 9.12
BAC (blood alcoho l
concen tration), 5.10-11
bee r, 1.1, 1.6, 1.9, 1.15, 1.17,
5.5- 5.6, 8.15
benzodiazepines and, 4.36
binge drinking, 1.40, 5. 15, 5.39,
8.4, 8.6, 8.18, 8.28, (See
also binge drinking )
blackout, 2.2, 2.29, 2.37, 2.39,
2.40, 4.39, 5.16, 5.21,
5.22, 5.45, 9. 12, 9.45
body weight and, 5.11
brain damage, 5.18
brownout, 2.37, 5.16, 9 .12
caffeine, 3.39
campus strategies, 8.33
cancer, 5.18, 5.20, 5,2 1
INDEX 1.1
car diovascular complica tions,
5.19- 20, 5.26, 5.45--6
chemistry of, 5.5
chronic h igh -dose use, 5.43
cirrhos is, 1.25, 5.17 - 18, 5.4 1,
5.46, 8.1, 8.3, 8.15
classification, 4.3, 5.19
cocaine , 3.50, 9.40
college, 8.27, 8.30-32, 8.33-34
consumpt ion, 1.14, 1.18, 1.25, 5.6
cultural bans on, 5.3-4, 5.33, 5.47
(See also Prohib ition
era; p rohib ition vs.
temperance)
I
del irium tr emens (DTs), 5.26
dermatologic complications, 5.21
detox ifica tion, 9.45-46
digestive system, 1.38, 5.17 - 19
disease conce pt of, 1.21, 1.25,
1.29, 5.22- 23 (See also
disease concept)
distille d spirits, 1.14, 1.15, 1.17-
18, 5.5-8
dist ribu tion, 5.8-10, 5.45
drinking age, 8.4, 8.7, 9.6
drug abuse, 5.24
drug interactions,3.6,3.11 - 12,
3.15 4.38
drug testing, 8.46, 8.49, 8.50,
8.53, 8.54
drunk driving, 5.1, 5.10, 5.19,
5.27, 5.32- 33, 5.44, 6.37
DTs (deli rium tr emens), 4 .30,
4.34, 9.45
dual diagnosis, 10.2, 10.32, 10.33
duration of u se, 5.11
eating disorde rs, 7 .50
educat ion, 5.39, 8.6-7
effects of use, 5.10-19, 5.42
eld erly, 5.40-41, 8.58, 8.55 - 56,
9.56
emergency room visits, 3.14-15,
4.38 4 .44 4, 5.15
energy drinks, 3.40
environmenta l factors, 5.24
epi dem iology, 5.35--44, 5.46, 8.41,
9.15, 9.16, 9.19, 9.45,
9.61, 9.63
ethc hl orvynol and, 4.38
excretion, 5.5, 5.9, 5.45
FAE, 5.30, 5.5.31, 5.46
FAS, 5. 1, 5.26, 5.27, 5.27- 29,
5.38, 5.44, 8.21 , 8.22
FASD, 5.29-30, 8.21
fermentation, 5.5, 5.6
GABA, 5.14, 5.25, 5.32
gastritis, 5.18, 5.20
gay comm un ity, 9.63
gen d er and, 5 .17, 5.45
Gin Epi demic, 1.17 - 18, 5.4
"go " circui t, 2.16, 2.17, 2.45
hangover, 5.5, 5.15 - 17, 5.2 4
harm reduction, 8.3, 8.7, 8 .14,
8.15, 8.44-46
health consequences, 5.10 - 11,
5.37
heavy drinking, defined, 5 .15
hepatitis, alcoholic, 5.17
hered ity, 5.21 - 22
high -dose episodes, 5.14-20
high school, 8.28, 8.29 - 31
history, 1.09- 10, 1.14, 1.17- 18,
1.19- 20, 1.21, 1.25, 1.38,
5.3
homeless, 5.2, 5.41-44
homicide, 5.21, 5.32, 5.44
immune system, 5.21, 5.26
impulse -contro l and, 10 .18-19
infused drinks, 5. 7
 1.2 INDEX
inhaled alcohols, 1.8, 1.38,
5.9, 7.8
inj uries, 5.35
kind ling, 5 .26
laws, 5.3 4
learn ing, 5.26, 5.29, 5.31- 38
lev els of use, 5. 1, 5.11- 13,
5.45--46
liver, 5.9, 5.16-17, 5.19, 5.25,
5.37, 5.43
long -term use, 1.3, 5.17 - 2 1, 9.46
low- level use, 5.13
low- to-mo d erate use, 5.13-14,
5.46
I
malnut rition, 5.19, 5.20, 5.21,
5.26, 10.15, 10.19
malt beverages, 5.8
mari juana dui 6.43
marker genes, 5.24 (See also
genes)
mental p rob lems, 5.27- 28, 5.40,
5.42, 5.46
men tal illness 10.2, 10.4 - 10,
10.12, 10.14-16
metabolism, 5.8-10, 5.40
mice stu dies, 2.37, 2.43-44, 2.47
military use, 8.49
mo rt ality, 5.27
Native Americans, 1.15, 9.61
nervo u s system, 5.15, 5.26, 5.29
neurochemistry, 5.14, 5. 17, 5.23,
5.24
neuro transm itte rs, 2.20 - 26, 2.4 1,
5.14, 5.26, 10.26
obesity recovery, 9.52
off-label medica tions, 9.66
overdose, 5.15, 5.16, 9.3
overview, 5.2- 5
P 300 wave
paten t medicines, 3.9 - 10
pa terna l drink ing, 5.31
patterns of consumpt ion, 5.2, 5.7,
5.37, 5.35- 36
per-capita use, 5.7
pharmaco logic research, 5.40
physical effects, 5.12, 5.14-15,
5.28
poison ing, 5.8, 5.15, 5.21, 5.37
po lydrug abuse, 5.27
pregnancy, 5.28-31, 8.18, 8.18-20
prohib ition an d tem p erance,1.7,
1.10, 1.14, 1.15, 1.18,
1.21, 1.23, 1.25, 8.3--4
psychiatric tr eatment, 10.28, 10.29
psyc hological effects, 5.13-14
re pro duct ive sys tem, 5.20
ru bbing alcoho l, 7.28
secondary drug, 9.45
secondhan d drink ing, 5.39, 8.33
sex, 8.35, 8.36, 8.41
sexua l assau lt , 8.32, 8.37, 8.40
sexua l performance, 5.15
sleep, 5.13, 5.14
sobering up, 5.17
sports, 7.25- 7.26, 7.26
subs titu tes for, 1.14
suicide, 5.27, 5.28, 5.35, 9.46,
10.18
the rap eu tic use, 5. 12
tissue dep endence, 5.24-26
to lerance, 5.24-25
treatment,1.25, 1.26, 1.29, 1.38,
9.3 1, 9.37, 9.45--46, 9.66,
9.68
treatmen t admiss ions, 9.16
types of alcoho lics, 5.22
use by age , 8.17, 8.18
vio lence, 5.31 - 33
wine, 1.9, 5.6, 5.7, 8.3, 8.20, 8.26,
8.34, 8.35, 8.36, 8.41
withdrawal, 4.30, 4 .34, 5.25- 28,
9.45--46
women,1.2 1, 5.2- 3, 5.9, 5.1,
5.28-29, 5.37- 38,
5.37,5.45, 8.36
alcohol congene rs, 5.8, 5. 12
alcohol dehydrogenase (ADH), 5.8,
5.9, 5.24
alcoholic beverages, 5.5
p ercentage of alcoho l, 5.8
types, 5.5-8
alcoholic hea rt muscle disease
(AHMD), 5.19
alcoholic he p ati tis, 5.1, 5. 17, 5.2 1
alcoholic psychosis, 5.23, 5.41, 8 .3
Alcoholics Ano nymous (AA), 1.25,
5.4, 7.31, 7.42
9.28-29, 9.62
12 step s of, 9.30
origin, 2.2, 5.4
Alcoho l Induced Disor d ers (DSM
category), 5.23
alcohol -induced mental illness
anx iety d isorder, 10.19
du al d iagnosis, 5.28, 10.18- 19
mood disorder, 10 .19
pe rsistent dementia, 10.19
pe rsis ting amnes tic disor d er, 10.19
psychotic disorde r, 10. 19
sleep disorder, 10 .19
alcoholism. See also alcoho l
blackouts, 5.16
brain imaging, 9.4
classifica tion, 5.21 - 23
de fective genes, 5.23
defin ition, 5.12
elderly, 5.40
ketamine -assisted psycho therapy,
6.22
markers for, 5.22
mice studies, 2.37, 2.43-44, 2.47
pa terna l drink ing, 5.3 1
po lydrug abuse, 5.26
research, 5.26-27
risk, 5 .9
Russia, 5.2, 5.36
self-assessmen t, 9.16
sym p toms of withdrawa l, 5.25
trea tmen t , 9.36, 9.39
true alcoholics, 5.22
Alcoho l Misu se Preven tion Study
(AMPS), 8.30
alcohol or othe r drugs (AOD), 8.27
alcohol -related birth de fects (ARBD),
1.18, 5.30-33, 5.46, 8.21,
8.22
alcohol -relate d neurodevelopmen tal
diso rder (ARNO), 5.26, 5.30,
8.21
Alcoho l Severity In d ex (ASI), 9.4
alcohol so lvents, 7 .8
Alcoho l Use Disor d ers
(DSM category), 5.23
Alcot t, Louisa May, 1.22
ALDH2, 5.9, 5.22. See also
acetaldehyde dehydrogenase
ale, 5.4, 5.6
Alert, ® 3.4
Aleutian Islands, 1.9
Aleve, ® 4.23
Ali (Mohammed's brother -in -law), 1.14
alkaloids, 1.12, 1.14, 1.17, 1.19, 8.51
caffeine, 1.14, 1.17, 1.19, 1.36,
3.1, 3.38, 3.58
cocaine 1.12, 1.15, 1.19 - 1.22, 3 .9
isolation of, 1.20-1.21
nico tine, 3.1, 3.43
plants an d , 1.11, 1.12
psychedelics, 1.28, 6.6
yoh imbe, 3.36
alkanes (inhalants), 7.8
all arounders. See psychedelics
allele gene. See DRD2 Al allele gene
allergic react ion, 7.24. See also
ant ihistamines
alcoho l, 5.23
an tihistam ines, 4.2
drug me tabolism
his tamine, 2.21, 10.26
Lunesta, ® 4.37
allergy med ications, 8.56
allostasis, 2.25-26, 2.29, 2.37, 2.43,
2.44, 2.45, 2.46, 2.47
defined, 2.44
Alpe rt , Richard, 6.6
alp ha -2 ad renergic antagonist, 3.35
alp ha alcoholism, 5.21
alp ha -endopsychosin, 2.20
alp hamethyltryptam ine (AMT;
Indopan ®), 6.13
alp hapyrones (kava), 7.28
alp razolam (Alprox, ® Tafil,® Xanax, ®
Xanor• ), 4 .1, 4.3, 4.4, 4.5,
4.26, 4.30, 4.31, 4.33, 4.34,
4.35, 4.39, 4.40, 4.44, 7.25,
8.24, 10. 18
cross tolerance, 2.28
pregnancy, 8.24
sports, 7.25
syne rgism, 2.8, 4.39
treatment, 4.34, 9.44, 10.29,
10.30, 10.34
Alprox. ® See alprazo lam
Al Qaeda 1.7
altered consciousness, 2 .32, 6.1
Alurate .® See aproba rbita l
alveoli, 2.3, 3.49, 8.24
Alzado, Lyle, 7.18
Alzheime r's disease, 2.23, 7.29, 10.17,
10.19, 10.29, 10.33
AMA. See American Medica l
Associa ti on
Amanita mushrooms (A. muscaria,
A. phalloides , A. pantherina),
1.3, I.II, 1.12, 6.1, 6.2, 6.4,
6.10, 6.20-21
amantadine (Symmetr el®), 9.21, 9.39,
9.66, 9.68, 10.29-30
Ama ret to,® 5.8
Amazon jungle, 3.8, 6. 11
Ambenyl, ®8.59
"ambe r glass, " 6.30
Amb ien. ® See zolpidem, 10.30
Amen, Dan iel, 2.40, 3.28, 7.30, 9.4
Amen Clinic, 7.30, 9.4
amenorrhea, 7.52
American Cancer Society, 1.23, 3.49,
3.50
American College of Sports Medicine,
7.18
American Home Products, 3.31
American Indians. See Native
Americans
American Nonsmokers ' Rights
Foundation, 8.16
American Pharmacists Associa tion,
4.16
American Psych iatric Associa tion
(APA), 1.29, 1.40, 5.23, 6.35.
See also DSM-IV-TR; DSM-5
American Revo lut ion, 1.7, 1.18-19,
7.34
American Society of Ad diction
Medicine (ASAM) 4 .15
pain contro l, 4.15
Patient Placement Criteria (ASAM
PPC), 9.4
Patien t Placement Cri teria Revised
(ASAM PPC-2R), 9.12- 13
American Spirit, ® 3.4
Americans wi th Disabilities Act, 9.62
American Tempe rance Society, 1.21
American Tobacco, ® 3.43
Amerit rade, 7.58
Amethyst In itia tive, 5.40, 9.6
amfebutamone (bupropion,
Wellbu trin, ® Zyban ®), 9.66,
10.26-27, 10.29- 30
amino acid p recu rsor loading, 9.24,
9.36, 9.36, 9.68
amino acids, 2.5, 2.21
d etox an d , 9.21, 9.24
amitrip tyline (Elavil, ® Ende p ®) , 8.40,
9.11, 10.30
amlod ip ine (Lotrel, ® Norvasc ®) , 9.68
ammonia, 8 .53
coca ine, 3. 7
methamphetam ines, 3.24
amnesia, 5.1, 5.24, 7.23, 8.39-40. See
also blackout; brownout
benzodiazepines, 4. 40
GHB,1.27, 1.33-1.34, 4.39
PCP, 6.21 - 22
amoba rbita l (Amyta l,® Tuinal ®), 4.31,
4.44. See also Dexamy l®
amo tivat ional syndrome, 10.21. See
also developmental arrest
amoxapine (Asendin ®), 10.30
amphe tamine (Adde rall, ®
Benzedrine, ®Biphetamine, ®
Obe tro l®). See d ,l
amphetamine
AMPHETAMINE CONGENERS, 1.2,
3.28-3 1. See also entries for
specific substances
ADHD, 1.26, 3.29, 10.27- 28
d exfenfluramine, 3.3, 3.32
d iethylpropion, 3.3, 3.32
diet pills, 1.2, 3.2, 3.32, 7.54, 9.52
fenfluramine, 3.2, 3.32, 3.58
"fen-phen, " 3.2, 3.29, 3.32, 9.52
methylphenidate, 3.3, 3.29 - 31,
3.58, 9.67, 10.24- 25,
10.29-30
pemoline, 3.3, 3.29, 10.30
phendimetrazine, 3.3
phen termine HCL, 3.3, 3.32
phen termine resin 3.3, 9 .52
AMPHETAMINES (includes
methamphetamines), 1.29
See also amphetam ine
congeners; dextroampheta-
mine su lfate; dex trome tham-
phetamine; d ,l amphetamine;
levo amphetam ine; MDA;
MDMA; metham p hetamines;
psycho -stimu lants; entries
for specific amphetam ines,
10.8, 10.14
amphe tamine ana logues, 3.2
appetite effects, 1.26, 1.27, 3.4,
3.5, 3.6, 3.22, 3.27,3.32,
9.52
benzphetam ine (Didrex ®) , 3.3
card iovascu lar effects, 3.5-6,
3.27 - 28
class ification, 3.2, 3.21
cocaine vs. amphetamines,
3.20 - 3.21
college sports use, 7.13, 7.20,
7.20, 7.26
cost, 3.32
crime, 3.17, 3.20, 3.22
curren t use in U.S., 3.2
d extroam p hetamine, 3.3, 3.20-21,
10.30
dextrome thamphe tamine ("ice "),
1.30, 3.5, 3.14-15,
3.21 - 24
diet pills, 3.22, 3.32, 7.20, 7.24, 7.51
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 1.4 INDEX
arrhythmias, 2.15. See also
cardiovascular system
alcohol, 5.15, 5.42
beta blockers, 7.22- 7.23
caffeine, 8.58
depressants, 5.16, 5.27
eating disorders, 7.49, 7.50
ephedra, 7.20
ephedrine, 7.21
he rbal med icines, 7 .20
inhalants, 7.6, 7.6, 7.8, 7.10, 7.10,
7.59
LAAM, 9.43
methadone, 4.29
I
opioids, 4 .32
smoking, 3.51
stimu lants, 2.15, 3.28, 3.50
ARRRT (trea tmen t for bad trips ) , 9.47
arsenic, 3.50
Artane. ® See trihexyphen idyl
10.28-30
art therapies, 9.36
ASAM. See American Society of
Addiction Medicine
Ascend Multi -Immunoassay, 8.50
asenapine (Saphris ®), 10.28, 10.30
Asend in .® See amoxapine
ashwagandha (Withania somnifera),
9.36
ASL See Addict ion/Alcohol Severity
Index
Asia, 1.9, 1.11, 1.16, 1.17, 1.27, 1.31,
1.32, 1.33, 1.36 See also
Asians and Asian Americans;
Asians and Pacific Islande rs;
Golden Crescent; Golden
Triangle; entries for
individua l coun tries
Cannabis, 1.9, 6.26, 3.29- 31
Kratom tree, 4.33
me th amp h etamine, 3.21, 3.23,
3.24
opium, 1.9, 4.7, 4.8, 4.11
tobacco, 3.50
"ya ha ," 1.36, 3.2
"Asian flush gene," 2.37
Asian gangs, 3.24
Asians and Asian Americans, 5.9.
See also Asians and Pacific
Islanders
alcohol, 5.43-44, 5.42, 8.21
alcohol gene, 5.22, 5.44
amphe tamines, 3.2, 3.23, 3.24,
9.38, 9.61
diabe tes, 7.50
inhalants, 7.3, 7.4
opioids 4.8
tobacco, 3.4 7
treatmen t , 9.60-61
Asians and Pacific Islanders (APis)
alcohol, 5.43-44, 5.47
treatmen t, 9.60-61
ASI-Lite, 9.11
Asmador ®cigarettes, 6.17
ASPD. See antisocial pe rsonality
disorde r
aspirin, 5.11, 7.15, 7.16, 7.21, 7.28,
7.29, 8.24, 8.53, 9.45. See
also nons teroidal anti -
inflammatory drugs
drug comb inations, 4.24, 4.27 - 28
emergency rooms, 4.38
smoking, 7.28
sports, 7.16, 7.21
assessment, 9.9
diagnostic tools, 9.4
asset forfeiture laws, 8.9
ASSIST (Alcohol, Smoking, and
Substance Involvement
Screen ing Test), 9.12
assisted suicide, 4.8
Assyria, 1. 10
asthma, 1.26, 7.16-7.17, 7.23. See
also oxygen insufficiency;
respiratory system
amphetam ines, 1.26, 3.22,3.35
caffeine 1.14, 3.41
cocaine, l.2I, 3.9, 3.11
ephedrine, 3.22, 3.24, 3.31 , 3.35
tobacco, 3.48, 3.54
asthma med ications, 7.11, 7.16-7.17,
7.21, 7.60
belladonna, 6.17
marijuana, 6.34
sports, 7.16, 7.21
astragali, 7 .34
astrocyte, 2.5
atenolol (Tenormin ®), 7.22, 10.30
AtharvaVeda (sacred psalms ) , 1.11
atherosclerosis, 3.5 I , 9.51
athletes. See sports and drugs
Ativan. ®See lorazepam
Atlantic City casinos, 7.32, 7.35
atomoxetine (Strattera ®) , 3.4, 3.29,
3.58, 10.27, 10.30
atropine, 6 .1, 6.4, 6.17, 6.41
attention deficit hype ractivity disorder
See (ADHD), 1.26, 1.37, 10.6
dopamine, 3., 3.34, 3.36, 3.48
dual-diagnos is, 10.6, 10.13, 10.22,
10.25, 10.27
medications, 3.22, 3.29, 3.31
10.33
pharmacotherapy, 3.29 - 30
treatment, 10.22, 10.25, 10.27,
10.33
atypical ALDH, 5.41
atypical antidepressants, 10.26, 10.29,
10.30
atypical antipsychotics, 10.24 - 25,
10.28, 10.30, 10.33
AUDIT, 9.12
auditory illusions and hallucinations,
6.3, 6.6, 6.24, 7.27, 10.14,
10.19, 10.21. See also
hallucinations; illusions
alcohol, 5.26
amphetamine 3.28
cocaine, 3.15, 3.19
auriculotherapy, 9.36
Australia, 1.34, 2.37, 5.6, 5.30, 6.20,
6.36, 7.6, 7.13, 7.28, 8.14,
8.45
Austria, 3.37, 5.6, 5.36, 6.29, 6.36,
7.52
automatic cigarette rolling mach ine,
1.22- 1.23, 3.41
automobile accidents (drunk driving),
5.1, 5.7, 5.19, 5.31- 32, 5.34,
5.44, 6.37, 8.29, 8.33, 8.51
autonomic nervous system, 2.8, 2.15,
2.21, 2.45, 3.13. See also
sympathe tic nervous system
alcohol withdrawal, 5.24
opioid receptors, 4.12
autoreceptors, 2.23
Aventyl ®See nortriptyline
aversion therapy, 9.26, 9.41, 9 .53
Avicenna (ancient physician), 1.17
Avinza .®See morphine
awareness gap, 8.14
Axocet ® (butalbital), 4.4I
Axokine .®See modified ciliary
neurotrophic factor
axon, 2.22, 2.46
ayahuasca (yage), 6.11 - 12
Ayurvedic medicine, 9.36
Azilect. ®See rasaqiline
AZT (zidovudine; AIDS medication),
8.20, 8.44, 8.45
Aztec culture, 3.39, 6.2, 6.10, 6.14,
7.13
chocola te, 1.15, 3.39
psychedelics, 1.8, 6.9- 10, 6.11
tobacco, 1.13 1.16
B behaviors
BAAD (bored, anxious, angry,
depressed), 9.24
Babor, T.E, 5.20
Baby Boomers, 8.54, 8.57. See also
elderly
baby laxa tive (adulterant), 3.16
Babylonian Epic of Gilgamesh, 5.2
BAC. See blood alcoho l concentration
Bacard i Silver,®5 .8
Bacchus (Dionysus), 1.9
baclofen (Lioresal ®), 2.29, 416, 7.15,
9.66, 9.68
Bacon, Sir Francis, 1.16
bacterial in fections, 1.29, 2.4, 4.16,
4.22- 24, 4.29,4.45, 8.45
immune suppression, 4.26
needle use, 4.9 - 10, 4.22 - 23
bad trips, 6.9- 10, 9.46-47
"bagging" (inhaling), 7.5
baking soda (and crack), 1.30, 3 .18
"balloon and cracker, " 7.5
"hammer, " 6.26
Banobese .®See phentermine HCL
Barbased. ®See butabarbital
barbital (Veronal ®) , 1.27, 4.36
BARBITURATES,1.27, 4.33-35,
4.40--41, 7.16
class ification, 4.35 - .36
drug test ing, 8.50
duration of act ion, 4.41
pregnancy, 8.25
treatment, 9. 44
types of tole rance, 2.27 - 28
withdrawa l, 4.39,4.41
barbituric acid, 4.3, 4.30, 4.36
barley and alcohol, 1.9, 5.6
"barrels " (LSD), 6.6
"bars " (alp razolam), 4.44
Barthwell, Andrea, 8.14
Bartisch, George, 1.17
basal ganglia, 6.34
"basay " (freebase cocaine), 3.3
"base " (smokab le cocaine or
methamphetamine), 3.3,
3.18, 3.56
baseball. See Major League Baseball
"baseballing " (smokable cocaine),
3.17
"Bash Brothers," 7.11
Basic®cigarettes, 3.51, 3.52
"bas ing," "baseballing " (smokable
cocaine), 3.17
"basuco, " "bazooka" (smokab le
cocaine), 3.3.17
bath salts (synthetic cocaine/meth),
1.31, 1.33, 134, 1.37, 6.18,
8.10, 8.53 3.21 , 3.34- 5
"batu "("ice ") . See smokable
methamphetamine
Baudela ire, Charles, 6.30
Bayer, Adolph Von, 4.2
Bayer Drug Company, 1.20, 4.2, 4.8
BBDO (advertising agency), 7.58
"BC Bud," 6.39
BD (1,3 butanediol), 4.43
"beans " (Dexedrine ®) , 3.3
Beechnut Chewing Tobacco, ®3.4
bee pollen, 7.24
beer, I.I, 1.3, 1.9, 1.15, I.I 7, 1.18,
1.38, 5.5-6, 8.4, 8.5, 8.15,
8.26, 8.33, 8.35, 8.40
alcoho l content, 5.6, 5.7, 5.42
consumption pat terns, 5.4, 5.5-6,
5.6, 5.33- 34
types, 5.6
bee r bong, 5.39
Beer Stree t , 1.18
behavioral addictions. See compulsive
behavioral /environmenta l model of
addiction, 2.36-37, 2.47
behavioral therapies. See also
cognitive behaviora l therapy
smoking cessation, 9.41
tobacco, 9.41
behavioral tolerance, 2.27, 5.10, 5.15,
5.22, 5.23, 5.23
behavior modification, 9.6, 9.53
Beijing Olympics, 7.16, 7.26
Belgium, I. 13, 6.6, 6.20, 6.36
alcohol use, 5.33
Belize, 3.36
belladonna, 1.13, 3.46, 6.20
"Belush i rocks," 3.19
Benadryl. ®See diphenhyd ram ine
"bennies " (Benzedrine ®), 3.3
Benzedrine ® (dextroamphetamine ) ,
3.21. See also
d,l amphetamine
benzene, 3.25, 3.50, 7.3, 7. 7, 7.8
"benzo fury" (6APB)
benzocaine, 3.3I
Benzodiazepine Anonymous, 9.44
BENZODIAZEPINES, 1.3, 1.24,
1.28, 1.39, 4.35- 37, 7.15,
7.16. See also alprazolam;
chlordiazepoxide;
clonazepam; clorazepate;
diazepam; flunit razepam;
lorazepam; temazepam
alcohol, 5.26
an tagonist, 9. 44
classification, 4.3 I , 10.30
drug testing, 8.50, 8.52
durat ion of action, 4.37, 8.37
effects, 4.30, 4.34-35, 4.36
elderly, 8.59
emergency rooms, 4.37 - 38, 4.40
GABA,4.34, 4.38, 4.41-42
history, 1.28, 4.32
HPPD, 9.47
medical use, 4.37 - 38, 10.24-25,
10.27- 31. 10.33
memory impairment, 4 .40
metabolism, 10.24
neurochemistry, 10.16
neurotransmitters, 2.20
nonmedical use, 4 .38
overdose, 4.21 - 25, 4.25,4.29,
4.35
polydrug use, 2.32, 4.44
pregnancy, 8.26-27
safety margin, 4.33, 4.36, 4.44
seda tive-hypnot ics treatment,
9.66-67
sex, 8.39
synergism, 4.25, 4.35
testing, 8.51, 8.52, 8.62
tissue dependence, 4 .37, 4.39-40
tolerance, 2.27, 4.39
treatment, 9.41, 9.42, 9.44
withdrawal, 4.39, 10.24, 10.29- 30
for withd rawal from alcohol,
4.38, 9.45
benzoylecgonine , 3.11, 8.53
benzphetam ine (Didrex ®), 3.3
benztropine ( Cogentin ®), 6.20,
10.28-30
Bernard, Claude, 2. 4 3
Berners -Lee, Tim, 7.55
Bernhardt, Sarah, 1.22, 4.10
Berthoud, Hans -Rudulf, 7.46

beta 2 antagonists, 7.16
beta alcoholism, 5.22
beta blockers, 10.24 , 10.26, 10.29-31
panic disorder, 10.31
in sports, 7.21-22, 7.26
betel nut, 1.2, 1.8, 3.35-36, 7.13, 825
"B-FLY," 6.4, 6.24
bhang (marijuana), 6.30
BHO. See butane hash oil
"bidi " cigarettes, 3.55
The Big Book (Alcoholics
Anonymous), 2.2, 9.23,
9.28, 9.29
"big C" (coca ine ), 3.3
biker gangs, 3.19, 3.24
Bill and Melinda Gates Foundation,
8.46
binding site. See receptor sites
binge drinking, 5.1, 5.16, 5.22, 5.39
adolescents, 5.38
college, 5.39--40, 8.4, 8.18, 8.28
culture and, 5.15, 5.34
defined, 5.15
employment, 8.46
ethnic groups, 5.9, 5.40, 5.41
military personnel, 5.41
mortalit y, 5.37
pregnancy, 5.27, 8.18
binge-eating disorder, 1.5, 7.45,
9.51-52, 10.4, 10.14,
10.18, 10.33
definition, 7.50-51
epidemiology, 7.48
binge use
alcohol,1.40, 3.50, 8.2, 8.6, 8.18,
8.27, 8.32, 8.34, 8.46,
8.47, 8.54
amphetamines, 3.26, 3.57
bulimia, 1.42, 7.49-50, 7.50
cocaine, 1.21, 1.30, 2.41, 2.42,
3.6, 3.8, 3.11, 3.14, 3.16,
3.33, 3.40, 3.56, 3.57,
3.58, 8.22, 8.27
college, 8.6, 8.29, 8.33-34
eating disorders, 1.15, 1.42, 7.45,
7.48, 7.50-51, 9.51-52,
10.4, 10.14, 10.18, 10.26
gambling, 7.39
khat 3.33
neural damage from , 2.17
"binlang, " 3.36
bioavailability, 2.4, 2. 7
biofeedback, 9.37
Biphetamine. ® See d,l amphetamine
bipolar affective disorder, 9.38, 10.6,
10.13-15, 10.29-30
alcohol, 5.26
psych iatric medications, 10.13,
10.27 -30, 10.33
"bird seed" (ma rijuana), 6.24
birth defects, 8.21. See also alcohol-
related birth defects; alcohol-
related neurodevelopment
disorder; fetal alcohol effects;
fetal alcohol spectrum
disorder; fetal alcohol
syndrome; pregnancy
alcohol, 5.28, 5.30, 5.46, 8.21
anorexia, 7.49
"bitchweed ," 6.29
"black beauties " (d,l amphetamine),
3.3
Blackberries, ® 7.54, 7.57
"black cherry" (be lladonna ), 6.4
Black community.
See African Americans
Black Extended Family Program, 9.59
black market. See smuggling
blackout (anterograde amnesia), 2.36
alcohol, 5.16, 5.23
benzodiazepines, 4. 40
compulsive gambling, 2.29, 7.37
date -rape drugs, 4.40, 4.43, 6.22
(See also date rape)
depressants with alcohol, 4.3,
4 .18,4.2 1, 4.25, 4.44
"blacks and whites"
(phentermine HCL), 3.3
"black tar." See "tar "
"black weed" (PCP), 6.4
bladder , 2.6, 8.40, 8.53
bleach distribution, 8.14, 8.4
blood alcohol concentration (BAC),
5.10-11
by body weight, 5.11
crime, 5.32
driving, 5.32, 5.34-35
elimination rate, 5.16, 5.17
level of impairment, 5.15, 5.10,
5.45
overdose, 5.15
pregnancy, 5.28
sex, 5.14-15, 5.20, 8.35, 8.61
women, 2.7, 5.9, 5.11, 5.12
blood -bra in barrier, 2.6, 2.5-6,
2.8, 2.45
antihistamines, 4.2
autonomic nervous system, 2.10
drug distribution, 2.4-5
heroin, 4.27
blood -cerebra l spinal fluid barrier,
2.5--6
blood circulation, 2.4-6.
See also circulatory system
blood clots, 7 .22
blood doping in sports, 7.12,
7.14, 7.22
Bloods (gang), 3.20
"blotter acid" (LSD), 6. 7---B
blotter paper, 6. 7
"blow " (coca ine ), 3.3
"blowing, " 3.10
"blue heavens " (amobarbital), 4.31
"Blue Mystic," 6.4, 6.19 See 2C-T-7
Blue Nitro ® (GBL). See GBL
"blue nun " (nitrous oxide), 7.10
"blues " (amobarbital), 4.31
Blum, Kenneth, 2.38, 7.31
"blunt " (marijuana), 6.37-39
B-MAST, 9.11
boating fatalities, 5.21, 5.35
bock beer, 5.5
body image , 7.17, 7.44, 7.48, 9.51.
See also eating disorders;
weight control
body size and absorption, 2.6-8, 5.11
body temperature, 6.20,
6.23, 6.17
boilermakers, 5. 7
bojalwa, 5.33
bolasterone (Finiject ®), 7.18
boldenone (Equipose ®), 7.18
Bolivia, 1.32, 3.7-9
Bonds, Barry, 7 .12
"bong," 6.30
Bonsack cigarette rolling
machine, 1.22
Bontril. ® See phentermine resin
"boo mers, " 6.4
borderline personality disorder (BPD),
5.28, 10.6, 10.13- 14, 10.18,
10.33. See also personality
disorders
Botswana, 5.33
botulism, 8.45
"bou lya " ("crack," freebase cocaine),
3.3, 3.18
bourbon, 5. 7
Bowman, Karl, 5.22
"boy" (heroin)
BPD. See borderline personality
disorder
BRAIN. See also blood-brain barrier;
new brain; old brain
addiction as a disease of, 9.1,
9.2-3 (See also disease
concept)
addiction-induced changes in,
9.46
amino acids, 9.21
behavioral tolerance , 2.26
circuit systems in addiction, 9.3
development, 2.34
drug -ind uced changes in,
2.39--40, 2.41
eating disorders, 7.48
effects of violence on, 5.32
evolutionary view of, 2.10-12
food addiction, 7.46-47
how drugs get to, 2.2-5, 2.45.
4.2, 4.26
imaging, 9.4, 10.19 -20
new brain, 2.9-10, 2.09
old brain, 2.9-10, 2.09
pharmacokinetics of drugs, 2.4-9
addictions pathway, 2.13-17
size, 2.9, 2.11
structural changes, 9.23
brain atrophy, 5.19
Brain Booster, ® 7.29
brain chemistry. See brain;
neurochemistry
brain development, 8.29, 10.17, 10.33
alcohol, 5.29-31
critical period, 5.3 1
environment, 2.38-39, 2. 48
violence, 5.32
brain imaging. See CAT scan; imaging
techniques; MRI,fMRI; PET
scan; SPECT scan
brain lesions, 7.53
brainstem, 2.18, 5.26, 6.5, 6.8.
See also locus coeruleus;
old brain
marijuana overdose, 6.30
opioids, 4 .17- 18
pain control, 4.17
psychedelics, 1.4
sedative-hypnotics, 4.34
Brain Tonix, ® 7.29
brain wave biofeedback, 9.37
brand names. See trade names
brandy, 5.7
as inhalant, 7 .8
sports use, 7.13
Brave New World (Huxley), 4.32
Brazil, 3.40, 3.58, 6.12-13, 6.31
breast cancer, 3.52
alcohol, 3.42, 5.18, 5.43
marijuana, 6.38
overeating, 7 .4 7
research, 5.18
steroids, 7.16
breast milk, 8.22, 8.23-24
benzodiazepines, 8.24
cocaine, 8.21-23
methadone, 8.23
opioids, 8.23
THC, 8.24
breathalyzer, 5.32
breech birth, 4.18
Brevital. ® See methohexital
British. See England
British East India Trading
Company, 1.20
Bromam. ® See bromazepam
bromazepam (Lexotanil, ® Somalium, ®
Bromam ®), 4.31
bromides, 4.2, 4.34, 4.36
INDEX 1.5
bromo-benzodifuranyl-
isopropylamine, 6. 4
bromocriptine (Pa rlodel ®), 9.21, 9.39,
9.66, 10.29
bromo-dragonFLY (2C-F ly,
2C-B-FLY, JC-FLY;
bromo-benzodifuranyl-
isopropylamine), 6.21-6.24
bronchi, 2.3, 3.11, 3.27, 3.49, 3.52,
3.56, 7.59, 10.29
bronchitis, 3.52, 3.59, 6.37, 8.25
bronchodilation, 3.36, 3.52, 7.16, 7.20
bronchopulmonary disease, 3.48
Bronte, Charlotte, 1.22, 4.9
I
brown heroin, 4 .1 1
Browning, Elizabeth Barrett, 1.22, 4.9
brownout (anterograde amnesia),
2.37, 2.39, 4.40, 5.16,
5.43, 9.12
brujas, 6.2, 6.11, 7.28
bruxism (clenching of the teeth), 6.15
buccal absorption, 2.3, 2.4, 3.8
"bud" (marijuana), 6.28
Budden, Sarajini, 5.30
Buddha Melt or Blend, ® 6.33
"Buddha Thai" (marijuana), 6.28
Bud Extra, ® 5 .8
Budweiser, ® 5.8, 8.15
bufotenine (Bufo toad), 6.4, 6.12, 7.28
bulimia nervosa, 7.24, 7.45, 10.14,
1018, 10.33
definition, 7. 49 -50
diagnosis, 7.50
epidemiology, 7.48
treatment, 9.51
"bum trip, " 6.9. See also bad trips
"bupe." See buprenorphine
Buprel. ® See buprenorphine
Buprenex. ® See buprenorphine
buprenorphine (Buprenex, ® Buprel, ®
Suboxone, ® Subotex, ®
Subutex • ), 1.3, 1.24, 1.29,
1.37, 1.38, 4.6-7, 4.19,
4.29-30, 8.24, 8.25, 9.43,
10.10, 10.29
abuse of, 9.43
action of, 4.30
drug testing, 8.53
with naloxone (Suboxone ®), 9.6,
9.14, 9.20, 9.43, 9.66
opioid detoxification, 9. 4 2
prescribing practices, 4.30, 9.43
time -release, 9.69
treatment, 1.29, 1.37, 1.38, 2.28,
9.1, 9.9, 9.14, 9.20, 9.42,
9.43, 9.66, 9.67, 9.69,
9.71, 9.72, 10.10
bupropion (We llbutrin, ® Zyban ®),
3.51, 9.9, 9.39, 9.41, 9.66,
10.26-27, 10.29-30
ADHD, 10.27
depression, 10.26-27 , 10.29 -30
smoking, 3.51, 9.21, 9.40, 9.41,
9.66, 9.66, 9.68, 9.73
stimulants, 9.39, 9.68
treatment with, 9.9, 9.39, 9.40,
9.41, 9.66, 9.68, 9.71,
9. 72, 10.26-27, 10.29 -30
Burma. See Golden Triangle
Bush, George, H. W
(U.S. president),1.5
Bush, George, W (U.S. president ),
1.5, 3.24
"businessman's special" (DMT),
6.4, 6.11
BuSpar. ® See buspirone
buspirone (Bu5pa r4), 4.30, 4.35,
4.42, 8.55, 9.39, 9.41, 9.44,
10.29 -3 1, 10.33
 1.6 INDEX
butabarbital (Barbased, ®Butisol ®) ,
4.4 1, 9.44
butalb ital (Esgic, ®Axocet, ®
Fiorinal ®), 4.41 , 4.36,
4.38, 4.44
butane, 7.3
butane hash oil (BHO), 1.35, 6.5, 6.30
butanol. See butyl alcohol
Butazolidin. ® See pheny lbutazone
Butisol. ® See butabarbital
but orphanol (Stado l• ) 4.33, 9.67
"but ton " (peyote ) , 6.4, 6.13- 14
butts (cigarettes ) , 3.4
bu tyl alcohol, 5.5
I
bu tyl nitrite , 7.9
Bwiti tribe, 6.11
Byron, Lord, 4.10
bystande r (witness ) of vio lence,
5.29- 3 1
C camel dung, 7.27
"C-boom " (2 C-1) 6.l S- 19
C57BL /6] (st rain of mice ) , 2.43
CA (Cocaine Anonymous ) , 9.29
"caap i" (ayahuasca ) , 6.4, 6.12 - 13.
See also ayahuasca
cacao, 1.14, 1.17, 3.39
cadmium (in tobacco ) , 3.50
caffeine, 8.27
CAFFEIN E, 1.2, 1.14, 1.17, 1.36,
1.38, 3.4, 3.37-42, 10.16,
10.29
alcohol, 5. 7
chocola te, content in various
substances, 1.22, 3.41
current use, 3.23, 3.33, 3.37, 3.40
d epen d ence , 3.42
diet, 9.53
d osage , 3.4 1
effects, 3.1, 3.6, 3.7, 3.38, 3.39-40,
3.58, 3.59, 7.29
eld erly, 8.58
energy drinks, 1.2, 1.34, 1.36,
1.38,3.40
history, 1.14, 1.17, 1.36, 1.38,
3.37 - 38
medicinal uses 3.41
miscarr iage risk 3.13, 3.42
pharmacology , 1.19, 1.36, 3.4 1--42
plan t sources of, 1.14, 1.37,
3.40--41
po lydrug abuse, 2.32
sports,1.4, 7.13, 7.14, 7.20, 7.23,
7.26
tolerance, 3.40
with drawal, 3.42
caffeinism, 3.42
CAGE-AID test, 9.4
CAGE Questionnaire , 9 .12, 9 .57
Cailliau, Rober t, 7.55
"caine " reaction, 3 . 15
calcium channel -blocking medica tion,
9.66, 9.68
calci u m pangamate (vitamin B 15
pengamic acid), 7.24 ,
CALDATA. See California Drug
and Alcoho l Treatment
Assessment
Calder6n, Felipe (Mexican p res ident ) ,
4.12
California
AIDS, 8.46
alcohol, 5.6
Asian, 9.60, 9.61
CALDATA,9. 7
crime prevent ion, 4 .24
d rug courts, 1.42, 9.5
d rug treatment, 9 .5, 9. 7, 9.50
gambling, 9 .50
Hispanic, 9.38, 9 .59
LSD manufacture, 6.8
mari j uana, 1.21 , 1.30, 1.36, 1.42,
6.25- 32, 1.36
medica l mari juana,1.34, 6.1,
6.26--27, 6.31- 32
me th man u facture 1.31 , 1.36,
3.24-25
Pain Patien t Bill of Rights, 4 .15
prisons, 9.8
Pro p osi tion 36, 1.24, 1.35
research, 3.26, 5.24
Salvia, 6.21 - 23
tobacco, 3.58
wine, 5.6
California Drug an d Alcoho l
Treatment Assessment
(CALDATA), 9.7, 9.70
Call of Du ty: Black Ops, 1.40
Cambodia. See Golden Triang le
Camels, ® 3.43
Caminiti, Ken, 7.17
Canada
alcohol, 1.25, 5.33, 8.22
ep hedrine, 4.5, 8.10, 8.50, 8.56
heroin, 4. 12, 8.45
mari j uana, 1.34, 6.27, 6.31 - 32
MDMA, 6.14, 6. 16
needle exchange, 8.45
on line medicat ions, 4.4 1
PMA, 6.15-16
shop p ing, 7.42
smoking , 1.35
cance r
AIDS, 8.45
alcohol, 5 .16--17, 5.18, 5 .19
betel, 3.34, 3.42
eating disorde rs, 7.47, 7.50, 7.62
HCV, 8.44
inha lants, 7.7, 7.9
liver, 4.22, 8.44
mari j uana, 6.34, 6.38
obesity, 7.47
opioids, 4.19, 4.27
pain, 4 .19, 4.27, 6.39
smoking, 1.3, 1.23, 1.35, 3.53
steroids, 7.16, 7. 18
tobacco, 3.53, 3.54, 3.59, 6.33,
7.21
"cancer stick " (cigare tt e) , 3.4
candidiasis (STD) , 8.43
"candy snaps " (LSD and ecstasy ) , 6.16
cannabidiol (CBD), 6.32, 6.4 5
cannabinoids, 5.25, 6. 1, 6.33. 6.35,
6.45, 10.3, 10.21 , 10.33
active ingredients, 6.28
alcohol and, 9.46
drug testing, 8.50
research, 6.33, 6 .35
street names, 6.4
cannabinol, 6.33
Cannab is, 6.26--45
ancient uses, 1.10, 1.11
C. ind ica ("Ind ian hem p "), l.ll ,
6.1, 6.26, 6.27, 6.39, 6.42
C. ruderalis (wee dy hemp ) , 6.26,
6.42
C. sativa, 1.19, 6. 1, 6.26, 6.27,
6.39, 6.42
cu lti vation, 6.23-24, 6.27, 6.28
economic uses, 1.10, 1.19
history, 1.2, 1.10, I.I 1, 1.23, 1.25,
1.26, 1.31, 1.34, 1.35
low -grade, 6.26
medicina l uses, 1.ll
pharmaco logy, 6.29- 30, 6.37--40
synthetic THC, 1.33- 1.35
Cannab is clubs (buyers' clubs), 6.38
Cannabis -induced disorders,
10.21, 10.33
Cannador. ® See dronab inol
Cannon, D.S., 2.43
Canseco,Jose, 1.38, 7.11- 12
cantharadin (Spanish fly) , 8.40
Captagon. ® See fenethylline
carbamazepine (Tegretol ®) , 9.39, 9.44,
9.66, 9.67, 9.69, 10.27, 10.30
carbidopa (Atimet, ® Sinemet ®), 9.39
carbohydrates, 7.43, 7.46, 7.47, 7.48,
7.51 , 9.52
carbon com p ounds. See vo latile
solvents
carbon diox ide, 2.5, 2.6, 5.5, 5.8,
5.9, 7.5
carbon monoxide, 3.51, 3.54-56, 8.25
carcinogens, 7.24, 7.27. See also
cancer
card iomyopa thy, 5 .19, 7.18
cardiovascu lar system, 8.58.
See also arrhythmias
alcoho l, 5.19- 20, 5.46
amphetamines, 3.24,
3.27- 28, 7.20
caffeine, 3.342
cocaine, 3.13, 3.15, 3.56
energy drinks, 3.38
ephedra, 3.36--37
IV drug use, 4.29
look -alikes, 3.32
LSD, 6.8
MDMA,6. 15
metha d one, 4.29
obes ity, 7.47
opioids, 4.29
psychedelics, 6.15, 6.16, 6.18
SIDS 3.14
steroids, 7.17 - 18
stimu lants, 3.5--6, 3 .56, 7.20
tobacco, 3.46, 3.51- 53, 3.59
yohimbe, 3.36
career function ing, 9.10-11
carisoprodol (Soma ®) , 4.2, 4.29 4.43,
7.15, 7.16, 7.60, 9.44, 9.61
camitine/coenzyme Ql0, 9.69
camitine/Co Q (Ubigold®) , 9.69
carotid artery; 3.48
Carter, Pres identjimmy, 1.5
"cartwhee ls " (dl am p hetam ine), 3.3,
3.23
CASA. See Center on Addictions and
Substance Abuse
CAT (computerized axial
tomography) scan, 2.35, 9 .3
"cat " 3.4, See (khat )
Catapres. ® See clonidine 10.29 - 30
catatonia, from PCP, 6.18, 6.41
catecho lamines, 2.2 1, 3.12, 3.26. See
also dopamine; ep inephrine;
nore p inephrine
"catha, " 3.4 (khat )
cathinone (khat ) , 1.34, 136, 137, 3.4,
8.41. See also khat
Catholic, 1.12, 1.16
"cau " (betel), 3.4
"cavia r" (cocaine and marijuana ) ,
3.19
CBD. See cannabidiol
CBl, CB2 receptors (anan d amide ) ,
2.22, 5.27, 6.33 - 35, 7.46
CBR (dime thoxyphenethy lam ine,
2CB, nexus ), 1.28, 6.1, 6.4,
6. 19, 10.29. See also nexus
CBT. See cogni tive-behavioral therapy
10.24
"CandC " (glutethimide ), 4.31
"CCC" (DXM), 6.24
"cebil " (DMT) , 6.12
Celebrex. ® See celecoxib
celecoxib ( Celebrex ®) , 7.16.
See also nonsteroida l
an ti-inflammatory drugs
Celexa. ® See cita lopram
cell body (soma ), 2.12, 2.6, 2.lS-19
cell membrane, 2.0, 2.23, 2.24
and d own regu lation, 6.5, 6.8,
6.17, 6.36
cell phone. See mobile phone
cellulitis, 4 .23
Center for Online Add iction, 7.55
Center on Addictions and Substance
Abuse (CASA), 8.32
Centers for Disease Contro l and
Prevention, 8.41
AIDS and HIV, 8.44, 8.45
Central Intelligence Agency (CIA ) ,
1.28, 1.41, 6.6, 6.24
CENTRAL NERVOUS SYSTEM
(CNS), 2.0, 2.1, 2.5, 2.8,
2.12, 2.22, 2.41, 2.45. See
also brain; neuroanatomy;
neurotransmit ters; addictions
pathway
alcohol, 5.30
cocaine neurochemis try, 3.11 - 12
how drugs get to the brain, 2.2-8
imaging techniques, 9 .3
Centrax. ® See p razepam
CERA, 7.24 . See also erythro p oietin
cerebellum, 2.9, 2.11, 2 .lS- 19, 3.15,
4.38, 5.18, 6. 11, 6.29. See
also old brain
cerebra l cortex. See cor tex; new brain
cerebrum, 3.28. See also new brain
CERN. See European Particle Physics
Laboratory
Cesamet ® (synthetic THC), 6.5, 6.32
cha, chai (tea), 3.4
"champagne " (marijuana an d
cocaine ) , 3 .19
champagne (wine ) , 5.2, 5.8, 5.9, 5.13,
8.36
Chantix. ® See varenicline 10.14
"chapapote " (hero in), 4.6, 4 .ll
charas (marijuana), 6.28, 6.30
"chasing " (gambling ), 7.3S-39
"chasing the dragon " (he roin
smoking ) , 4.8
Chasnoff, Ira, 8.20, 8.27, 9.12
"chat " (khat ) , 3.4. See also khat
chat group, 7.55
Chavin Indians, l.ll, 6 .12
"chaw " (chewing tobacco), 3.4
"chaw, " "chew " (chewing tobacco ) ,
7.21
"cheap basing, " 3 .18
"cheese " (heroin), 4.6, 4 .10
chemica l dependency, 9.3
chemotherapy, 6.30, 6.39
Cheque ® drops. See mibolerone
Cheracol. ® See codeine
"chew " (chewing tobacco), 3.4.
See also chewing tobacco;
smokeless tobacco
chewing (stimulan t ingestion)
betel, 3.35 - 36
coca leaf, 1.7, 1.8, 1.12, 1.15, 1.33,
3.S-9
khat, 3.34
tobacco, 1.12, 1.15, 1.16,
2.5, 7.21, 9.22, 9.40,
9.41,3.43-44, 3.46,3.53
chewing tobacco, 1.9, 1.32, 2 .5, 3.4,
3.41, 3.43, 3.43, 3.49- 50,
3.59, 7.21, 9.22, 9.40, 9.41.
See also smokeless tobacco
Chichimecas, 6.14
"chicken power, " 6.20
"chicken yellow, " 6.20

chil dre n . See also adolescents; Adu lt
Children of Alco holics;
codependency; elemen tary
schoo ls; high school;
pregnancy; youth
of addicts, 8.32, 9.34 - 35, 10.4,
10.17
brain development, 2.40
excessive emotional p ain, 2.40
family roles, 8.32
homelessness, 5 .39
medications for, 1.37, 4.40, 10.28
opiates, 4.23
prescribing practices, 4 .2
Chil dress, Anna, 2.14, 2.28, 9.24-25
"chill pills." See benzodiazep in es
Chill Sp ice. See synthe tic marijuana
"chillum," 6.30
chimpanzee brain, 2.11
Chimu p eop le, l.ll
China, 5.3
AIDS, 4.23
alcohol, 1.9, 1.10, 5.2, 5.33
behavioral compulsions, 7.35,
7.54, 7.55
betel nut, 3.35
Cannabis, 6.26
ep he dra, 3.36
heroin ("Ch in a whi te"), 4.11, 4.31
Internet, 7.54, 7.55, 9.54
IV drug use, 4.19
marijuana,1.11, 6.42
me th, 3.22 - 24
opia tes/opium, 1.7, 1.20, 9.42, 4 .8
opi u m tra d e, 1.7, 1.20, 4.8
smoking, 3.50- 5 1
sports, 7.13, 7.26
tea, 1.14, 1.15 3.37 - 38
tobacco,1.15, 1.16, 1.36
treatment, 9.54-55
ya ba, 3.22
"Ch ina white," 4 .7, 4.11, 4 .3 1. See
also designer drugs; heroin
Chinese Americans, 9.60-61
Chinese Canon of His tory, 5.4
Chinese triads (tongs), 4.10
"ch iva" (heroin) 4.6, 4.11
chlamyd ia, 8.43
chloral hy dr ate (Noctec, ® Somnos, ®
Aquachlora l®), 4.2, 4 .34,
4.43, 9.39, 9.45, 10.30
chlor di azepoxi d e (Librium, ®
Librita bs,® Limb it rol,®
Risolid, ® Tropi um ®), 4.35 -
36, 9.20, 9.25, 9.39, 9 .45,
9.66, 10.29, 10.30
chlorofluorocar bon (freons), 7.3, 7.8
chloroform, 1.19, 7.3, 7.4
chlorpromazine (Thorazine ®), 2.4 1,
8.41, 9.11,10.14, 10.27,
10.30, 10.33
chlorproth ixene (Taractan ®), 10.30
chlorzoxazone (Para fon Forte ®), 4.2
CHOCOLATE, 1.2, 1.14, 1.17,
3.39,3.41
cholecys tok in in (antagonis t), 2.27
cholinergic effects, 3.46.
See also anticholinergic
choreoatheto id movemen ts , 3 .15
Christian ity, 1.15
"Christmas trees," 3.3
CHRM , , 2.39
chromatography (thin layer TLC),
8.50
chromosome, 7.7
"chronic" (mari ju ana), 1.2, 6.4, 6.26
chronic obstructive lung disease
(CO PD), 3 .48, 3.59
Chu Dynasty, 1.6
CIA. See Cen tr al Intelligence Agency
Cialis .® See tadalafil
cigare tt e rolling mach ine, 1.22, 3.41
cigare tt es. See below at tobacco;
tobacco
circuit part ies, 9.63
circulatory system
blood dop ing, 7.22, 7.60
drug distribution, 2.4-8
inhalants, 7.6, 7.9, 7.10
oxygen capacity, 7.22, 7.24, 7.60,
16
oxygen depriva tion, 7.9, 7.10, 7.59
cirrhosis, 1.25, 5.17 - 18, 5.18, 5.19,
5.44, 5.46, 8.1, 8.3, 8.15,
8.55
citalop ram (Celexa ®), 9.39, 10.26,
10.30
Civil War, U.S., 1.1, 1.19, 1.21, 3.10,
4.9, 4.8
gambling, 7.34
op ioids,1.19, 9.42
CIWA-Ar. See Clinica l Institu te
Wi th drawal Assessment of
Alcohol Scale, revised
CJS (criminal ju stic e system)
p opul ations. See pri sons
and j ails
Clarren, Sterling K., 8.22
CLASSIFlCATl ON OF DISORDERS.
See also DSM-IV-TR; DSM-5;
International Classification of
Diseases
ADHD, 3.29-30, 10.17
com pulsive behaviors, 7.29, 7.29 -
3 1, 7.35, 7.37, 7.43, 7.52,
10.4, 10. 14, 10.16, 10. 18,
10.26, 10.31
eating disorders, 7.4 5, 10.4, 10.14,
10.18, 10.26, 10.33
substance -relate d disorde rs,
10.1- 3, 10.14, 10.18,
10.31 - 33
types of alcoholism, 5.5
CLASSIFlCATl ON OF DRUGS,
1.1- 1.5. See also schedu led
drugs; street names; trade
names
alcoho l, 5.21 - 23
amphetamines, qw - 10.29 - 30
chemical names, 1.2
downers, 4 .2- 3
inhalants, 7.11
major de pressants, 4.2
minor dep ressants, 4.2 - 3
opium, opi ates and opioi ds, 4.5-8
other unusual drugs, 7.29
psychedelics (all arounders), 6.3-5
psychiatric medicat ions, 10.29 - 30
sedative-hypnotics, 4.33 - 37
stero ids and sports drugs, 7.16
stimu lants (up pers), 3.3 - 3.4
tr ade names, 1.2
class ificati on sys tems, 2.48
Claviceps purp urea (e rgot fungus),
1.9- 1.10, 6.6. See also LSD
"clean pee" (drug-free urine), 8.53
clen buterol, 7.14, 7.16
"clic kers, " "click ems," 6.39, 7.27
client confiden tiality, 9.6 4
Clinical Institute Wi thd rawal
Assessment of Alcohol Scale,
revised (ClWA-A r), 9.1, 9.20,
9.20, 9.45
Clinical Opiate Withdrawal Scale
(COWS), 9.20
clini cal trials of new drugs, 9.70
Clinoril .® See su lindac
Clin ton, Bill (U.S. president), 1.5
clomipramine (Anafranil ®), 10.30,
10.31
clonazepam (Klonopin, ® Rivotril ®),
2.32, 4.25, 4.29, 4.33, 4.36,
4.47, 7.15, 8.2, 8.54, 8.57,
9.47, 10.29, 10.30
clon idi ne (Catapres ®), 2.4, 2.31, 9.2 0 ,
9.37, 9.41, 9.42, 9.66, 9.67,
10.29, 10.30
Cloninger, Robert , 5.20
cloraze p ate (Tranxene ®), 4.31,
10.29, 10.30
Clou d 9,• 3.37, 6.19, 7.29
"Clown Royal." See synthe tic
marijuana
cloza pin e (Clozari l®), 10.28,
10.29,10.30
Clozaril. ® See clozapine
clubbing. See rave clubs
club drugs, 1.33, 1.34, 1.37, 4 .33,
6.15 - 18, 7.9, 7.29, 8.9, 9.47
CNS. See central nervous system
CNTF. See modified ciliary
neurotrophic factor
Coast Guard, 5.32, 8.8
Coca -Cola, 3.39
cocada, 1.12
cocae th ylene, 2.6, 3.11 - 13, 3.15, 5.25
COCA INE, 3.3, 3.6--20. See also coca
leaf
absorp tion, 1.8, 1.15, 1.20-1.23,
3 .5, 3.S-11
adultera tion, 3.16
age of first use, 8.12, 8.18
alcohol, 3.13 - 14, 3.19, 9.40
au tonomic nervous system, 2.8,
2.45
brain chemistry; 3.2, 3 .11- 12,
3.14, 10.2, 10.4, 10.5,
10.8, 10.14, 10.17,10.20
10.25, 10.29
brain scan, 2.17, 3.12
classification, 3.3
"coke bugs, " 3.15
Colom bia 3. 7, 3.16
conse quences of use,1.21, 122,
3.10, 3.15 - 16, 3.19
crack cocaine,1.2, 1.8, 1.21, 1.30,
1.32, 8.9, 8.37, 8 .4 13.10,
3 .16--19
"crac k dancing," 3.15
crash after use, 3.5-6, 3.12, 3.14
crime, 3.7, 3.9, 3.17
d enta l problems, 3.15
dru g testing, 8.46, 8.4 7, 8.50
effects, 3.11 - 15
elderly, 8.54, 9.56
emergency rooms, 3.14 - 15, 4.38
energy changes, 3.2
epidemio logy, 9 .38
freebase,1.2, 1.23, 1.30,3.17-19
genes, 2.26, 2.36--40, 2.46--4 7
"go" circuit, 2.1, 2.10, 2.13-17,
2.39, 2.41, 2.45--46
ha lf-life, 2.6--7, 3.11
high school, 8.28
history 1.7, 1.8, 1.12, 1.15, 1.15,
1.20- 1.24, 1.30, 3.6--11
hypnotiz in g effect, 2.41
1V use, 3.8, 3.18
marijuana, 6.39
medical treatment, 9.38-40
medical use, 3.11
memory of use, 2.12, 2.14
metabolism, 3.11 - 12
methods of use, 1.20, 1.21, 3.8-11
Na tive Americans, 9.61
neurotransm itters, 2.1, 2.2, 2.19,
2.20, 2.20--26, 2.25, 2.29,
2.41, 2.44, 2.46, 3.6,
3. 11, 3.12, 3. 14
INDEX 1.7
overdose, 3. 15-16, 3.19, 3.47,
3.56, 3.57
paranoia, 3.6, 3.11 - 13, 3.15
polydrug u se, 3.6, 3.15, 3.19, 4.3,
4.22, 4.25, 4.25
pregnancy, 3.13 - 14, 3.56, 8.60
psychosis, 3.6, 3.11, 3.15, 10.15,
10.17
PTSD an d , 10.16
refinement from coca leaf,1.20,
1.21, 3.7
replacement therapies, 9.67
respiratory effects, 3.15, 3.19
reward/reinforcement cente r, 3. 12
I
sex, 3.12 - 13.19, 8.36, 8.38, 8.42,
8.61
sexual dysfunction, 10. 19
smokab le cocaine, 3.16-19
smuggling 3. 7
snorting 3.10, 3.16, 3.18 (See
also mucous membrane
absorption)
sports use, 7.14, 7.25
SSRls and, 10.26, 10.29
street names, 3.3
symptoms of abuse, 9.38
synthe tic (ba th salt.s),1.31,
l.3}-1.3 4
tolerance, 3.6, 3.14-15
topical anesthetic, 1.21, 3.16
(See also cocaine
hydrochloride)
treatment, 9.31, 9.38---40, 10.6,
10.26
treatment admissions, 9.16
vaccine (ITA-CD), 9.21
violence, 3.6, 3.12 - 13
withd rawal, 3.5-6, 3 .14
Cocaine Anonymous (CA), 9.29
cocaine avers ion the rap y, 9.39-40
cocaine hydrochloride (HCL), 1.2,
1.30, 2.44, 3.9 - 10
cocaine vaccine, 9.21, 9.67
cocaine wine (Vin Mariani), 1.17, 3.6-9
coca leaf, 1.7, 1.8, 1.12, 1.15,
1.21,1.22, 1.33, 3.6--9
coca paste. See "pasta"
coca wine, 1.21, 3.6-9
cocoa beans,1.1 4 , 3.6-9. See also
chocolate
"cocoa pu ff," 3.19
codeine, 1.32- 1.34 , 2.32, 4.2 4.6---8,
4.17 - 18, 4.15, 4.24, 4.31,
4.42, 7.15
drug testing, 8.54
ecstasy and, 6.17 (See also
"spee dball")
se dative -hypnotics an d , 4.33
syn the tic op ioids an d , 4.27
codependency, 9. 19, 9.3 1, 9.34
Coffea arabica, 1.14 , 3.4 1 COFFEE,
3.4, 3.36, 3.37, 7.20, 7.36.
See also caffeine
history, 1.14, 1.17 (See also caffeine)
medicina l use ,1.17, 3.41
coffee sho p s, 1.17, 1.36
"coffee shops " in Amsterdam,
6.24, 6.37
"coffin nails, " 3.4
"coffins " (alprazo lam), 4.31
Cogentin. ® See benz trop in e
cognac, 5.7
Cognex. ® See tacrine, 10.29
cogn itive behavi or al therapy (CBT),
7.43, 7.51, 9.26, 9.39, 9.42,
9.50, 9.53, 10.18, 10.24
cogn itive development. See also
cogn itive impairment
smoking, smokeless tobacco, 8.25
treatment, 9.55 - 56
 1.8 INDEX
cognitive distortion
compu lsive gambling, 7. 40-41
cognitive effects. See also cognitive
impairment; delusions;
ha llucinations; illus ions;
memory
cannabis intoxication delirium,
10.3, 10.21, 10.33
compu lsive gambling, 7.40-41,
10.4, 10.18, 10.33
d extromethorphan, 6.24
LSD, 6.3, 6.6
marijuana, 6.30-31, 6.32, 6.39
psychedelics, 6.21 - 25
I
Z-hypnotics, 4.42
cognitive impa irmen t , 2.29
alcohol, 5.19, 5.44, 9.45
dual diagnosis,10.5 - 13, 10.15,
10.22 - 25, 10.31 - 33
eld erly, 9.57
fetal alcohol syndrome, 5.29 - 31
fetal effects, 8.24
formaldehyde, 6.33
inhalants, 7.6, 7.10, 7.11
paterna l drinking, 5.31
substance -in duced, 10.7, 10. 11,
10.13, 10.14, 10.20,
10.21, 10.26, 10.32- 33
treatmen t, 9.23, 9.64, 10.33
cohoba (DMT) , 6.12
coke. See cocaine
"coke bugs, " 3.15
Cola nitada (co la nut or kola
nut),1.14, 1.15, 3.4, 3 .10,
3.35, 3.36, 3.38
colas, 3.39-41
cold turkey de toxification, 9.13, 9.43,
9.47
Cold War and sports d rugs, 1.27, 7.13
Coleridge, Samu el Taylor, 4.10
Colima drug cartel (Mexico), 4.11 - 12
COLLEGE . See also sports an d drugs;
youth
alcohol, 5.39--40, 5.44, 8.31
anxiety disorder, 10. 16, 10.22,
10.28
binge drinking, 5.15, 5.22, 5.39 -
40, 8.4
campus strategies, 8.33
d rinking age, 8.4
d rug testing, 8.53
eating d iso rders, 7.45, 7.48, 7.62,
10. 14, 10.18, 10.26
electronic addictions, 7.57
energy drinks, 3.38
epidemio logy, 8.41-46
gambling, 7.3&--37, 10.3, 10.4,
10.10, 10.15, 10.18
inhalan t use, 7.5
marijuana, 8.5
mental health trea tment, 10.9 - 13,
10. 18, 10.19, 10.22 - 25,
10.27 - 28, 10.31 - 33
norma tive assessmen t , 8.33-34
Ritalin, ® 3.6, 3.29
secondhand drink ing, 5.39, 8.32 - 33
sexual behavior, 8.33, 8.43
sports and drugs, 7.14, 7.15
Colombia, 1.12, 1.31, 1.32, 3.7, 3.16,
3.20, 3.38, 6.31
an ti-drug efforts, 8.8
heroin, 4.10-11, 4.20
U .S. an ti-drug policies, 8.34
Colombian (mari ju ana ) , 6.4
Colombian Cartels, 1.32, 4. 10-11, 4.24
Colombian white hero in, 4.11
Colonia l America, 1.18, 1.19, 5.4, 5.7
Colorado, 3.59, 8.18
medica l mari j uana, 1.25, 1.34,
1.35, 6.37 - 38
Columbia University, 8 .10- 11
Columbus, Christopher, 1.12, 1.15,
1.16, 3.41
coma
alcohol, 5 .15, 5.19
am p hetam ine, 3 .32
cocaine, 3.15
depressants, 4.2, 4.36, 4.39
GHB, 7.23, 8.38
halothane , 7 .10- 11
inha lants, 7.6, 7.7, 7.10
opioids, 4.21, 4 .32
sedative -hypnotics, 4.40, 4.43
Combunox. ® See oxycodone
commercia lization of sports, 7.14
communicable diseases, 8.44
community drug programs, 9.5
commun ity invo lvement, 8.30
Community Mental Health Centers
Act, 1.24
comorbidity. See dual diagnosis
Compazine .® See prochlorperaz ine
competency building, 8. 7
Comprehensive Drug Abuse
Preven tion and Contro l Act
(1970), 1.24, 1.27, 8.10
compulsion. See addiction;
com p ulsive behaviors
COMPULSIVE BEHAVIORS, 1.1,
1.5, 1.6, 1.40-1.42, 3,16
7.29 - 31, 7.60-6 1, See also
eat ing disorders; gambling,
compulsive; Internet
addiction; sexual addiction
as ad d iction, 3.6, 7.29 - 31
brain wiring, 2. 4 2
eating disorders, 7.43-52, 7.62
gambling, 7.43-52, 7.62,
9.49, 10.18
games, 7.56
Internet addiction, 7.32, 7.54,
7.55 - 56
OCD and, 7.30, 10.13, 10.14,
10.16,10.21, 10.24, 10.26
practice of, 7.32
recovery and, 9.22
sexual addict ion, 7.52 - 54, 7.62-63
shop p ing, 7.32, 7.42--43, 7.61- 62
susceptibili ty, 7.32
television, 7.56-57
treatment, 9.49 - 53, 9.49 - 55, 9.72,
10.3 1, 10.33
triggers, 7.43
compulsive overeating, 7.31 , 7.50-52,
9.51 - 52, 10.4, 10.14, 10.18,
10.29, 10.33
self-diagnostic test, 7.52
compulsive shopping/buying disorder
(oniomania), 7.42-43
computer games addiction, 7.56.
See also video games
computerized axial tomography.
See CAT scan
computer relationship ad diction, 7.1,
7.55, 7.56, 7.63
COMT met 158met, 2.39
concentration cam p surv ivors, 7.13,
7.l&--17
Concerta. ® See methy lphenidate,
10.24, 10.25, 10.29, 10.30
condoms, 8. 4
con frontation (intervention), 9 .55,
10. 11, 10.33. See also
nonconfron tational strategies
congeners, 5.11, 5.14. See also alcohol
congeners; amphetamine
congeners
Connecticut, 7.36, 9.50
Conocybe, 6.11
Conquista dors, 3.8, 6.14
conspiracy theory of crack, 9.59
constipation,1.3, 1.11, 4.18, 4.31
opioids, 4.1, 4.15, 4.28, 4.42
constriction bands (heart), 3.13
construct ion industry, 8.48
contact absorption, 2.2, 2.4, 2.45,
3.55. See also adhesive
p atches
Contador, Alberto, 7.14
contam inants. See adulterat ion/
contam ination
Conte, Victor, 7. 12
contem pl ation stage, 9.27
contingency management, 9.42
controlled drinking through behavior
modifica tion, 9.6
controlled (scheduled) drugs.
See sche du led drugs
Controlled Subs tance Analogue Act
(1986), 8.9
convulsions (seizures ) , 10.26.
See also seizures
alcoho l, 5.46, 9.45
amphetamine, 3.27, 3.32
antidepressants, 10.26
cocaine, 3.15
ergo t , 1.13, 6.6
inhalants, 7.8, 7.10
op ioids, 4.21,4.38, 4.40
PCP 6.21 - 22
sedative -hypnotics, 4.34, 4 .35,
4 .37, 9.44
co -occurring disor d ers. See dual
diagnosis
Coors, ® 5.6
COPD. See chronic obstructive
pulmonary disease
Cop enhagen ® snuff, 3.4, 3.44
Cop ing Cat (program for schoo l-aged
children), 8.6
cop ing skills, 8.6, 9.62
Cora Indians, 6.14
Corici dan, ® 6.21
com syrup, 7.46-47
coronary arteries, 3.13, 3.42, 4.34
corpus callosum, 8.22
correction fluid, 7.3, 7.4, 7.5, 7.8
Cor so, Gregory, 1.26
Cortes, Heman, 1. I 7
cortex, 4.17, 4 .38, 7.20, 7.30.
See also new brain; old
brain; orbitofrontal cor tex;
p refronta l cortex
corticosteroids (Prednisone, ®
cort isone), 7. 16, 7.48,
9.36, 10.26
corticotropin (ACTH, cortisone ) ,
2.22, 10.26. See also
cort isone
corticotro p in -releasing factor (CRF ) ,
5.28, 9.68
CortiSlim, ® 9.53
cortiso l, 2.41, 7.38, 9.53, 10.29
cortisone, 7.16, 7.60, 10.26.
See also corticotropin
Costa Rica, 6.41, 9.60
costs of abuse
access to trea tment, 9.17
AIDS and HIV, 4.23, 4.45, 8.14,
8.47
alcoho l abuse, 5.4 I
alternat ive treatment services, 9.36
amphetamines, 3.27 - 28
bu p renorphine, 1.29, 1.37. 1.38
cocaine
drink ing in the m ilitary, 5.38
drug abu se, 9.3
drug courts, 8.11, 8.12
drug testing, 8.50
EAPs, 8.47--48, 8.58
gambling, 7.35 - 36, 7.38
healthcare, 4.28, 4.45, 8.19, 8.48
homelessness, 5.39
incarceration vs. treatment,
9 .5, 9.7
medica l model treatment
programs, 9.14
methadone maintenance 1.29,
1.37, 1.38, 4.2&-29
methamphetamine 3.20
nicotine, 3.5 1, 3.58
resources for effective treatment,
9 .5, 9.9
steroids, 7.19
substance -exposed children, 8.19
supply reduction approach, 8.2,
8.3, 8.11
treatmen t effectiveness, 8.26
12-step programs, 9.29
War on Drugs, 1.6, 1.29
workp lace drug testing, 8.47-48
cough me dications, 6.24, 8.57. See
also dextromethorphan
counseling, 9.9. See also recovery;
treatment
12-step programs, 9.30
adolescents, 9.55 - 56, 10.18, 10.24
eating d isorders, 7.51, 9.5 1, 10.21,
10.25
effect iveness, 9.21
elderly, 8.59
errors of new counselors, 9.31 - 32
family therapy, 9.32 - 35
gender, 9.55
indiv idual vs. grou p the rapy,
9.2&--32
opioid treatment, 9.43
stimu lant abuse, 9.38-39
treatment, 9.40, 9.41
counter-behavior, 2.40
counter -trans ference, 9.32
coup le's the rap y, 9 .53
court -referred treatment, 1.31 , 1.42
COWS. See Clinical Op iate
W ithdrawa l Scale
CP- 154, 526, ®9.68
CP 47,497, 6.4, 6.29
crabs (STD), 8.42
"crack " cocaine, 3.17 - 18, 8.9, 8.41.
See also freebase; smokable
cocaine
age of first use, 8. 18
crack bums, 3 .19
"crack coolers, " 3.19
"crack dancing, " 3.16
crack epi d emic, 1.30, 8.36 3.16-17
crack keratitis, 3 .19
crack lung, 3.19
crack thumb, 3.19
sex,for drugs 3.20, 8.36, 8.42
CRADLE TO GRAVE. See also
adolescents; college; elderly;
high school; pregnancy
college, 8.33-35
d rug testing, 8.50 - 55
drug use by age, 8.18
elderly, 8.54--58
love, sex, and drugs, 8.34-47,
8.61--63
military, 8.49 - 50
patterns of use, 8 .17- 19
pregnancy, 4.21, 8.18-27
prevent ion strategies, 8.44
sexually transm itted diseases,
8 .19, 8.20, 8.23, 8.41,
8.42, 8.44, 8.47, 8.58
workplace, 8.46--48, 8.58
youth and school, 8.27 - 34
CRAFFT, 9.12
Craig's List, 7.56

"crank " (methamphetamine HCL),
3.3, 3.21, 3.23, 3.28, 3.31 ,
8.5210.6---8, 10.14, 10.18,
10.20-21, 10.30, 10.32 See
also methamphetamine
crash. See also depression; withdrawal
shopping, 7.42, 7.61
stimulants, 3.5-6, 3 .12, 3.14,
3.16, 3.34
CRAVING. See also anticraving drugs;
detoxification; tolerance;
withdrawal
alcohol, 5.14, 5.25, 9.68
amphetamine and cocaine, 3.9,
3.11, 3.14, 3.16, 3.18,
3.19, 3.20, 3.25, 3.26,
3.26, 3.27, 3.56, 3.57,
9.68
benzodiazepines, 4 .40
compulsive shopping, 7.42
diagnosis and, 9.11
eating disorders, 7.46
endogenous, 9.21, 9.24, 9.39,
9.67, 10.17
environmental cues, 4.20, 4.25,
9.24, 9.25
exogenous opioids, 4.13, 4.32
gambling, 7.38
marijuana, 6.40, 9.47
medications, 4.29, 4.30, 4.32, 9.3
memory, 2.1, 2.10-12, 2.40-41,
2.45
negative feelings, 2.12, 10.17
neurotransmitters, 9.21
new vs. old brain, 2.9- 10, 2.13
nicotine, 3.47- 51, 9.41, 9.68
old brain, 2.9-10
opioids, 4.25, 4.32, 9.42
relapse prevention, 9.24
television, 7.56, 7.57
treatment, 9.39, 9.42
creatine, 1.4, 1.27, 1.38, 7.23
CREB (gene), 2.39, 5.24
CRF. See corticotrophin -releasing
factor
crime
adolescent drug use, 8.29
alcohol, 5.2, 5.32, 5.41, 8.5, 8.29
amphetamine, 3.22
cartels, 1.31, 1.32, 1.33, 3. 7, 3.33,
4.5, 4.10-11
chemical dependency, 9.58
cocaine, 1.30, 3.17, 3.20
consensual, 4.20
drug -related incarcerations,
8.10, 8.11
gambling, 7.35
Internet, 7.52
methadone maintenance, 8.14
opioids and heroin,1.20, 1.32,
4.20, 4.21, 4.26, 4.42,
4.24, 4.29
prevention, 1.29
Prohibition,1.23, 1.25, 8.5
sexual acts, 7.52
sexual assault, 8.33, 8.38, 8.40
workplace, 8.48, 8.49
Crimean War, 1.19, 3.10
Crime Control Act of 1990, 1.24
criminal justice system (CJS).
See also prisons and jails
costs, 8.46
marijuana referrals, 9.47
principles of treatment, 9.9 - 10
treatment, 9.5
criminal thinking, 9.9
Crips (gang), 3.20
Critser, Greg, 4.45
cromolyn (antiasthmatic ) , 9.16
cross -dependence, 2.28, 4.44
cross -tolerance, 2.28, 4 .19, 4.44,
6.8, 7.11
"crosstops" (amphetamines), 1.23, 3.3
"crystal" (methamphetamine HCL),
3.3, 3.25
"crystal meth"
(dextromethamphetamine),
1.2, 1.27, 1.30, 1.36, 3.23-
24, See also amphetamines;
dextromethamphetamine;
methamphetamines
Crystal Meth Anonymous, 9.29
Cuba, 1.16, I.I 7, 5.40
Cuban Americans, 5.40, 9.59, 9.60
Cubensis. See psilocybin
cue extinction, 8.13, 9.24-25
cues. See triggers
culture
African-American community,
5.42
body image, 7.44, 7.45
college drinking and, 8.35
disagreement about drugs and,
8.58
drinking behavior, 5.33-34, 5.39,
5.41, 5.44
elderly drug use, 8.55
minority communities, 9.59
new addictions, 1.8
sexual addiction, 7.52
transitions between cultures, 8.32
treatment, 9.57 - 62
Custer, Robert, 7.38
cutoff switch. See on -off switch;
"stop" circuit
cyberaddiction, 7 .63-65
cyber -relationship addiction, 7.55
cybersexual addiction, 7.52, 7.55,
9.53, 9 .54
cyclazocine, 9.67, 9.68-69
cycling (of drugs), 2.33, 4.25,
7.17, 7.60
cycling (sport ), 7.14, 7.22
cyclobenzaprine (Amrix ,®Flexeril ®),
4.3, 4.23, 4.41, 7.15-16
cyclohexyl nitrite, 7.3, 7.9
cyclopropane (anesthetic ) , 7.9
cycloserine (Seromycin ®), 9.69
Cylert. ® See pemoline 10.30
Cymbalta .® See duloxetine
CYP2A6 genes, 2.39
CYP2D 6 *2 "novelty seeking"
gene, 2.39
CYP2D 6 allele gene, 8.25
CYP26 ,2A allele gene, 8.25
cyproheptadine (Periactin ®), 7.24
CYT-002 -NicQb (Nicotine-Qbeta),
9.67
D deliriants, 7 .2. See also inhalants
D 2 receptors (dopamine), 2.39,
2.41, 3.14
D-9-tetrahydro-cannabinol (THC), 6.4
DA. See dopamine (DA)
"dabbing, " 1.34, 1.35, 6.30
"dacha," 6.25
"daggha," 6.25
DailyStocks.com, 7.56
daime tea, 6.12 - 13. See also ayahuasca
Dalmadorm. ® See flurazepam
Dalmane. ® See flurazepam
danazol (Danocrin ®), 7.18
dance therapy, 9 .3 7
"dank" (marijuana), 6.4, 6.28
Danocrin. ® See danazol
Dantrium. ® See dantrolene
dantrolene (Dantrium ®), 4 .3
darbepoetin (Aranesp ®), 7.24
DARE, 8.30-31
Dare to Be You, 8.30
Darvocet N. ® See propoxyphene
Darvon. ® See propoxyphene
OASIS. See Drug and Alcohol Services
Information System
DAST (Drug Abuse Screening Test),
9.12
date rape, 7.23, 7.25, 8.36,
8.38-39, 8.41
alcohol, 5.21 , 8.29
benzodiazepines, 4. 4 2
GHB,4.45
memory loss, 4.40, 6 .18
DATOS. See Drug Abuse Treatment
Outcome Study
datura (jimsonweed), 1.13, 1.10, 6.1,
6.4, 6.17- 18
"<lava" (heroin), 4.6
Davidson,Judith, 7.25
Davy, Sir Humphry, 1.19, 7.9
daytrana Patch (methylphenidate) 3.3
Day's Work ® (chewing tobacco), 3.4
DBA/2] (strain of mice), 2.44
DEA. See Drug Enforcement
Administration
"deadly nightshade" (belladonna),
1.13, 3.46, 6.4
debt counseling, 7.42
Debtors Anonymous (DA), 7.43, 9.29
DecaDurabolin. ® See nandrolone
deconditioning, 9.24
decongestant, 1.26, 1.41 , 3.32,
3.41, 7.20
decriminalization, 1.31, 6.25, 8.3,
8.15, 8.58, 9.6
DeDomenico,John, 9.33
defective genes, 5.23. See also genes
defense mechanisms, and
interventions, 9.19.
See also denial
degreasers (inhalants), 7.3, 7.8
dehydration
amphetamines, 3.15, 3.27
eating disorders, 7.49
hangover, 5 .16
MDPV3.35
sports, 7.23, 7.24
dehydroepiandrostenedione
(DHEA), 7.21
dehydrogenase. See acetaldehyde
dehydrogenase; alcohol
dehydrogenase
Deitch, David, 1.42
deja vu, 6.30
Delatestryl. ® See testosterone
cypionate
delayed emotional development,
10.17, 10.23. See also
emotional maturation
delirium. See also delirium tremens
alcohol, 5.26, 9.45, 10.19
anticholinergics, 1.10-11, 6.20
ergot, 1.13, 6.6
inhalants, 7.1, 7.6, 7.11, 9.48
marijuana , 10.6, 10.21, 10.33
mescal beans, 1.11
Salvia divinorum, 6.23
stimulants, 10.14 - 16, 10.19 - 21,
10.26, 10.27
substance-induced disorders,
10.3, 10.7, 10.11,
10.14, 10.18-22, 10.26,
10.32- 33
delirium tremens (DTs), 5.26, 5.43
alcohol, 9.45
GHB, 9.47
delta alcoholism, 5.22
deltaFosB, 2.40
delta receptors, 4.15
INDEX 1.9
deltatetrahydrocannabinol. See THC
delusions, 7.6, 7.49
alcohol -induced disorder, 10.14
auditory or visual illusions, 6.8,
6.10, 6.12, 10.2, 10.14,
10.19, 10.21, 10.25
definition, 6.5
somatoform disorders, 10.17,
10.33
thought disorder (schizophrenia),
10.2- 7, 10.13-14, 10.19,
10.21 - 23, 10.25, 10.27-
29, 10.32
Delysid ® (pharmaceutical LSD), 6.6
I
demand reduction, 1.29, 8.2, 8.3-4,
8.10, 8.11, 8 .14
drug courts, 8.12
federal funds, 8.3
dementia, 5.41, 7.6
alcohol abuse, 5 .19
dual diagnosis and, 10.17, 10.19,
10.33
Demerol. ® See meperidine
dendrite, 4 .14, 9.46
dendritic spines, 2.11, 2.11, 2.12,
2.22, 2.40, 2.46
denial, 10.11, 10.23, 10.24
adolescent brain, 9.56
alcohol, 9.45
drug testing, 8.50
eating disorders, 7.48, 7.49
high school and college use,
8.27 - 28
as obstacle, 9.64, 10.24
secondary prevention, 8.13, 10.23
as symptom of alcoholism, 5.23
Denmark, 3.38, 5.36, 5.35, 6.20
dental problems, 3.15, 3.27, 3.27,
3.36, 3.53
amphetamines, 3.27
bulimia, 7.50
cocaine, 3.15
tobacco, 3.53
Depade. ® See naltrexone
Depakene .®See valproic acid
Depakote. ® See divalproex sodium
Department of Defense Alcohol Abuse
and Tobacco Use Reduction
Committee, 5.38
Department of Defense drug policies,
8.8, 8.49
dependence (addiction), 2.2, 2.14,
2.24, 2.26, 2.28, 2.30- 31,
2.36, 2.39, 2.40, 2.41,
2.46. See also addiction;
psychological dependence;
tissue dependence;
withdrawal
alcohol, 5.1, 5.10, 5.21- 23, 5.46
in disease model, 2.36
DMT, 6.13
genetics and, 2.36-37
inhalants, 7.11
ketamine 6.22
LSD, 6.10
MDMA6.17
medical marijuana, 6.39-40
opioids, 7 .15
steroids, 7.18
tissue dependence, 5.24
dependent users, 8.3, 8.14, 8.61
depersonalization, 6.9 6.21 - 22,
6.25 10.16
depersonification, 6.24, 6.35
depobuprenorphine, 9.67
deponaltrexone, 9.42, 9.67
Depo-Provera, ® 2.4
Depotestosterone. ® See testosterone
cypionate
 1.10 INDEX
DEPRESSANTS (DOWNERS).
4.-, 5.-. See also alcohol;
antidepressants; opiates/
opioids; pres crip tion drugs;
sedative-hypnotics; entries
for specific drugs
alcohol, 4.2
antihistamines, 3.32, 4.3, 8.56
classification, 1.3, 4.2-4
cross-tolerance and cross
dependence, 4 .40
drug interactions, 4.46, 10.31
MAO inhibitors, 10.24, 10.26,
10.30, 10.33
I
mental effects,1.3, 4.39
opiates/opioids, 4.3
OTC downers, 4.3
pharmaceutical industry, 4.44-7
physical effects, 1.3, 4.2
sedative-hypnotics, 4.3
skeletal muscle relaxants, 4.2
sports use, 7 .25
depression, 9.38. See also bipolar
affective disorder
alcohol, 5.26, 10.2,10.4-8, 10.16,
10.19, 10.29, 10.32-33
anxiety disorders, 6.9, 10.2, 10.3,
10.13-14, 10.16, 10.lS-
20, 10.29-33
compulsive shopping, 7. 4 3
diagnosis, 5.27-28, 10.2-11,
10.13-15, 10.18
dual diagnosis, 10.5-9,
10.15,10.18, 10.22, 10.25,
10.27. 10.30-33
eating disorders, 7.47, 7.50, 7.51,
10.4, 10.18, 10.26, 10.33
factors, 10.3, 10.4, 10.7, 10.15,
10.32
gambling, 7.39, 10.18
major depressive disorder, 10.1-7,
10.14, 10.15-16, 10.19,
10.30-33
medical marijuana, 6.39, 10.25
medications, 9.51, 10.24, 10.26,
10.27, 10.29, 10.30, 10.33
(See also antidepressants)
prevalence, 10.13
psychiatric medications, 4.38,
10.21, 10.25-27, 10.30,
10.31, 10.33
substance-induced, 10.3, 10.6,
10.7, 10.11, 10.13-16,
10.18, 10.21, 10.26,
10.32, 10.33
treatment process, 9.19, 9.37,
9.39,10.13, 10.15, 10.19,
10.20, 10.25, 10.26. 10.27
Deprol. ®See meprobamate
desensitization techniques, 9.41
relapse, 9.24-25
designated-driver programs, 8.14,
9.6, 9.15
designer drugs (new synthetics), 1.4,
3.3. See also MDA; MOMA
1.2, 1.24, 1.28, 1.33
bath salts, 1.2, 1.3, 1.31, 1.33,
134, 1.37, 3.34, 10.14
cannabinoids, synthetic
(Spice• ),1.3, 1.33, 1.34,
6.3,2-33 6.42, 10.21
drug testing, 8.49, 8.52
heroin, 4.27
laws, 8.9
psychedelics, 6.4, 6.15-16, 6.19
psycho-stimulants, 3.22, 3.34,
4.27, 6.19-20 (See also
MOMA)
STP or DOM, 3.22, 6.4, 6.17
desipramine (Norpramin, ®
Pertofrane ®), 8.40, 9.20,
9.39, 9.68, 10.26, 10.29,
10.30
desire. See craving; love; sex and
drugs
desired effects vs. side effects,
2.31-32, 2.47, 6.19.
See also select tolerance
alcohol, 5.10-11, 5.45-46
ketamine, 6.22
Desoxyn. ®See methamphetamine
HCL: 10.27, 10.30
desperation phase (gambling), 7.36,
7.38, 7.39
Desyrel. ®See trazodone: 10.26, 10.30
detection period range, 8.50-51
determination stage, 9.27
detoxification, 9.13, 9.20-21
acupuncture, 9.36
alcohol, 5.24, 5.25, 9.45
amphetamines and cocaine, 9.20,
9.3&-39, 9.66
buprenorphine, 9.43
cognitive deficits, 9.23
co-occurring disorders, 10.14,
10.22
depression, 10.20
elderly, 9.57
hospital-based programs, 9.20
inhalants, 9.48
medical model programs, 9.14
medications, 9.1, 9.4, 9.9,
9.20-21, 9.39--40,
9.42--44, 9.46, 9.66--67
meth abuse, 3.21, 3.23,
3.27-28, 10.20
from methadone, 9.43
opiates/opioids, 4.20-21, 4.25,
4.30, 8.25, 9.41, 9.42,
9.67 (See also methadone)
prevention during pregnancy, 8.26
psychedelics , 9. 4 7
psychiatric symp toms, 10.14,
10.20, 10.22
rapid opioid detoxification, 4.33,
9.67
sedative-hypnotics, 9.44
stimulants, 9.38
tobacco, 9.40, 9.41
treatment programs, 9.9, 9.44
developmental arrest, 9.1, 9.64,10.22,
10.23, 10.33
developmental disorders. See
also alcohol-related
neurodevelopment disorder;
attention deficit hyperactivity
disorder
alcohol and, 5.29-31
amphetamine-exposed infants,
3.27-28
dual diagnosis and, 10.17
"devils herb." See belladonna
"dex," 6.4, 6.24
Dexadiet, ®3.32
Dexamyl, ®3.22
Dexatrim. ®See phenylpropanolamine
Dexedrine. ®See dextroamphetamine
sulfate
dexfenfluramine (Redux ®), 3.3, 3.31
"dexies," 3.3
dexmethylphenidate (Focalin ®),
3.3, 10.30
dextroamphetamine sulfate
(Dexedrine, ®Dextrostat ®),
3.23, 10.30
dextro isomer methamphetamine.
See dextromethamphetamine
dextromethamphetamine ("crysta l
meth," "ice"), 3.21, 3.23,
8.38, 9.63. 1.3, 1.30.
See also amphetamines;
methamphetamines
dextrom ethorphan (DXM, Robitussin
DM,®Romilar, ® Coricidin, ®
etc.), 6.24, 8.54, 9.69 1,3,
1.34, 4.18
Dextrostat. ®See dextroamphetamine
sulfate
DHEA. See dehydroepiandrosterone
diabetes, 9.51
alcohol, 5.21
eating disorders, 7.1
epidemiology, 7.47
obesity, 7.44, 7.47, 7.62
diacetylmorphine, 4. 7. See also heroin
diagnosis
of ADHD, 3.29-31
alcohol dependence, 5.23, 5.25,
5.43, 5.46
alcohol problems of elderl y, 5.40
co-occurring disorders, 9.46,
10.S-9, 10.32
drug -in duced symptoms, 5.28
dual diagnosis, 5.28, 10.5-7,
10.16, 10.32, 10.33
of eating disorders, 7.45, 9.51,
10.4, 10.18
elderly, 8.56-57, 8.59, 9.57
FASO, 5.29- 31
of gambling, 7.37-38, 7.41, 9.49,
9.50, 10.18
of PFAS or ARNO, 5.29
of psychedelics, 9.46
sexual addiction, 9.53
tools, 9.11 - 13
Diagnostic and Statistical Manual
of Mental Disorders.
See DSM-IV-TR; DSM-V
Diamond, Ivan, 2.16
Dianabol. ®See methandrostenolone
diarrhea
alcohol abuse, 5.18
Kratom leaves, 4.33, 4.43
opioids, 4.2, 4.5, 4. 7-9, 4.12, 4.18
diathesis. See predisposition to
addiction
diathesis -stress theory of addiction,
2.37, 2.43-44,2.45, 2.47
diazepam (Apozepam, ®Valium, ®
Viva!• ), 2.8, 4.3, 4.4, 4.5,
4.30, 4.31, 4.32, 4.33, 4.34,
4.34, 4.35, 4.37, 4.38, 4.44,
7.15, 7.28, 8.26, 8.40, 8.57,
9.39, 9.44, 10.29, 10.30
Didrex. ®See benzphetamine
diencephalons, 2.09
Dietamine, ®3.22
dietary supplements, 7.23, 8.56
diethylpropion (Tenuate ®Tepanil ®),
3.3, 3.31
dieting. See also weight control
eating disorders, 7.51, 10.4, 10.18
medications and, 9.52
diet pills,1.2, 1.27, 3.22, 3.32,
7.23, 9.53
anorectics, 7.49
natural products, 9.53
diffusion tensor imaging (DTI), 2.22,
9.3, 9.4
digestive system and alcohol, 5.17-19,
5.43. See also gastrointestinal
problems; nausea; vomiting
Dilantin. ®See phenytoin
dilated pupils. See under pupil size
dilation of blood vessels.
See vasodilation
dilation of bronchii.
See bronchodilation
Dilaudid. ®See hydromorphone
"dillies" (hydromorphone), 4.6, 4.31
diluents, 3.16, 7.8
diluted opium (Paregoric ®), 4.7
dilution of drugs, 4.20. See also
adulteration/contamination;
diluents
dimethoxyphenethylamine
(2C-B, CBR), 6.4, 6.19
dimethyltryptamine (DMT), 6.4, 6.12
Dionysus, 1.6, 1.9, 1.10
"dip" (lion's tail), 6.4
"dip" (snufO, 3.4
diphenhydramine (Benadryl ®), 3.32,
10.28, 10.29, 10.30
Diprovan. ®See propofol
direct to consumer (DTC)
advertising, 4.41
"dirty basing," 3.10, 3.18
disabilities. See physical disabilities
disease concept of addiction, 5.20-21,
9.1, 9.2-3, 9.8, 9.9, 9.15,
9.21, 9.29, 9.32, 9.33, 9.35,
9.52, 9.59, 9.64
disinhibition, 2.32
alcohol, 5.14, 5.23, 8.38, 8.39
amphetamines and cocaine, 3.12,
3.14, 3.19 3.25
depressants, 4.2
GHB,4.38
marijuana, 8.38
MDMA,8.39
opioids, 8.38
sedative-hypnotics, 4.3 7, 4 .38,
4.39, 8.38
sexuality, 3.12,3.19, 3.24, 3.28,
7.54, 8.38
dispositional (metabolic) tolerance ,
2.27, 4.37, 5.24, 6.34
dissociative effects, 6.21-22
distillation of alcohol, 1.7, 1.14,1.15,
1.17,1.18
distilled beverages, 5.6-7, 5.42
distribution. See drug distribution
disulfiram (Antabuse ®), 9.9, 9.39--40,
9.46, 9.66
sedative-hypnotics and, 4.38
treatment using, 9.69
"ditchweed " (marijuana), 6.4, 6.26
diuretics
eating disorders, 7.49-50
sports, 7.18, 7.23, 7.24, 7.26
"divale " (belladonna), 6.4
divalproex sodium (Depako te®),
9.66,10.20, 10.27 , 10.30,
10.33
diversion of legal drugs. See also
misuse and diversion
opiates, 4.28--29
prescription drugs, 4.10, 4.25
sedative-hypnotics, 4.5
"divine nectar," 6.26
"diviner 's sage," 6.4. 6.22 See also
Salvia divinorum
d,l amphetamine (Adderall, ®
Benzedrine, ®Biphetamine)
3.21-25, 4.18, 4.20, 6.16,
7.20, 10.20. See also
amphetamines
emergency room visits, 4.18, 4.33
medical use, 10.27, 10.30
d,1-phenylalanine, 9.21, 9.36, 9.39,
9.68
DM. See dextromethorphan
DM in Romilar, ®6.4, 6.24
DMT. See dimethyltryptamine
Dole, Vincent, 9.42
Dolophine. ®See methadone

DOM. SeeSTP
Dama r.®See pinazepam
domestic violence
alcohol, 1.25, 5.21, 5.32, 8.5,
8.22, 8.41
cocaine, 3.13, 3.27
sexual abuse, 8.7, 8.41
Domicum. ® See midazolam
donepezil (Aricept, ® Rivotril ®),
9.66, 10.26
dopamine (DA),1.5, 2.13-16, 2.20,
2.21-23, 2.24-25, 2.26,
2.39, 2.41, 2.42, 2.42,
2.44, 2.46, 3.5, 7.31, 7.54,
10.3, 10.4, 10.25, 10.26,
10.28, 10.29,10 .30 See also
norepinephrine -dopamine
reuptake inhi bi tor s
add iction, 7.18, 7.31-32, 7.43
ADHD, 3.28, 3.30
alcohol, 5.12, 5.28, 5.43, 9.46
am p hetam in es and cocaine, 2.20,
3.5, 3.12, 3.14, 3.15, 3.25
bloc k to release of, 9.68
DRD,Al allele, 5.22, 5.23, 7.31-
32, 7.61
drug relationships, 2.20
eating disorde rs, 7.46, 7.48, 7.62
gambling, 7.62
genes, 2.38, 5.23, 7.31-32, 7.61
imaging, 9. 4
medications, 9.68
nicotine, 3.46, 3.48
psychiatric me dications, 10.24,
10.25, 10.26, 10.27,
10.28, 10.29, 10.30
receptors, 2.39, 2.43, 3.14
reward/deficienc y syn drome, 2.39
schizophrenia, 10.3, 10.4, 10.25,
10.30
sedative-hypno ti cs, 4.30, 4.34,
4.38
sex,7.54, 8.35
stimulants, 3.5, 3.6, 3.12, 3.14,
3.15, 3.25, 3.27, 3.29,
3.33, 3.44, 3.45, 3.56
(See also above at
amphetam ines an d
coca in e)
tissue d ependence, 4.16
tolerance, 3.5
treatment, 9.39, 9.46
dopamine agonists, 7.43, 9.39,
9.66, 10.29
dopaminergic reward pa thway, 4.13,
4.17, 7.49, 7.51. See also "go"
circui t; addictions p athway
"dope" (heroin), 4.6
"d ope" (marijuana), 6.26
Dope Project (Cla rion Alley), 4.33
Doral. ® See quazepam
Doriden. ® See glute thimide
Dormonoc t.® See loprazolam
DOSAGES
2C-B, 6.4, 6.15 18
alcohol, 5. 12-17
alcohol during p regna n cy, 5.28
am p hetam in es, 7.20
benzodiazepines, 4 .39-40
bu prenorph in e, 9.43
caffeine, 3.37, 3.38, 3.39, 3.40,
3.58
dex tromethorphan, 6.21
elder ly, 8.55
GHB, 4.38
ibogaine , 6.11
ketamine, 6.22
LSD, 6.8
MDMA, 6.16--17
PCP, 6.21
peyote, 6.14
salvinorin A, 6.23
select tolerance, 2.26
stero ids, 7.13, 7.17
volatile solvents, 7.6
double tro ubl e (dual diagnosis ), 10.6
"double trouble " (secobarbital and
amobarbital, Tuinal ®),
4.31, 4.44
downers. See de pressants
down regula tion, 2.24, 2.24,
2.46, 10.26
marijuana, 6.36
sero ton in receptors, 6.17
stimu lants, 3.6
doxepin (Sinequan, ® Adapin ®),
10.30
Drano, ® 8.53
DRD 2A 1 allele gene, 2.40, 7.31-32,
7.46
alcoho l, 2.38, 5.22, 5.24, 5.26
nico tin e, 3.50
DRD 1 gene, 2.39
Dreser, Hein rich, 4 .8
drink ing age, 5.26, 5.40, 8.4
driving and drugs. See also blood
alcohol concentration
accidents, 5.2, 5.14, 5.21, 5.33,
5.37, 6.43, 8.18, 8.29,
8.32, 8.47
alcoho l, 5.10, 5.33-35
arrests, 5.33
driving under the influence (DUI),
5.10, 5.33-34. See also drunk
driving
dronab in ol (syn thetic THC; Marinol, ®
Cesamet, ® Sativex, ®
Cannad or ®), 2.3, 6.4, 6.32
"drone," 3.34
drown in gs, 8.28
doctor shopping, 8.10
drug abs or p tion. See abs or p tion
of drugs
drug abuse, defined, 2.35
Drug Abuse Con trol Amendment,
1.24
drug abuse costs. See costs of abuse
Drug Abuse Treatment Ou tcome
Study (DATOS), 9.7, 9.70
Drug Abuse Warning Network, 6.28
Drug Addict ion Treatment Act (2000),
9.14
Drug and Alcohol Services
In form ation System
(DASIS), 9.7
drug aut oma tism, 2.29, 4.37
drug courts, 1.31, 1.42, 8.11, 9.5, 9.64
drug developmen t process, 9.69-70
drug distribution, 2.4-8
drug diversion programs.
See drug courts
Drug Enforcement Adm in istra tion
(DEA),1.24, 3.16, 3.23, 4.11,
4.24, 4.28, 6.8, 9,14
cocaine, 3.16
drug seizures, 8.10
methamphetamine, 3.23
Sche du le I psychedelics, 6.3-4,
6.7, 6.13, 6.16, 6.22
synthetic drugs,1.27, 1.30, 6.33
drug -free workp lace, 8.46, 8.50
drug -free zones, 8. 7
drug gangs, 1.6, 3.25, 4.11, 4.12. See
also Asian gangs; Mexican
drug cartels
drug hunge r. See craving
drug -indu ced disorders. See
su bstance-ind u ced men tal
disorders
Drug- Ind uced Rape Prevention Act,
4.39
dru g information programs, 8.5-6
dru g interactions. See also polydrug
use and abuse; syne rgism:
10.31
alcohol, 4.36, 4.39-40
downe rs, 4.1, 4.25, 4.36, 4.39--40,
4.44
emergency rooms visits,4.2,
4.37-8, 4.33
older people and, 4.27-35
pharma cists and, 4.5
dru g kits in history, 1.22
dru g labs. See manufac tur e of drugs
dru g regula tions. See laws an d
regula tions
dru g replacement therapy, 9.6
dru gs. See absorp ti on; ad d iction;
costs of abused substances;
dependence; dilu tion
of dru gs; dru g testing;
metabolism; p regnancy;
rou tes of adminis tration;
synergism; tissue
d ependence; tolerance;
wi th drawal; entr ies for
spe cific drugs
dru g seizures, 8.10
"drugst or e heroin" (D ilaudi d®),
4.7, 4.28
d rug swi tch in g, 9.22
dru g testing , 8.50-55
accuracy, 8.53-54
alcohol, 7.25, 8.1
amphe tamines, 7.20
co llege, 7.14
d etection period, 8.50-53
dru nk driving , 8.52
effectiveness, 8.58
false negatives, 8.50
false positives, 8.50, 8.52-53
ha ir ana lysis, 8.51-52
ha lf-life, 2.6
home-testing kits, 8.51
latency, 8.51
LSD, 6.8
man ipul ations by, 8.52
marijuana, 6.33, 6.42-43, 9.48
medical marijuana, 6.39
mili tary; 8.51
Olympics, 7.14
pre-employment testing,
8.47, 8.50
ran dom testing, 8.32, 8.50
schools, 8.31
self-repor ted drug use an d , 8.50
spor ts, 7.11, 7.14, 7.19, 7.25,
7.26--27, 7.26--27
steroids, 7 .19
urine tests, 8.23, 8.49, 8.53
workplace, 8.48, 8.49, 8.64
d rug the rap y. See
psychopharmacology
d rug-traffick in g organ izations (DTOs)
meth, 3.20
Mexico, 3.20, 3.23, 3.25, 6.31
Drug Treatment Alterna tive-to-Prison
(DTAP) program, 9.5
Drug Use Forecasting (DUF), 3.8, 3.56
dru nk driving, 5.26, 5.33
accidents, 5.21,5.33, 5.37, 6.37,
8.5, 8.29, 8.5 1
tes ting, 8.51, 8.52
d ry cleaning fluid, 7.3
d ry drink in g cultu res, 5.36
dry drunk, 5.30, 9.46
DSM-IV-TR, 9.11
ADHD,3.30
alcohol abuse, 5.23
INDEX 1.11
dru g-rela ted disorders, 9.11, 10.3
eating disorde rs, 7.45, 7.48
HPPD, 6.9
inhalant disorde rs, 7.11
pathological gambling, 7.37, 9.50
sexual addiction, 7.52, 9.53
sexual dis ord ers, 7.54
substance-r elated disorders, 2.35,
5.21
DSM-V,2.35, 6.35, 9. 11, 9.49, 10.2
10.3, 10.17, 10.18, 10.21,
10.32
DTAP. See Drug Treatment Altemative-
to -Pri son program
I
DTC. See direct to consumer (DTC)
adver tising
DTI. See diffusion tensor imaging
DTO. See drug traffickin g
organizations
DTs. See delirium tremens
DUAL DIAGNOSIS (co-occu rring
disor d ers), 10 .6-21. See also
entries for specific disorders
alcohol, 5.28, 5.42, 10.2, 10.6,
10.7, 10.9, 10.12, 10.15,
10.16, 10.22, 10.32, 10.33
definition of, 10.5, 10.6, 10.32
diagnosis of, 5.28, 10.4-8, 10.10-
13, 10.18, 10.22-25,
10.27, 10.31, 10.32. 10.33
eating disorde rs, 7.47-48, 10.4,
10.14, 10.18, 10.26, 10.33
eld erly drinkers, 5.40-41
epidem iology, 10.2, 10.6, 10.32
gambling, 7.36, 9.50, 102, 10.3,
10.18, 10.33
mari j uana 10.6, 1016, 10.21,
10.29
menta l health commun ity and,
10.10-13
multiple diagnoses and, 10. 7, 10.8,
10.12, 10.18
patterns of, 10.7-8, 10.17, 10.18,
10.32
personality disorders, 10 .17-18
pre -exis ting mental illness, 10.2,
10.6, 10.13, 10.14,
10.17-18
psychiatric disorders and,
10.6--14, 10.16--21,
10.26, 10.31-33
reasons for inc rease in, 10.8
relapse and, 10.9, 10.11, 10 .12
10.13, 10.22, 10.23
research -base d recommen dations,
10.2--4, 10.11-12, 10.18,
10.20, 10.22, 10.285
se dative-hypno tics, 9.44
soma toform disorders, 10.17,
10.33
substance abuse community and,
10.9- 13, 10.32
substance-induce d menta l
disorders, 10.3, 10.6-7,
10.11, 10.14, 10.18,
10.26, 10.32-33
treatment, 9.9, 9.10, 9.18, 10.1,
10.6--29, 10.31-33
understanding the patient, 10.10-
11, 10.22
"dubie" (marijuana), 6.4
DUE See Drug Use Forecasting
DUI. See driving un d er the influence
Duke,J. B., 1.23
du loxetine (Cym balta®), 10.25 ,
10.26,10.29, 10.30
"dumm ies" (meperidine), 4 .7
Durabolin. ® See nandrolone
Duragesic. ® See fentanyl
 1.12 INDEX

DURATION OF ACTION. See eBid, 7.56 electronic dance music (EDM), eating disorders, 7.48, 7.49, 7.50
also flashback; half-life; ecgonine, 3.11, 8.54 1.33-34, 4.18, 4.27, receptors, 4 .13
metabolism; speed of action; E-cigarettes, 3.56 6.18, 6.19 sex, 7.54
withdrawal Economic and Social Research electronic games, 7 .54 energy, biochemistry of, 3.5-6.
alcohol, 5.S-10, 9.44 Council, 7.42 elementary schools, 5.37, 8.58. See also withdrawal
Amanita mushrooms, 6. 11, 6.23 Economic Benefits of Drug Treatment: See also youth energy drinks, 1.34, 1.36, 1.38, 3.37,
amphetamines, 3.23 A Critical Review of the elimination. See excretion 3.40, 7.20
barbiturates, 4.34 Evidence for Policy Elizabeth I (queen of England), 1.16 alcoholic, 5.7-8
benzodiazepines, 4.35 - 36 Makers, 9.8 Ellis, Alben, 9 .31 energy packets, 3.37
caffeine, 3.41 economic factors. See also costs embalming fluid (formaldehyde), England, 8.10
cocada, 1.12 of abuse 6.21, 6.39, 7.27 alcohol, I.15, 5.4, 5.9, 5.36, 5.37,
cocaine, 3.11, 3.13, 3.20 dealer incomes, 9 .58 embolism (needle use), 2.4, 8.43 8.9, 8.33, 8.39
codeine, 4.27 drugs as income resource, emergency care, 9.20, 9.45, 9.47 college drinking, 8.33
dextromethorphan, 6.24 6.36, 9.58 emergency room visits, 1.37, eating disorders, 7.43

I
DMT,6.12
drug testing, 8.50 - 51
GHB,4.38
half-life and, 2.6
khat 3.33
LAAM, 4.32, 9.43
LSD, 6.3
marijuana 6.39
methadone, 4.29, 9.42-43
nicotine, 9. 40-41
nitrous oxide, 7.10
opiates and opioids, 4.34
PAWS and, 9.23
PCP, 6.22
routes of administration, 2.4-6
sedative -hypnotics, 4.34
titration, 2.3
tobacco, 3.44
tryptamine, 6.12
volatile nitrites, 7 .9
volatile solvents, 7
Dutch traders, 1.17
"dwale " (belladonna), 6.4
DWI (driving while intoxicated). See
driving under the influence
DXM. See dextromethorphan
Dynacirc. ® See isradipine
dynorphins, 2.20, 2.21, 2.22
E Egypt
"E." See MOMA
EAP. See employee assistance program
Eastern Europe, l.ll, 1.13, 4. 7
East Germany, 7.13
East India Trading Company.
See British East India Trading
Company
"easy lay" (GHB), 4.38
EATING DISORDERS,1.5, 1.31,
1.40- 1.42, 7.43- 52, 7.62
anorexia nervosa, 7.48--49, 9.51,
10.14, 10.18, 10.33
binge -eating disorder, 7.50-52,
10.4, 10.14, 10.18, 10.33
bulimia, 7.49- 50, 9.51, 10.14,
10.18, 10.33
causes, 7.49, 7.50, 7.51
classification,1 .5, 7.45
compulsive overeating, 7.50-52,
7.52, 9.51 - 52, 10.29
dual diagnosis,10.4, 10.14, 10.18,
10.26, 10.29, 10.33
effects, 7.50
epidemiology, 7. 48
heredity, 10.4, 10.32
pharmaceutical treatments,
9.52 - 53, 10.26, 10.31
reward system, 2.41
self-esteem, 7.49
sports, 7.48
substance abuse and, 9.52
support groups, 7.51 - 52
symptoms, 7.45
treatment, 9.50 - 52
eBay, 7.56
gambling revenues, 7.32 - 33,
7.35, 7.36
marijuana,6.26, 6.41
opium trade, 1.10, 1.20
prison costs, 6.41
tobacco trade, 1.15, 1.16, 1.22,
1.23, 1.36. (See also
tobacco industry)
economics of drug trade. See costs
"ecstasy," 6.4, 6.15. See also MDMA;
MOMA
Ecuador, 3. 7, 6.12
eczema, 5 .21
edema, 5.21
EDM. See electronic dance music
Edronax. ® See reboxetine
education. See also prevention
IO.II, 10.23
alcohol, 5.40, 8.4
high school, 8.5HI
HIV prevention, 8.45
responsible decisions, 8.4
educational groups, 9.18, 9.31
EEG. See electroencephalogram
efavirenz (HIV medication; Sustiva ®),
6.4, 6.25 8.45
Effexor. ® See venlafaxine
"eggs" (phentermine HCL), 3.3
"eggs" (temazepam ) , 4.31
alcohol,1.9, 5.4, 5.6
hieroglyphic, 1.9
opium,1.10, 4.7 4.7
henbane, 1.13
EIA. See Enzyme Immunoassay;
exercise -induced asthma
Eighteenth Amendment, 1.23, 1.25,
6.27. See also Prohibition Era
Elavil. ® See amitriptyline
Eldepryl. ® See selegiline
ELDERLY,8.54 - 59, 10.28, 10.29
alcohol, 5.40-41 , 5.44, 8.56
assessment, 9.12
brain development, 2.40-42
common drugs abused by, 8.56
contributing factors, 9.56-57
forged prescriptions, 8.57
gambling, 7.36, 7.37
kava and, 7.27
liver, 5.40
metabolism, 9.56
physiological changes, 8.54-55
treatment, 9.56-57, 9.57
electroencephalogram (EEG), 5.14
electrolytes, 7.50, 9.46
electronic addictions,1.40, 1.42,
7.54-58, 7.63, 9.54-55.
See also electronic games;
information addiction;
Internet addiction; mobile
phone addiction; television
addiction; video games
electronic cigarettes, 1.8, 1.31, 1.36,
3.4, 3.51, 9.41
electronic dance clubs. See rave clubs
1.40,4.33
alcohol,3.40, 5.35, 5.40, 5.43
bath salts, 3.35 6.18
benzodizapines 4 .3
cocaine 3.15, 3.19, 3.27
drug interactions, 3.40, 4.21
for drug problems, 4.24, 4.28, 4.33
ephedrine, 3.36, 7.21
GHB, 4.43
heroin 4.22
hydrocodone, 1.37, 8.55 4.5
inhalants, 7.7
methadone, 4.25, 4.43
muscle relaxants, 7.15 - 16
oxycodone, 4.24, 4.28
PCP, 6.21
prescription drugs,1.37, 4.18
zolpidem (Ambien ®), 4.42, 10.30
EMIT. See Enzyme -Multiplied
Immunoassay Techniques
emotional center. See limbic system
emotional maturity, 8.29, 9.64, 10.23
alcohol, 5.35- 36
children of addicts, 9.34-35
treatment and, 9.64
emotions
binge eating, 7 .51
brain development, 2.40-42
children of addicts, 9.34-35
gambling, 7.37- 38, 7.41
memories, 2.10-12, 2.46
metabolism, 2.6-8
empathogens, 6.3
empathy, 9.27
emphysema, 3.48, 3.59
Empirin ® (w/codeine), 4.6
employee assistance program (EAP),
8.48, 8.47-48, 9.18
types, 8.50
emtricitabine, 8.45
enabling, 8.32, 9.34, 9.61
Endep. ® See amitriptyline
Endocannabinoid ligand
(e.g., anandamide), 6.34
endocannabinoids, 2.22, 6.29
endocarditis. See heart valve damage
Endocodone. ® See oxycodone
Endodan. ® See oxycodone
endogenous cannabinoid
neurotransmitters, 6.33
endogenous craving, 9.21, 9.24,
9.39-40endogenous
neurotransmitters, 5.22
endogenous opioids, 2.20, 4.12, 4.6,
4.12 - 13, 4.17, 4.32.
See also dynorphins;
endorphins; enkephalins
defined, 2.20
neurotransmitters, 2.20, 2.20-26
endogenous triggers, 9.24
endorphins, 1.29, 2.20, 4.2, 4.6,
4.12 - 13, 4.17, 4.28,4.32
4.41-42, 9.36, 10.29. See
also endogenous opioids;
enkephalins
alcohol, 5.12
gambling, 7.34
Gin Epidemic, 1.14-15
hemp,I.11, I.19
heroin, 1.17, 4.17
inhalants,1.8, 7.4
marijuana, 6.36
methods of use, 1. 7
opiates,1.20, 9.42
Opium Wars,1.20, 4.5
sex and, 8.38
tea, 1.17
tobacco, 1.16, 1.17, 1.18
enkephalins, 2.20, 2.20, 2.21, 2.22,
2.23, 2.25, 7.54, 10.29.
See also endogenous opioids;
endorphins
eating disorders, 7.48, 7.49, 7.50
sex, 7.54
Enlightenment (historic period),
II.17 - 1.22
entactogens, 6.3
enteric division of the nervous
system, 2.9
ENVIRONMENT
addiction, 2.40-41, 4.43
alcoholism, 5.21, 5.22, 5.35
brain development, 2.40-42, 2.48
compulsive behaviors, 7.32, 7.61
drug choice, 9 .37
eating disorders, 7.43, 7.46
factors in, 2.39, 4.26
family and, 8. 7
mental balance, 10.3, 10.4 - 5,10.7,
10.22, 10.32
prevention programs, 8.6, 8.30
protracted withdrawal, 2.30-31,
2.30, 2.39, 2.43-45
research, 5.30
risk ofrelapse, 9.21, 9.24
stimulant craving, 3.27, 9.39
theories of addiction, 2.36-38
treatment and, 10.22
triggers, 2.30,3.12, 4.20, 4.25, 9.24
environmental damage from drugs
drinking water, 4 .39
drug laboratories, 3.16, 3.17,
3.21, 3.24
ozone depletion, 7 .8
environmental triggers (protracted
withdrawal), 2.30-31,
4.20, 4.40
Enzyme Immunoassay (EIA), 8.50
Enzyme -Multiplied Immunoassay
Techniques (EMIT), 8.50-51
enzymes, 3.25, 4.44, 8.44, 8.55, 10.26
alcohol, 2.4, 2.6, 2. 7, 2.27
drug metabolism, 2.4, 2.6-8, 2.27
inhibition of, 2.8
"epena" (DMT), 6.4, 6.Il
ephedra (ma huang), 1.2, 1.7, I.II,
3.33, 3.36, 7.1, 7.20.
See also ephedrine
effects, 7.29
historical uses,1.8
history of use, 7.13
sports use, 7 .20-21

ephedrine, 3.21, 3.25,3.32, 3.37-8,
8.10, 8.25, 8.50
college sports use, 7.15
drug testing, 8.50
sports use, 7.13, 7.16, 7.20--21,
7.60 (See also lookalikes)
ephedrone (methcathinone), 3.4, 3.34
epidemic
AIDS and HIV,1.29, 1.33, 8.44,
10.12-13, 4.23
amphetamine, 1.26--1.27, 3.24
cocaine, 1.26, 3.7, 3.10, 8.35,
10.20
crack, 1.26, 3.6, 3.16, 3.18, 8.35,
10.20
diabetes, 7.47, 7.47, 7.62
ergot, 1.13
gin, 1.17, 1.18, 5.4, 5.42
hepatitis C, 4.24, 10.12
nicotine, 3.42
obesity, 7.43-44
prescription drug abuse, 4.1,
4.4--5, 4.41
epidemiology, 5.35-38, 8.41
EPIDEMIOLOGY, 1.30, 5.1. See also
emergency room visits; twin
studies; entries for specific
addictive substances and
behaviors
ADHD, 3.29
age, 8.41
AIDS and HIV,3.14,3.17, 4.5, 4.19,
4.43, 8.44--45
alcohol, 5.35-44, 5.46, 9.15, 9.16,
9.19, 9.45, 9.61, 9.63
amphetamine, 3.14, 3.28
chemical dependency, 9.2
cigarettes (See tobacco)
cocaine, 3.8-9, 3.17, 9.38
college, 8.19, 8.26-30, 8.32-33
compulsive buying, 7.42
compulsive gambling, 9.49-50
cradle-to-grave, 8.62
diabetes, 7.47
diet pills, 3.22, 3.31
drug-testing results, 8.51-52
eating disorders, 7.43-45, 7.48
elderly, 8.%-58
gambling, 7.36--39
hepatitis C, 8.44
heroin, 4.11-12, 4.19-20, 4.21-22
high school and junior high
school, 8.18, 8.19,
8.26-30, 8.38
illicit drugs, 8.23-25, 8.40, 8.59
inhalants, 7.5, 7.59, 9.48
LSD, 6.8
marijuana, 6.27-43, 9.47, 9.56,
9.58, 9.59, 9.61
mental health, 10.6-8,
10.13,10.17, 10.18, 10.32
needle use, 8. 44
nutrition, 7.43-44
pregnancy, 5.26--47, 8.19-27
prescription drugs, 4.18, 4.32-33
psychedelics, 9. 46
sedative-hypnotics, 4.35, 9.44
social class, 8.18
sports and steroids, 7.14
STDs (sexually transmitted
diseases), 3.12,
3.lS-20,3.24, 8.43--44
stimulant abuse, 9.38
tobacco, 3.47, 3.47
twin studies, 3.34, 5.22, 6.36, 10.4
workplace, 8.48
youth, 8.26-30, 8.38
epigenetics, 2.26, 2.37, 2.46
epilepsy, 5.18, 6.39, 10.12, 10.26
epinephrine (E; adrenaline), 2.20, 3.2,
3.6, 3.11-2, 3.14, 3.25-26,
3.5-36,3.48, 5.18, 7.22, 7.24,
7.54, 7.60, 10.27, 10.29
with nitrites, 7.24
psychedelics, 6.1, 6.12, 6.15
epithelial cells, 2.5
EPO. See erythropoietin
Equate, ®4.3
equine therapy, 9.37, 9.37
Equinil. ® See meprobamate
erectile dysfunction, 5.14, 7.52, 8.35
ergogenic drugs. See performance-
enhancing drugs and
techniques; steroids
ergotamine, 1.28
ergot extract. See hydergine
ergot fungus ( Claviceps purpurea),
1.13, 6.2, 6.6
ergotism (ergot poisoning), 1.13, 6.6.
See also LSD
erythropoietin (EPO), 7.14, 7.22, 7.60
escape-seeking gambler, 7.37, 7.38,
7.39, 7.42, 7.55
escitalopram (Lexapro ®), 4.3, 10.26,
10.29, 10.30
Esgic .® See butalbital
Eskalith. ® See lithium
esophageal cance r, 3.36, 3.53, 5.18
esophagus, 3.34, 5.18, 5.21, 7.50
Espiritismo, 9.15
espresso, 3.4, 3.41
estazolam (ProSom ®), 4.42, 10.30
estradiol, 7.21, 8.38
estrogen, 5.12, 5.20, 8.35
anorexia nervosa, 7.49
eszopiclone (Lunesta ®), 4.2 4.34-37,
4.42, 10.30
ethanol, 8.52. See also alcohol
ethanol (ethyl alcohol).
See also alcohol
beverages, 5.5-8
cirrhosis rate, 5.17
elimination rate, 5.9
inhalation of, 7.8
per capita use of, 5.18
therapeutic use, 5.12
ethchlorvynol (Placidyl ®), 4.42--43
ethene, 7.4
ether, 1.19, 7.3, 7.4, 7.13, 8.10
Ethiopia, 1.14, 3.2, 3.36
ETHNIC CONSIDERATIONS,
5.42-44. See also African
Americans; Asians and Asian
Americans; Hispanics; Native
Americans; Whites
alcohol abuse, 5.41-43
epidemiology, 8.18
genetic susceptibility, 5.22,
5.23-24, 5.44
inhalant use, 7.5
treatment, 9.57-62
ethyl acetate, 7 .3
ethyl alcohol (ethanol). See ethanol
ethyl chloride, 7.3
ethylene glycol, 5.11
ethylestreno l (Maxibolan ®), 7.18
ethyl glucuronide (EtG) test, 8.52
Etrafon. ® See perphenazine
"euphoria" (methyl pemoline),
3.3, 6.4
euphoric recall, 2.12, 2.14, 2.46
Eurasians, 1.9
Europe, 3.7, 3.38, 3.44, 3.59, 4.5,
4.10, 4.40 9.43
alcohol blood volume limits in,
5.10
approved drugs, 9.48
cirrhosis rates, 5.17-18, 5.18
coffee, 1.13, 14
colonization period, 1.11-14
DARE program, 8.30
distillation, 1.10, 1.14, 1.15
drug markets, 4.2
electronic addictions, 7.54
ergot, 1.13
heroin, 4.10, 4.11
nootropics, 7.29
opium, 4.3-4, 4.9 - 10
prescription drugs, 4.32, 4.40-41
smuggling, 4 .5
tobacco and, 1.12, 3.59
European Part icle Physics
Laboratory, 7.55
euthymia, 3.14, 9.38
"Eve" (MDMA), 6.4, 6.15
Everclear, ® 5.8, 5.9
evidence-based principles and
practices
alcohol dependence treatment,
9.46
approva l of new drugs, 9.69-70
co-occurring disorder treatment,
10.11, 10.24
evaluation metric, 9.4-5, 9.11
principles for prevent ion, 8.13
stimulant abuse, 9.38-39
treatment, 9.36, 9.38-39
Evidence-Based Programs, 8.7, 8.6-7,
8.13, 8.29, 8.31
evolutionary perspective, 2.5, 2.9-10,
2.45--46
excessive exercise, 7.50
excise taxes. See taxes on drugs
excitatory neurotransmitte rs, 2.13,
2.21, 2.23, 3.2, 3.5-6,
3.11 5.14
excretion, 2.6-8
of alcohol, 5.9
of benzodiazepines, 8.24
defined, 2.6
detox phase, 9.20
executive functions, 2.34
Exelon. ® See rivastigmine
exercise, 7.49, 9.51, 9.54
exercise-induced asthma (EIA),
7.16, 7.60
exhibit ionism, 7 .54
exogenous opioids, 2.20, 4.12,
4.18, 4.32
defined, 2.20
experimentation, 2.33
alcohol, 5.11, 5.37
college, 8.33
primary prevention, 8.30
sex, 8.33
EXPERIMENTATION TO
ADDICTION, 2.31-35, 2.47
"eye balling,"1.38
eye movement desensitizatio
relaxation, 9.36
eye nystagmus test, 5.34
EZWhip ®), 7.10
F "fen-phen" (amphetamine congener
"F-40s" (secobarbital), 4.36
Facebook, 7.1, 7.32, 7.56
facial edema, 5.21
facilitated groups, 9.27-28
facilitator
group therapy, 9.27
intervention, 9.18, 9.19
FAE. See fetal alcohol effects
Fair Sentencing Clarification Act
(2010), 8.8
faith-based treatment init iatives, 9.15
INDEX 1.13
FAMILY,9.18. See also Adult Children
of Alcoholics; environment;
family therapy; he redity
ACoA, 9.29, 9.35
addict denial, 9.17
addictions and, 2.35, 2.38, 2.39,
2.45
adolescents, 8.31
alcohol treatment, 5.29
anorexia nervosa, 7.49
children of addicts, 9.34-35
codependency, 9.34
diagnostic process, 10.4, 10.5
drug tests, 8.33
I
enabling, 9.34
family history, 3.50, 5.22, 5.23
gay/lesbian clients, 9.63
homelessness, 5. 4 2
impacts on, 10.5
intervention, 8.31, 9.18-19, 10.09,
10.14, 10.17
parental use, 8.31
prevention, 8.8, 8.31
sexual compulsions, 7.32
social network approach, 9.34
treatment, 8.8, 8.13-14, 8.51,
9.32-35, 9.42, 9. 71-72
(See also family therapy)
A Family Matter, 8.31
family models of recovery, 9 .33-34
family therapy, 7.51, 9.32-35,
9.51, 9.53
Asian Americans, 9.61
behav ioral approach, 9.33
eating disorders, 9.51
functioning approach, 9.33-34
systems approach, 9.33
Fanapt. ® See iloperidone
"fantasy" (GHB), 4.3
FARC. See Revolutionary Armed
Forces of Co lombia
Farmville, 7.56
FAS. See feta l alcohol syndrome
FAS (fetal alcohol syndrome),
5.29-31, 5.38, 8.21-22, 8.27
fasciculus retroflexus, 2.17
FASO. See fetal alcoho l spectrum
disorder
FASO (feta l alcohol spectrum
disorder), 5.29-31, 8.22, 8.62
fast food, 7.51
fasting, 7.50. See also abst inence;
anorexia nervosa
fat solubility. See lipophilic drugs
fat-soluble (lipophilic) drugs, 2.2, 2.5,
4.38, 7.26
fatty liver, 5.17, 5.19, 5.21
FDA. See Food and Drug
Administration
female athlete triad, 7.48
females. See gender differences;
women
fenethylline (Captagon ®), 3.3, 3.23
fenfluramine (Pondimin ®), 3.3, 3.23
combination), 3.3, 3.28,
3.31, 3.58, 9.52
fentany l (Actiq, ® Duragesic, ® Fentora,
® Sublimaze, ® Sufenta, ®
Sufentanil ®), 2.4, 4.1, 4.6,
4. 7, 4.13, 4.16, 4.20, 4.27,
4.42.4.43, 8.52
Fentora. ® See fentanyl
fermentat ion, 1.8, 1.9, 1.18, 5.5, 5.6
See also alcoholic beverages
fetal alcohol effects (FAE), 5.31,
5.32. See also alcohol-related
birth de fects; alcohol-related
neurodevelopment disorder
 1.14 INDEX
fetal alcohol sp ectrum disorder
(FASD), 5.29- 31, 8.36
fetal alcohol syn drome (FAS),
5.29- 31, 5.40, 8.2 1,
8.27, 8.22
fetal development, 8.23
fetal effects, 8.24
fetal stroke, 8.22
fetishism, 7.54
fetus. See pregnancy
fibrosis, 3. 15, 5.15
Fielding, Henry, 1.18
fight center, 3.2, 3.12, 3.21, 8.35
fight/flight response, 3.20
I
Figi family,6.45
Fiji, 7.50
Fili p ino Americans, 5.41, 9.60--61
Fin iject. ® See bo lasterone
Fin land , 1.25, 3.38, 3.58, 5.35
Fiorentine, Robert, 9.30
Fiorinal. ® See buta lbital
first-pass me tabo lism, 2.4, 5.8.
See also liver
first -time use. See also age of first use
bad trips, 6.9
heroin injection rush, 4.9
PCP, 6.18
5HT, 6.5, 7.29
5HT 2A receptors, 6.5, 6.8
5-hydroxytryptophan (5-HTP), 9.36
5-Me-DIPT (Foxy), 6.4, 6.13
5-MeO-DMT, 6.4, 6.12
"flake" (cocaine), 3.3
"flamers," 5. 7
"flaming Dr. Pepper," 5. 7
flashback (protrac ted withdrawal),
2.30. See also hallucinogen
pers isting perception
disorder
HPPD, 10.5, 10.7, 10.21, 10.33
LSD, 6.10
MDMA,6.17
morning glory, 6.12
PCP, 6.18
"flesh-eating" disease, 4.23, 8.43
Flexeril. ® See cyclobenzaprine
flowering tops. See sinsemilla
flumazenil (Anexate, ® Mazicon, ®
Romazicon ®), 4.36, 9.44,
9.67, 9.69
Flun ipam. ® See flunitrazepam
flunitrazepam (Flunipam, ® Fluscan d ,®
Rohypno l• ), 4.2, 4.5, 4.38,
4.42, 6.22, 8.38
fluorocarbons, 7 .3
fluoxetine (Prozac, ® Sarafem ®), 2.6,
2.2 1, 7.54, 8.40, 8.55, 9.20,
9.39, 9.41, 9.51, 10.25,
10.26, 10.30, 10.31
wi th ecstasy, 6.18
eld erly, 8.55
ha lf-life, 2.8
sex, 8.4 1
fluoxymesterone (Halotestin ®), 7.18
fluphenaz ine (Pro lixin, ® Pennit il®),
9.11, 10.27, 10.30
flurazepam (Dalmadonn, ® Da lmane ®),
4.6, 4.42, 9.39, 10.30
Fluscand. ® See flunitrazepam
flush ing reac tion, 5.36, 5.44
fluvoxamine (Luvox ®), 10.26,
10.30, 10.31
FLY. See bromo-dragonFLY
fly agaric (Aman ita mushroom),
I.I I , 6.23
fMRI. See functional magnetic
resonance imaging
Focalin (dexmethy lphenidate),
3.3, 10.30
follow-through (moni toring), 9.6~5
follow-up evaluations, 9.25 - 26
Food and Drug Adminis tration
(FDA), 4.27 - 28, 4.30,
4.32, 4.40-45, 7.21, 7.29,
8.25, 9.39
downers, 4.24, 4.26, 4.28, 4.36,
4.37, 4.38, 4.40, 4.41
drug development process, 4.41,
9.69 - 70
energy drinks, 5.8
food prepara tion in dus try, 8.46
formal dehyde, 6.39, 7.27
fonn ication (itching), 3.13, 6.12
fortified wine, 5.6
Fortwin. ® See pentazocine
Fort Worth, Texas, 9.13
4Ps Plus screening program, 9.12
4-bromo -2,5 -d imethoxy-
phenethy lamine (2C -B,
CBR). See 2C-B
4-M MC (methylme thcathinone), 6.18
Four Loko, ® 3.40, 5.8
4 methy l 2,5 dimethoxy -amphetam ine
(STP, DOM). See STP
4-methy lpemoline (U4Euh), 3.3, 6.4
"fours and doors" (glutethimide),
4.31
"420" (mar ijuana), 6.4
Foxy (5-Me-DIPT), 6.4, 6.13
France,1.13, 1.13, 1.13, 1.38, 4.12
alcohol use, 5.7, 5.18, 5.30, 5.35
cirrhosis, 5.18
eating disorde rs, 7.43, 7.49
ergotism, 1.13
gambling, 7.34
inha lants, 7 .4
marijuana, 6.37
opium, 1.7
sport5, 7.14
tobacco, 1.16, 3.53
Tour De France, 1.3 1, 1.39
fraternity drink ing, 5.40, 8.33
freebase, 1.26, 1.37, 1.4 I, 3.6, 3.10,
3.16--19. See also "crack"
cocaine; smokable cocaine
cocaine,1.30, 3.1, 3.3, 3.11,
3.16--20, 3.19, 3.56, 3.57
methamphetamine, 3.3,
3.25 (See also
dextromethamphetamine)
nicotine, 1.23, 3.44, 3.47, 3.53
process, 3.1, 3.19
French Connection, 4.10
freon. See chlorofluorocarbon
Freud, Sigmun d , 1.21, 2.18, 3.9,
6.12, 10.23
fright, 3.12, 8.36
frog secret ions. See toad
fronta l cortex, 2.18, 5.19, 6.5, 6.37,
8.12. See also prefrontal
cortex
frotteurism, 7.54
"frozen addict" syndrome, 4.28
fruits and alcohol, 1.5, 5.2, 5.6 1.9.
See also grape
"fry" 3.18
"fry daddies," 3.19, 6. 18
fuel gas (butane, isopropane), 7.3
FullT iltPoke r.com, 7.55
functiona l magnetic resonance
imaging (fMRI). See also
MRI, !MRI
functiona l magnetic resonance
imaging (fMRI) scans,
9.3, 9.64
G inhala ti on, 7.3, 7.4, 7.5, 7.6, 7. 7,
GABA,4.48, 4.42, 5. 14, 6.20, 6.31
alcoho l, 5.30
benzodiazepines, 4.34, 4.35,
4.37, 4.44
neurochemistry and, 4.2, 4.38
neurotransmitter, 10.3, 10.24,
10.25, 10.29
opioids and, 4 . 14
sedative-hypnotics, 4.34
treatment medications, 9.68
GABA (Xyrem ®), 10.25
gabapen tin (Neurontin ®), 9.20, 9.44,
9.67, 9.69, 10.27, 10.29,
10.30, 10.33
Gabitri l.® See tiagabine
GABRA,, 2.39
GABRG" 2.39
GAD. See generalized anxiety disorde r
(GAD)
galantamine (Rem iny l®), 10.29
Galan ter, Marc, 9 .30
Galen, 1.10, I.II, 1.17, 6.26
gall bladder disease, 7. 4 7
Garn-Anon, 9.50
Garn-A-Teen, 9.50
Gamblers Anonymous (GA), 1.25,
7.33, 7.35, 7.36, 7.39,
7.41-42, 9.29, 9.49-50
20 questions of, 7.41
"gamb lers fallacy," 7.40
GAMBLING, COMPULSIVE, 1.8,
1.40, 1.41, 1.34, 7.31,
7.32-42, 7.61
brain wiring, 2.42
characterist ics, 7.37 - 38
class ification, 7.35 - 36, 9.11
definitions of gambling, 7.33
diagnosis, 9.49
effects, 7 .39-41
epidemiology, 7.36--39
Gamblers Anonymous, 7.33, 7.35,
7.36, 7.39, 7.41-42
his tory 7.33- 35
Indian gaming, 7.33, 7.35, 7.36
In terne t compulsions, 7.56
pathological gambling, 7.33,
7.35- 39
phases of, 7.38-39
problem gambling, 7.35-36
symptoms, 7.37- 38
treatment, 9.49-50
types of gamblers, 7.35, 7.37
game p laying. See computer games
addiction
gaming industry, 9.49
revenues, 7.32 - 33
gamma alcoho lism, 5.22
gamma aminobutyric acid. See GABA
gamma butyro lactone. See GBL
Gamma G® (GBL). See GBL
gamma hydroxy butyrate. See GHB
gangrene, 1.13, 4.22, 6.6, 8.45
gangrenous ergotism ("St. Anthony 's
Fire"), 1.13, 6.6, 6.40
gangs, 1.6, 3.19-20. See also Asian
gangs; bike r gangs; Mexican
drug cartels
ganja, 6.5, 6.28, 6.30, 3.37
gardnerella (STD), 8.43
Garland, Judy, 4.4 1
gas chromatography/mass
spectrometry. See GCJMS
"gas frolics," 1.19
Gas Liquid Chromatography
(GLC), 8.51
gasoline
in cocaine manufacture, 37
ingestion, 7.27
7.8, 7.59
gas tric bypass surgery, 7.49, 7.51, 9.52
gas tritis, 5.18, 5.21
gas trointestinal problems
alcohol, 5.18, 8.22, 8.56
an ti-inflammatory drugs, 7.16
caffeine, 3.42
cocaine, 3.15
khat, 3.33
meth and cocaine, 3.15
gateway d rug, 6.41
gay community, 8.44
AIDS and HIV, 1.33, 8.44, 8.45
amphetamine 3.24 8.36, 9.63
inhalants, 7.9
prevent ion, 8.45
treatmen t, 9.63
GBL (gamma butyrolactone,
Blue Nitro, ® Revivarant, ®
Insom -X,®Gamma G,® GH
Revitalize r,® Remforce ®),
4.31, 4.39, 6. 16, 8.40
GCJMS (gas chromatography/mass
spectrometry), 8.51, 8.53
Gebe r (alchemist), 1.14
"geezing," 8.42
gende r differences. See also males;
women
alcohol use an d effects, 5.17 - 18
Asian Americans, 9.61
drug metabolism, 2.26, 2.46
low serotonin levels, 7.43
nitrous ox ide, 7.10
pathological gambling, 7.38
treatmen t adm issions, 9.55
gene dop ing, 7 .24
general competency build ing, 8.6
generalized anxiety disorder (GAD),
4.38, 4.41, 4.42, 10.2, 10.13,
10.14, 10.16, 10.28 10.30,
10.31, 10.32
"Generation Rx." See also prescription
drugs 1.37, 4.45
"Generation X," 1.37, 6.16
generic names (chemical names),
1.2, 3.51
genes, 3.46, 3.47, 3.51. See also
environmen t; heredi ty;
twin studies
addict ion-associated genes,
2.39-40, 2.48, 3.46-4 7
alcohol use, 5.23-25, 5.26, 5.30
changes in, 2.16, 2.26, 2.46
DRD 2A 1 allele gene, 2.40,3.50,
5.22, 5.24, 5.26, 7.31- 32,
7.46
eating d isorders, 7.46
he redity and, 2.41
morphine in breast milk, 8.23
neural connections, 2.16
nicotine, 3.50
susceptibility and, 2.36--38
gene therapy, 10.22
genetic function, 1.31
genetic suscep tibili ty, 2.47
gen ital herpes, 8.41
genital warts, 8.41
Geodon. ® See ziprasidone
geopolitics of drugs, 1.27- 29, 1.41.
1.31- 132 See also drug
gangs; taxes on drugs; entries
for various countries
caffeine, 3.36, 3.37, 3.38
cocaine, 1.28-29, 3.8 1.32- 1.33
heroin,1.31, 1.32, 4.11 - 12, 4.19,
4.21 - 22, 4.25
insurgencies, 1.2, 1.3 1
miscellaneous plant stimulants,
3.32, 3.33-34, 3.35

opium, 4. 7-8
sports, 7.13-14, 7.26
supply reduction, 8.3, 8.5, 8.7-8
George lII (king of England), 1.19
"Georgia home boy," 4.43
Germany 4.28
alcohol, l.ll, 5.7, 5.18, 5.36, 5.38
amphetamines, 1.26
cirrhosis, 5.18
ephedrine, ephedra, 3.25, 3.36
marijuana, 6.36
methadone, 1.28
obesity, 1.42
refinementofdrugs,1.7, 1.19, 1.20
GHB (gamma hydroxybutyrate,
sodium oxybate, Xyrem ®),
1.27, 1.33, 1.34, 4.43, 6.8,
6.18, 6.22, 9.46
replacement therapies, 9.67
sex, 8.38
in sports, 7.23
tissue dependence, 9.46, 9.47
use in treatment, 9.67
withdrawal, 9.47, 9.66
ghrelin (hormone ), 7.46, 9.52
GH Revitalizer ® (GBL). See GBL
Giedd, Jay, 2.33
Gilgamesh, Epic of, 5.2
gin, 1.17-1.18, 5.3, 5.7
Gin Epidemic,1.17, 1.18, 1.25, 5.4
ginkgo biloba (Bio Ginkgo, ®
Gumsmoke ®), 9.69
Ginsberg, Alan, 1.23 1.26
ginseng root (Panax wuinquefolium),
1.ll, 1.36, 3.37, 3.38,
7.29, 9.37
"girl" (coca ine ), 3.3
giving-up phase (gamb ling ),
7.38, 7.39
"glass " (smokable
methamphetamine),
3.3, 3.21, 3.23
glaucoma, 6.30, 6.39, 7.16
Glenn, Steven, 8.30
glial cells, 2.6
globus palladus, 2.14
Glucophage. ® See metformin
glucose, 3.39, 5.18, 9.3
glue, 7.5
glutamic acid (glutamate, glutamine),
2.21, 5.12, 6.5, 6.31, 9.21,
9.36, 9.68, 10.3,10.29
glutamine. See glutamic acid
glutethimide (Doriden ®), 4.2, 4.6,
4.31-32, 4.35-6
glycine, 2.20, 2.20, 2.21
"go" circuit, 2.1, 2.10, 2.13-17, 2.39,
2.41, 2.45--46, 7.30, 9.4
DRD 2Al allele gene, 7.31-32
eating disorders, 7.46
inhalants, 7 .6
Golden Crescent 1, 4.10
goldenseal tea, 8.55
Golden Triangle, 1.29, 1.32, 4.11, 4.42
"goma" (heroin ), 4.6, 4.11
gonorrhea, 8.43. See also sexually
transmitted diseases
"goob" (khat ), 3.4. See also khat
"goofba lls goofers" (glutethimide),
4.36
Gorbachev, Mikhail, 5.37
Gorski, Terry, 9.46
government. See also laws and
regulations; taxes on drugs
alcohol prohibition and,
5.3-5, 5.37
amphetamines, 3.24, 3.3
drug-free workplace, 8.50
eating disorders, 7.43
excise taxes, 5.4, 5. 7 8.16
federal mandates 8.50
facilities, 9.13
financial aid, 8.32
gambling, 7.36, 9.5
Internet, 7.35, 7.52, 9.55
marijuana, 6.44, 8.10, 8.30-31,
8.4S-50
MDMA,6.15
nicotine 3.43, 3.44, 3.57
opium, 4.10
psychedelics, 6.3, 6.11, 6.12, 6.13
resources for effective treatment,
9.5
revenues, 5.5, 5. 7
supply control, 1.6, 1.7, 1.29.
See also supply reduction
tax revenues from drugs, 1. 7, 1.10,
1.15, 1.16, 1.18,
1.22-1.26, 1.31, 1.35,
1.41, 3.42, 5.3, 5.7, 6.41
testing, 8.49, 8.51
texting by drivers, 1.33 1.31, 1.40,
1.42
tobacco, 3.42, 3.52, 3.53, 3.59,
8.8, 8.16
treatment, 4.10, 9.13
grain alcohol. See ethanol
grape (fermentation ), 1.9, 5.6
"grass" (ma rijuana ), 6.4, 6.26, 6.31
"gravel," 3.18
Great Depression, 8.4
Greece, ancient, 1.10, 1.11, 1.13,
1.27, 5.4, 6.2, 7.4
"Gree n Grenade." See synthetic
marijuana
Greece, modern,4.7, 6.36
"gree n weenies" (ethchlorvynol), 4.43
Greenberg, Leon, 5.20
"gre mmies, " 3.19
GreySheeters Anonymous, 9.52
grief counseling, 8.58
"grievous bodily harm" (GHB), 4.43
Griffiths, Richard, 6. ll
Grinols, Earl, 7.35
GROUP THERAPY,9. 7, 9.13,
9.26-32, 9.27-32, 9.41,
9.42, 9.53, 9.71
12-step groups, 9.28-29
eating disorders, 9.51
educational groups, 9.31
effectiveness, 9.21
elderly, 9.57
errors of new counselors, 9.31-32
facilitated groups, 9.27-28
peer groups, 9.28, 9.62
substance-abuse disorders, 10.9,
10.15, 10.22, 10.23-24,
10.33
targeted groups, 9.31
topic -speci fic groups, 9.31
growth hormone . See human growth
hormone
guanfacine (Intuniv, ® Tenex ®),
3.30, 10.30
guarana plant , 1.14, 3.4, 3.37, 3.38
guided imagery, 9.36
Gulf Canel, 4.ll-12
gums. See mucous membrane
absorption
"gutka" (betel), 3.36, 3.45, 8.25
Guzman,Juaquin "El Chapa," 4.12
Gwynn, Tony, 7.21
Gypsy Jokers (gang) , 3.24
H harm reduction,1.29, 8.2-3, 8.14,
"H" (heroin ), 4.6
Habitrol (patch), 9.40
habituation (level of use ), 2.33, 2.34,
2.37, 2.47, 5.11, 8.2, 8.13
Haggard, Howard, 5.22
Hague Resolutions, 4.10
Haight Ashbury Free Clinics, 2.33,
3.22, 5.28, 5.44, 6.40, 8.38,
9.6, 9.19, 9.26, 9.55, 9.58,
10.31
hair analysis for drugs, 8.51
hair pulling, 7.29
hairspray, 7.28
halazepam (Paxipam ®), 4.36,
10.29, 10.30
Halcion. ® See triazolam
Haldol. ® See haloperidol
Haldol ® Decanoate, 2.5
half-life, 2.6-7
benzodiazepines, 4.35
bromides, 4.34
caffeine, 3.38
cathinone, 3.32
cocaethylene, 2.6, 3.13
cocaine, 2.6, 3.11, 3.13
codeine, 4.27 -29
drug metabolism, 2.6-8, 3.11
flunitrazepam (Rohypnol ®), 8.38
fluoxetine, 2.6
LAAM,®4.32
marijuana, 2.8
methadone, 2.6, 4.29
sedative-hypnotics, 4 .34
urine testing, 2. 7
halfway houses, 9 .15
hallucinations, 2.20, 2.25, 3.19,
3.28, 6.12, 9.45,10.2, 10.14,
10.19, 10.21
alcohol withdrawal, 5.24
belladonna, 1.13, 6.20
Cannabis, 1.3, 1.4, 6.35
defined, 6.5
DMT, 6.12
efavirenz, 6.22
ergot, 1.13
ergotism, 6.6
hexing herbs, 1.13
HIV/ AIDS medication,
(e favirenz) 6.25
inhalants, 7.6, 7.8, 7.10, 7.ll,
7.27, 7.59
jimsonweed, 6.20
LSD, 6.6
marijuana, 6.35
mescaline, 6.14
PCP, 6.21
peyote, 6.12
Salvia divinorum, 6.23
San Pedro cactus, 1. 11
hallucinogen persisting perception
disorder (HPPD), 6.10,
6.39, 9.47, 9.47, 10.5, 10.7,
10.21, 10.33
hallucinogens. See psychedelic
haloperidol (Haldol®), 8.40,
9.20, 9.39, 10.14, 10.28,
10.30, 10.33
Halotestin. ® See fluoxymesterone
halothane (Fl uothane ®), 7.10-11
HALT (hungry, angry; lonely, tired),
9.24
hana fuda (card game), 7.34
hand sanitizers, 8.55
hangover, 5.15-17, 5.24, 9.45
inhalants, 7.6
psychedelics, 6.8, 6.24
Happ y Farm, ® 7.56
harmaline (yage), 6.4, 6.12-13
9.6, 9.10, 9.13, 9.15, 9.23,
10.10 See also replacement
therapies
AIDS and HIV prevention, 8.45
alcohol, 8.15
INDEX 1.15
controversy over, 8.16
definition, 9.6
Internet addiction, 9.54
methadone, 4.25-26, 8.14, 9.10,
9.42--43, 9.66, 9.67, 9. 72
needle exchange, 8.15
outcomes, 9.6
prevention, 8.14-15
relapse , 9.23
techniques, 9.6, 9.13
tobacco, 8.14
as treatment model, 9.54
treatment options, 9.15
Harrison Narcotics Act (1914), 1.23,
I
4.10, 8.9
"Harry " (heroin), 4.6
Harvard University, 3.31, 4.25, 5.32,
7.9, 7.34, 7.36, 8.33
"Harvey wallbanger" (LSD and STP
combo), 6.4
hash (hashish), 6.5, 6.26, 6.29-30,
6.42, 7.27, 8.39, 10.29
hash oil, 6.5, 6.30
Hathayoga, 9.37
Hawaii, 1.30, 1.34, 3.23, 5.44, 6.38,
7.35, 9.38, 9.49, 9.60
Hawaiian woodrose, 6.4. See also
morning glory
Hay Fever Association, 1.22
HCG (human chorionic
gonadotropin), 7.24
HCV. See hepatitis C
HDL (high-density lipoprotein),
5.12, 7.17
"head shop," 6.19, 6.32, 8.10
Healing Visions Clinic, 9.69
healthcare costs, 4.25, 8.19
heantos (Vietnamese tonic ), 9.37
hearing loss, 4.27, 5.29, 7. 7
Hearst newspapers, 1.25, 6.27
heart disease research, 5.19. See also
cardiovascular system
heart valve damage
(endocarditis ), 4.20
fen-phen, 3.29
IV drug use, 4.23-24
Heath, Rohen, 2.15
heat stroke, 7.20, 7.24
"heaven ly blue," 6.4, 6.12
heavy drinking, defined, 5.15
Hebrews, 1.10
hedonic set point, 2.32, 2.47, 7.52
hek (ancient beer), 1.10
Helen of Troy, 1.10
Helicon, ® 7.29
Hell:SAngels, 3.23
hemp, 1.16, 6.26-29, 8.11. See also
Cannabis; marijuana
henbane, 1.13, 1.17, 6.4, 6.20
hepatitis (A, B, C)
alcoholic, 2.7, 5.1, 5.17, 5.21
epidemiology, 8.42
hepatitis A, 8.42
hepatitis B, 3.14, 3.16, 3.26, 3.57,
8.43, 8.42, 9.9, 9.10
hepatitis C, 1.29, 1.33, 3.14, 3.16,
3.16, 3.26, 4.5, 4.19,
4.41, 4.43, 5.16, 8.20,
8.42, 9.42--43, 10.12
heroin addiction, 4.10, 4.22, 4.28
IV drug users, 1.33, 4.22-23,
9.42--43
needle use , 8. 4 3
newborns, 3.14
steroids, 7.17
treatment programs, 9.9, 9.10,
9.35, 9.42
hepatitis C, 8.43
"he rb " (ma rijuana), 6.28-30
Herbal Ecstasy, ® 3.32, 6.17
 1.16 INDEX
herbal incense, 3.2, 3.22, 8.10, 8.50
he rbal products, 7.20, 7.23,
7.28-29, 7.60
designer cannabinoids, 6.28
ecstasy, 6.19
stimulants, 3.35 (See also p lant
stimulants)
weight -loss pills, 9.53
herbal teas, 7.20, 8.54
he rbal therapy, 9 .36-3 7
HEREDITY
addiction, 2.3 6- 37, 5.24
addiction gene, 7.31
alcoholic mice sober mice,
I
2.43--44, 2.47
alcoholism, 5.24
alcohol use, 5.10, 5.23- 24,
5.26, 5.31, compulsive
behaviors, 7.31- 32, 7.61
drug reaction, 3.39
eating disorders, 7.46, 7.49
gene therapy, 10.22
marijuana dependence , 6.28,
6.32, 6.39
men tal illness,10.2, 10.3,
10.4,10.5-9,10.11 - 13,
10.18, 10.19, 10.21- 25,
10.28, 10.29, 10.32- 33
metabolism, 2. 7
pathological gambling, 7.31
research, 2.36, 5.24
susceptib ility, 2.48
twin stud ies, 2.38-39, 3.30, 7.31 ,
7.49, 9.38
HEREDITY, ENVIRONMENT, and
PSYCHOACTIVE DRUGS,
2.38--42, 5.23-24. See also
environment; genes
ad d ict ion gene, 7.31
alcohol, 5.10, 5.23- 24, 5.26, 5.31
brain, 2.10- 12
compu lsive behav iors, 2.42,
7.31- 32, 7.61
drug reaction, 3.39
eating disorders, 7.46, 7.49
env ironment, 2. 40-41
he redity, 2.36-38
how drugs get to the brain, 2.4-9
levels of use, 2.33-35, 2.47
marijuana dependence, 6.40
men tal illness, 10.3, 10.4, 10.5,
10.21, 10.22, 10.32, 10.33
metabolism, 2.6-8
neuroanatomy, 2.18-19, 2.46
neurotransmitters, 2.20, 2.20-26
physiological responses to drugs,
2.26-28
psychoactive drugs, 2. 41-4 2
theories of addict ion, 2.36-38
He rod otus, 1.11, 6.29
HEROIN, 1.2, 1.19, 1.20, 1.24-1.29,
1.31- 1.34, 1.37, 1.38.
See also harm reduction;
me th adone; need le use;
opi ates/opioids
abscesses, 4.23
addiction, 4 .9- 10, 4 .13
ad di tion of crack, 3.15, 3.19
age of first u se, 8.12, 8.18
an tipsychotic drugs,10.7, 10.14,
10.19, 10.20, 10.22,10.24,
10.25, 10.27, 10.28,
10.29, 10.30, 10.33
buprenorphine,1.29, 1.37 - 1.38,
4.30 8.3, 8.14, 8.23, 8.25,
9.14, 9.20, 9.42, 9.43,
9.66, 9.67, 9.69
cost, 4.45
crime, 4.5, 4.24
d esigner dru gs, 4 .31
dilution and adu lteration, 4 .24
dirty need les, 4.22 - 23, 9.41, 9.42
drug testing, 2.34, 8.50
ecs tasy and, 6.16
effects, 4.2, 4.9, 4.12, 4.18, 4.22
elderly, 8.59
emergency rooms, 4 .3 7- 38
epidem iology, 4.10-11, 4.20-21
flesh -eating bacteria, 4.22 - 23
globa l view of, 4.10-11
"go " circuit, 2.1, 2.10, 2.13 - 17,
2.39, 2.41, 2.45--46
history, 1.19- 1.20, 1.25, 1.27,
1.28, 1.29, 1.31
hypnotizing effect, 2.41
ibogaine treatment, 6.12
IV use, 4.18, 4.19 - 20
menta l illness, 10.3, 10.5, 10.7,
10.9, 10.16
methadone,1.28-1.29, 2.27, 2.32
4.28-29
military use, 4.26, 8.49
neonatal effects, 4.2 1
neurotransmitters, 2.20, 2.23,
2.24, 10.10, 10.29
overdose, 4.21 - 22
pain, 4.8-9, 4.12 - 13, 4.22 - 23
pharmacology, 4.12 - 17
pleasure, 4 .12
polydrug use, 4.20--21, 4.24-25
pregnancy, 4.21, 8.24
recovering addicts, 10.13
refinement of, 1.20, 4.8- 11
sex, 8.35, 8.41
smoking, 4 .8
"snor ting, " 4.19
sports use, 7.14
street names, 4 .6
tar heroin, 3.19, 4.7, 4.10-11
tissue dependence, 4.22, 4.43
tolerance, 4.17, 4 .19- 24
treatment, 4.6, 4 .10, 9.26
treatment admissions, 9.41
Vietnam experience, 4.10, 4.25
withdrawal, 4. 17, 4.24
herpes, 8. 41
Hershey's, ® 3.4
heterocyclics, 10.30
hexane, 7.3
hex in g herbs, 1.12 - 1.13
hexobarbital (Sombulex ®), 4.31
HGH . See human growth hormone
high blood pressure, 2.15, 7.46
high cholesterol, 7 .4 7
high -risk behavior, 3.19 - 20, 5.14,
8.20, 8.35, 8.40, 8.46, 9.42,
9.53. See also unsafe sex
HIGH SCHOOL, 8.28-33.
See also adolescents
ADHD,3.31
alcohol, 5 .3, 5.13, 5.35- 36, 8.28
assessment, 9.11
attitudes, 8.16, 8.34
cocaine, 8.28
drug education, 8.5
drug testing, 8.53
eating disorde rs, 7 .48
epidemiology, 5.35-44, 7.5, 7.14,
7.36, 7.48, 8.17, 8.18,
8.27 - 29, 8.38
gambling, 7.37
inhalants, 7.5
MDMA,8.39
prevention, 8.59
school policies, 8.30-31
sex, 8.27, 8.41
sports, 7.14
steroids, 7.17
tobacco, 3.58
use trends, 8.27
hijacked brain, 2.13-15
"hillbilly heroin " (oxycodone ) ,
4.7, 4.25
Himmelsbach, C.K., 2.37, 9.68
h indb rain, 2.9, 2.11
hippocampus, 2.12, 2.15, 3.26, 5.22,
6.34, 7.6, 9.23, 9.64
Hippocrates, 1.10, 5.18
Hispanics, 6.3
AIDS, 8.46
alcoho l, 5.30, 5.43--45, 8.18
cultural diversi ty among, 9.59-60
homelessness, 5.42
inhalants, 7.5
pregnancy, 5.31, 8.22
psychedelic use, 6.3
smoking, 3.57
treatment, 9.15, 9.59-60
women, 5.38, 5.40
histamine, 2.21, 4.3, 4.16, 7.24, 10.28,
10.29. See also an tihistamines
h istorical themes of drug use, 1.6-1.9
HISTORY, 1.5- 1.42. See also laws and
regulations
alcohol, 1.09-1.10, 1.14, 1.17- 1.21,
1.25, 1.38, 5.3-5
amphetamine , 1.26-1.27, 1.36,
3.21- 23
ANCIENT CIVILIZATIONS,
1.9- 1.12
belladonna, 1.3, 1.13
caffeine , 1.2, 1.14, 1.19, 1.36,
3.36-38
coca and cocaine, 1.7, 1.8, 1.12,
1.15, 1.15, 1.20- 1.24,
1.30, 3.9- 11
cocoa, 3.39
coffee, 1.14, 1.17, 1.36, 3.38
crack, 1.30, 3.10
energy drinks,1.36, 3.37- 38
gambling, 7.33- 35, 7.33- 35
heroin,1.19 - 1.20, 1.25, 1.27, 1.28,
1.29, 1.31, 1.32, 1.34,
4.7- 11
inhalants,1.19, 7.4-5
laws and regulat ions, 1.6, 1. 7,
1.15, 1.21, 1.23- 1.25,
1.27, 1.34
LSD, 1.13, 6.6
"magic " mushrooms, 1.11- 12,
6.10--11
marijuana, 1.6, 1.7, 1.10-1.11,
1.24, 1.25-1.26, 1.30,
1.33, 1.34, 1.35, 6.22- 25
mescaline, 1.3, 1. 11
MDMA, 1.24, 1.28, 1.33, 6.15 - 16
methadone, 1.28-29, 1.37, 4.2,
4.5 - 7
MIDDLE AGES, 1.12- 1.14
mushrooms, 1.11 - 1.12
n itrous oxide, 1.19, 1.33, 7.4-5,
7.9- 10
opia tes/opioid.s/opium,
1.19- 23, 1.32, 1.37,
4.7- 12
peyote, 6 .14
plant stimulants (miscellaneous),
3.32- 35
PREHISTORY and THE
NEOLITH IC PERIOD,
1.8-1.9
prevention, 1.6, 1.24, 1.27, 1.29,
1.35, 1.36
prohib ition, 1.7, 1.9, 1.14, 1.15,
1.18, 1.21, 1.23, 1.25,
5.4- 5
psychedelics, 1.10--13, 1.26, 1.28,
1.33-1.34, 6.2- 3 (See
also above at specific
substance)
rave clubs, 1.33, 1.34, 1.37
refinement of drugs, 1. 7, 1.19,
1.20- 2 1, 1.22- 1.23, 1.34,
3.7-8
RENAISSANCE and THE AGE OF
DISCOVERY, 1.14-1.17
sedative -hypnot ics, 1.27- 1.28,
1.34, 1.37, 4.8
sports and drugs, 1.2, 1.4, 1.27,
1.31, 1.38, 1.39, 7.13- 14
stimulants (See amphetamines;
cocaine; coffee; tea;
tobacco)
tea, 1.14, 1.17, 1.20, 3.36
temperance movemen t , 1.10, 1.14,
1.15, 1.21, 8.3, 9.28
themes of drug use in, 1.6-1.8
tobacco, 1.8, 1.12, 1.15 - 1.17,
1.18-1.19, 1.22- 1.23,
1.35- 1.36, 3.41--43
TWENTIETH CENTURY,
1.22- 1.30, 4.8-10
"hits " (glutethimide ) , 4.36
HIV disease. See AIDS and HIV
hoarding, 7.43, 7.61--o2
hoasca, 6.4
Hoffmann, Albert, 1.25, 6.6, 6.11 1.28
Hoffmann, Friederich, 1.19
Hoffman, Philip Seymour, 1.32
"hog " (PCP), 6.4
Hogarth, William, 1.18
holiday heart syndrome, 5 .19
Holland. See Netherlands
Hollander, Eric, 7. 4 3
"holy anorexia, " 7.48
Holy Light of the Queen Church, 6.12
homeless, 5.41--42, 8.18
drug and alcohol problems, 5.1,
5.3, 5.41--42, 5.44
men tal illness, 10.9, 10.32
homeopathy, 9.37
homeostasis, 2.9, 9.24, 9.24
defined, 2.26
medications, 9.68
physiologic, 9.45-46
restoration of, 9.24, 9.36,
9.65, 9.68
Homer, 1.10
homicide , 3.13, 3.19, 5.21, 5.30, 5.41
homosexual. See gay commun ity
"honey b lunt" (marijuana), 6.39
Hong Kong, 1.20
hoodia gordonii, 9.53
"hookahs," 6.30
Hoover, Herbert (U.S. president),
1.5, 8.4
hops, 5.5, 5.9
hormones. See adenosine
"homing, " 3.10
"horse" (heroin), 4.6
hospita l treatment
detoxification, 9.13, 9.20, 9.45
gambling, 7.38
inpa tient care, 8.2, 9.45, 9.49,
9.51, 9.62, 9.69
outpatient care, 9.51
partial hospitalization, 9.12, 9.14
"hot rocks, " 3 .19
Household Survey on Drug Abuse
cocaine, 3.8
inhalants, 7 .5
Houston, Whitney, 4 .3
how drugs get to the brain,
2.2--4, 2.45
HOW program (hones ty, open -
mindedness, willingness to
change), 9.29, 9.52
HPPD. See hallucinogen pers ist in g
percept ion disorder

Hua T'o (Ch in ese physician), 1.11
"hubba" (smokable coca ine), 3.3,
3.18, 3.19
"huffers," "huffing ," "huffs," 7.4,
7.5, 7.6
Huichol Indians, 6.2, 6.14
hul gil (plant of joy), 1.10
human chorionic gona d otropin
(HCG), 7.24
human grow th hormone (HGH),
7.19- 20, 7.60
sports use, 7.12
human immunodeficiency virus
(HIV), 1.33, 8.45. See also
AIDS and HIV
"Hu mbo ldt green " (marijuana), 6.28
hunger. See ap peti te; eating disorde rs;
nu trients and nutrition
Hun ter, Charles, 4.9
HU~210 ® (synthetic cannabinoi d), 6.5
Huxley, Aldous, 4.35, 6.14
Hycodan. ®See hydrocodone
Hycom in e,®8.57
Hydal.® See hydromorphone
hydergine (ergoloid mesylates),
7.29, 9.66
Hydergine ®brand, 7.29, 9.37,
9.66, 9.69
hydrocarbons. See volat ile solvents
hydroc hloric acid, 3.24
hydrocodone (Hycodan, ®Vicodin, ®
Lortab, ® Lorce t,® Zydone, ®
Norco, ® Tu ssend, ® Symtan ®),
2.27, 2.31, 4.5--6, 4.29, 6.17,
7.15, 7.16, 8.28, 9.11
drug testing, 2.34
ecstasy and, 6.16
elder ly, 8.5, 8.57
overdose, 4.18, 4.24
pregnancy, 8.25
hydrocortisone, 4.23
hydrogen cyani d e, 3.47
hydrogen peroxide, 8.53
hydromorphone (Dilaudid, ®Hydal ,®
Hydrostat, ®Opana, ®
Palladone, ®Soph ido ne ®),
4.6--7, 4.20, 4.31, 8.54
hydrophilic (wate r so luble) drugs, 2.6
Hydrostat. ®See hydromorpho n e
hydroxizine (Vistaril ®), 9.42,
9.69, 10.29
hyoscyamine, 6.4, 6.20
hyperactivity. See attention deficit
hyperactivity disorder
hyperalgesia, 1.37, 4 .13-14, 4.17,
4.19, 7.15
hyperemesis, 6.38
hyperglycemia, 5.17
Hypericum pe rfora tu m
(St. John's wort), 9.36, 9.37
hyperpathia, 1.37, 4.14, 4.17, 4.19
hyperpigmenta tion, 4.23
hypersensitivity to stress, 9.23
hypertension
alcohol, 5.19, 5.21, 5.26, 5.41
beta blockers, 7.21- 22
cocaine, 3.15, 3.18
inhalants, 7 .6
khat, 3.33
steroids, 7.18
hyperthermia, 3.15, 3.19, 3.26, 3.57,
6.17, 6.20
hypnosis, 9.36, 9.41
hypnotics (defin ition), 4 .30. See also
sedative -hypnotics
Hypnovel. ®See midazolam
hypochondria, 10.17
hypodermic need le, 1.20, 4.9, 8.42.
See also injection; needle u se
cocaine, 3.10
nee dle exchange, 4.23, 8.14
hypoglycem ia, 5.17
hypothalam us, 2.8, 2.17, 3.6,
6.30, 8.35
eating disorders, 7.46
iatrogenic addict ion, 1.22, 4.16
ibogaine, 6.1, 6.4, 6.11 - 12, 9.66, 9.69
ibotenic acid , 1.11, 6.4, 6.25
ibupro fen (Advil,®Motrin ®) , 4.16,
7.14, 7.14, 7.16, 7.16, 8.50.
See also nonsteroidal
anti-inflammatory drugs
ICD. See Int ernational Class ificat ion
of Diseases (I CD)
"ice" ("crysta l me th "). See smokable
methamphetamine
ideal body, 7.44. See also body image
"ikwa" (khat), 3.4
illegal drug labs, 1.31, 1.36, 3.20,
3.23-24, 4.27
illicit Drug Anti -Proli ferat ion Act
(2003), 8.9
illus ions, 6.10- 11, 6.35
iloperidone (Fanapt ®), 10.28, 10.30
imag ing techniques, 9.70. See also
CAT scan; MRI, fMRI;
PET scan; SPECT scan
abused chil dr en, 5.30
alcoho l, 5.32
changes in brain, 2.41, 2.42, 2.42
cogni tive impairment, 9.64
craving, 2.14, 3.26
developments, 9 .3-4
diagnosis, 3.28
fetal alcoho l syndrome, 5.30
inhalants, 7.6
MRI, !MRI, 3.25, 3.28
neuro transmitters, 2.21
PET scan, 3.12
SPECT scan, 3.28, 5.30, 5.40
stimu lant effects, 3.26
imidazobenzodiazep in e (Ro 15-4513),
9.67
imipramine (Tofranil, ®Janimine ®),
9.20, 9.39, 10.27, 10.30
immune system. See also AIDS
and HIV
AIDS and HIV, 8. 44
alcoho l, 5.21, 5.26
marijuana, 6.34, 6.38
neona tes, 8.26
n itrites, 7 .9
pregnancy, 8.21
immunoassay, 8.50, 8.51
Imovane. ®See zop iclone
impaire d cogn ition, 10.19,
10.22, 10.33
implants, 7.17
imprinting, 2.10, 2.12, 2.26, 4.20,
7 .32. See also memory
impu lse-con trol, 7.29, 7.30, 7.52.
See also su icid e; unsafe sex;
violence
alcoho l abuse an d , 10.18-19
impurities. See adulteration/
contam ination
I'm Special program, 8. 7
Incas, 1.15-1.16, 3.9, 3.41
Incredible Years program, 8.6
IND. See Investiga tiona l New Drug
Inderal. ®See p rop ranolol
India, 5.2, 6.6, 6.29- 30
alcoho l, alcohol, 1.10, 5.8
Amanita mushrooms, 1.11- 1.12
betel (supari), 3.4, 3.36
bu p renorphine, 9.43
Cannabis, 1.11, 1.14, 1.25, 6.26
coffee, 3.38
gam bling, 7.34
gut kha, 3.34, 3.45
hashish, 6.26
inhalants, 7.5
In ternet , 7.55
opium, 1.20, 4.8
psyche d elics, 6.24
tea, 3.38
tobacco, 1.18, 3.34, 3.40, 3.42,
3.43, 3.51 - 52, 3.58
Ind iana, 1.36
Ind ian Gaming Regulatory Act, 7.35
Ind ian Health Service, 8.22, 9.62
Ind ians. See Native Americans
indica ted pr evention p rograms, 8.14
INDIVIDUAL THERAPY,9.7,
9.26--27, 9.26--32, 9.42, 9.71
Asian Americans, 9.6 1
mo tivational interviewing, 9.27
substance-abuse disorde rs, 10.1,
10.23, 10.24
Ind ocin. ®See indomethacin
indo le p syched elics, 6.5-10
indomethacin (Indocin ®) , 7.16, 7.28.
See also nonsteroidal
an ti-inflammatory drugs
Ind onesia, 1.36, 3.8, 3.36, 3.52,
5.43, 6.37
indoor gar d ening, 6.31- 32
Ind opan. ®See alphame thyltryptamine
Ind us trial Revo lut ion, 1.17- 1.19
in fan ts . See p regnancy
in fectious diseases and need le
use, 8.45
in forma tion ad diction, 7.56
in forma tion programs, 4.22 - 23, 8.5
In fumorph. ®See morphine
inges tion, 2.2, 2.3 2.45. See also
alcoholic beverages; caffeine;
chewing; chewing tobacco;
eating disorders
cocaine, 3.9
meth, 3.25
opium, 4.9
steroids, 7.17
stimulants, 3.10, 3.25
INHALANTS, 1.4, 1.19, 4.33, 7.2- 11,
7.3, 7.6, 7.58-59. 4.43 See
also anesthe tics; smoking;
"sniffing"; snor ting; volatile
nitrites; volatile solvents
absorp tion,1.19, 2.4, 2.5, 2.45
age of first use, 8.18
anesthetics, 1.19, 7.9- 11
classification, 1.4, 7.2, 7.3, 7.11
d epen d ence, 7.11
epidemio logy, 7.5
history, 1, 7.4-5 1.19
lifetime use by type, 7.5
methods of inhaling, 7.5-6
mos t widely abused, 7.4
Native Americans, 9.61
nicotine treatment, 9.41
ni trous ox ide, 1.19, 2.3, 2.8, 8.40
prevention of abuse, 7.11
removal from expos ur e, 9. 48
sex, 8.63
treatmen t adm issions, 9.16
treatment of abuse of, 9.49-50
volatile n itrites, 7.3, 7.9, 8.40
volatile solvents, 1.19, 7.3, 7.6-8
warning signs of abuse, 7. 7, 7.59
inhala tion (me thod of use), 2.3,
2.4, 2.45
inh ibition. See disinhi bit ion
inh ibitory neurotransmitters, 2.21,
2.23, 3.29, 3.39, 4.34.
See also GABA; serotonin
INDEX 1.17
initial abs tinence, 9.1, 9.21 - 22.
See also detoxification
initiation of drug u se. See age
of first use
injection (method of use), 1.1, 1.20,
1.29, 2.4, 2.46, 7.17. See
also hypodermic needle;
intramuscula r inj ection;
intravenous drug use; needle
use; subcutaneous injection
inpatient treatment, 5.26, 8.49, 9.14,
9.20, 9.45, 9.49, 9.51, 9.62,
9.69,10.8, 10.18
facilities, 10.8, 10.9, 10.33
I
insomnia, 3.6, 3.14, 3.18, 3.33, 3.39,
3.56, 4.20, 4 .38, 4.42, 7.39,
10.16, 10.26, 10.29. See also
sleep-aids
Insom-X ® (GBL). See GBL
insufflation. See snorting
insulin, 3.42, 5.17, 7.47, 9.36
intake (trea tment), 9.46
interdiction, 8.3, 8.8, 8.27
internal caro tid artery, 2.5
International Agency for Research
on Cancer, 3.54
International Classification of
Diseases (ICD), 2.36,
2.47, 3.29
ADHD, 3.30
International Olympic Commi tt ee
(lOC), 1.38-1.39, 6.37,
7.12- 13, 7.14, 7.16,
7.20, 7.21
international poli tics. See geopolitics
of dru gs
Internet addic tion, 1.5, 1.40-41, 4.10,
4.43, 7.32, 7.55-56, 9.11,
9.54-55
electronic addic tions, 1.34, 1.39,
1.42, 7.54, 7.55-56
gambling,1.40-1.41, 7.33, 7.35
pornography, 7.52, 7.53
Internet drug sales, 1.37, 4.4, 4.5,
4.41, 7.19
interpersonal factors and relapse,
9.24. See also family
interpersonal p sychothe rap y, 7.51.
See also cogni tive behavioral
therapy; group therapy;
individual therapy
intervention, 9.18-19
alternative/complementary
treatments, 9.35- 37
beginning treatment and, 9.18-19
boun d aries and, 9.58-59
eld erly drinking, 8.58
gambling, 9.49
gen d er, 9.55
HIV prevention, 8.45
intervention statements, 9.18
intervention strategies, 8.12
intestines. See also gastro intes tin al
problems
drug absorption, 2.4
gastric bypass, 7.49
intoxication, 5.10, 5.14-15, 5.23
intramuscular (IM) injection, 2.4,
3.10, 6.19, 8.42
intravenous (IV) drug use, 2.4.
See also needle use
AIDS, 8.43-45, 9.42
cocaine, 3.8, 3.10, 3.15- 16, 3.18,
3.20, 8.43
ma terna l risks, 8.19, 8.23
me tham p hetamine, 3.20, 3.25,
3.28, (See also needle u se)
M-KAT,3.34
needle kits, 8.42
terms for, 8. 4 2
 1.18 INDEX

Intuniv (guanfacine), 3.29
Invega. ® See paliperidone 10.28,
10.29, 10.30
inverse agonists, 2.24, 4 .26
inverse tolerance, 2.28, 3.15, 5.26, 6.39
Inve rsine. ® See mecamylamine
Investigational New Drug (IND), 9.70
IOC. See International Olympic
Committee
Ionamin. ® See phentermine res in
ions, 2.23
Iowa Practice Improvement
collaborative, 9.4
Iowa Strengthening Families Program
Japanese Americans, 5.44, 9.60, 9.61 knowledge-based prevention in terven tion treatment, 9 .17
"java " (coffee), 3.4 programs, 8.5 law enfo rcement, 8.8-11, 8.17
Java, Indonesia, 3.8 kode ia (poppy head), 4.8 lega l intoxication, 5.10
Jekyll and Hyde, 3.11 kola nut, 1.14, 1.15, 3.37, 3.39 LSD, 6.7
Jellinek, E. M., 5.22 Koller, Karl, 1.21, 3.9 opiates and opioids, 4.10
"jelly beans" (chloral hydrate), 4.31 Koo l Aid Acid Test, 6. 7 in other countries, 6.42
Jenny Craig, ® 7.51 Koran. See Qu r'an paraphernalia, 8.10, 8.22
J ericho, 1.6 Korea,1.23,3.23, 5.36, 9.54 prohibition, 1.25, 8.3-4
Jessor, Richard, 8.30 In ternet, 7.55 Salvia divinorum, 6.22
j imsonweed. See datura mobile phones, 7.57 sexual addiction, 7 .53
"joe" (coffee), 3.4 Korean Americans, 5.41 supply reduction, 8.8-9
Joe Camel, • 3.52, 8.15 Korean War, 1.23 texting by drivers, 1.40
J ohnson, Allen, 7.27 Korsakoff's syndrome, 5.20, tobacco, 1.22- 1.23,
J ohnson, Vernon, 9 .18 10.14, 10.19 1.35- 1.36, 3.58

I
(ISFP), 8.31 "joint " (marijuana), 6.4, 8.54. kratom (mitragyna), 7.28 treatment, 1.24, 1.25, 9.5, 9.14,
IPA® (Ind ia Pale Ale®), 5.7 See also marijuana Kratom tree, 4 .33 10.10
iPad, • 7.54, 7.56 Jolly Rancher Cand ies, 1.34, 4.18, 6.18 "krystal j oint" (PCP), 6.4 laxatives, 7.50
iPhone, • 1.34, 1.40, 7.54, 7.57 Juarez drug cartel, 4 .11 K2 (syn thet ic THC), 1.3, 1.34, L-Dopa • (levodopa), 8.40, 9.66, 10.29
iPod, ® 7.54 Judaism, 1.9. See also Israel 6.32- 33, 8.10, 8.50 lead acetate, 3.25
!ran, 1.9, 1.10, 4. 7, 5.5, 6.37, 6.37. "juice" (methadone), 4.6 Kubey, Robert, 7.57 lead poisoning, 7 .8
See also Mesopotamia Jung, Carl, 6.13 kudzu (Pueroria lobata, Radix learning
Ir aq, 1.9. See also Mesopotamia "junk" (heroin), 4.6 pueratiae), 9.36 alcohol, 5.27, 5.38
Ir aq war, 4.22, 4.24 'junkie, " 4.8, 4.23 kumiss, 5.5 marijuana, 6.34
Ireland, 3.54, 5.36 juvenile arrestees,8.29 "kunya" (be tel nut), 3.4 maternal substance abuse, 5.26
irritable baby syndrome, 3.26 JWH -015, 018, 073, (synthe tic kvass, 5.5 memory, 2.10 - 12
ischemia, 3.15 cannabinoids), 6.4, 6.29 kykeon, 6.6 nootropics, 7.29
"ischott," 3.4 recovery, 9.23
ISFP. See Iowa Strengthening K L Leary, Timot hy, 1.28, 6.1, 6.6
Families Program lecithi n , 9.21, 9.36
Islam, 1.14 "K" (ke tamine), 6.4, 6.21 - 22 LAAM (levomethadyl acetate, Ledge r, Heath, 4.3
Islamic countries "kaad" (khat), 3.4 Orlam • ), 4.6, 4.32, 9.20, left cauda te putamen, 2.17, 3.26
alcohol, 5.3, 5.36 Kadian. ® See morph ine 9.42, 9.66, 10.29 left cingulate gyrus, 2.17
Cannabis, 6.26 "kafta" (khat), 3.4. See also khat lactose, 3.16, 4.20 legal drugs, 5.3--4, 8.15 - 16. See also
hashish, 7.27 "kahi" (ayahuasca), 6.4 "la dama blanca " (cocaine), 3.3 alcohol; harm reduction;
isoamyl nitrite, 7.3, 7.9 Kah lua, ® 5.7 "lady" (cocaine, smokab le cocaine), over -the-coun ter drugs;
isobutyl ni trite, 7.3, 7.9, 7.24 Kald i the goat herder, 3.36 3.3 prescription drugs; tobacco
isocarboxazid (Marplan ®) , 10.26, 10.30 kannabis, 1.10 See also Cannabis lager, 5.5, 5.6, 5.8 "legal speed " (looka likes), 3.4
isomer, 3.3, 3.21 , 3.23 Kaposi's sarcoma, 8.43 lag phase in prevention, 8.14 legislation. See laws and regulations
isopropane, 7.3 kappa receptor, 4.13, 4.19, 4.43 I alpha acetyl methadol. See LAAM Leo notis leonurus (Lion's tail, wild
isopropanol. See isopropy l alcohol kava, 7.27- 28, 9.36 "lam" (long -acting methadone), 4.7 dagga), 6.4, 6.25
isopropy l alcohol (isopropanol; Keats, John, 4.10 lam ivudine (HIV medication), 8.45 Leo Xlll (Pope), 3.10
rubbing alcohol), 5.5, 7.8, Keep Alert,® 8.58 lamotrigine (Lamicta l®), 9.68 lept in, 7.46
7.27 Kenya, 3.36, 5.18 I-amphetamine. See levo amphetamine lesbian, gay, bisexual and transgender
isopropy l nitrite, 7.3, 7.9 Kerli nkowske, Gil, 8.3 Landis, Floyd, 7.14 (LGBT) communi ty, 9.63. See
isradipine (Dynacirc ®), 9.68 kerosene, 3.8, 3 .17 lanugo, 7.49 also gay community; lesbians
Israel, 6.33 Kerouac, Jack, 1.26 Laos. See Golden Triang le lesbians, 9.31, 9.62, 9.63
!SU-LSD Kesey, Ken, 6. 7 Larsen, Ernie, 9. 46 Lesieur, Henry, 7.36
drug testing, 8.53 Kessler, David, 1.41 laryngeal cancer, 5.20 lethal dose, 2.27, 4.37, 4.40
lT-290, 6.4 Ketaject. ® See ketamine "la salade," 3.4 leukoplakia, 3.50
Italy Ketalar. ® See ketamine Lasix. ® See d iuretics level of response (LR), 5.24
alcohol use, 5.7, 5.36 ketamine (Ketalar, ® Ketaject, ® Las Vegas, 7.35 levels of use, 2.33 - 35, 2.47.
marijuana, 6.36 Ketanest, ® Ketaset ®), 4.33, lateral habenula, 2.13, 2.13, 2.16, 2.16 See also addiction
itching, 8.42 6.21- 22, 9.46, 9.47, 9.69 lateral hypothalamus, 2.13, 2.13, 2.16 alcohol, 5.11- 13
IV drug use. See intravenous drug use; Ketaset. ® See ketamine Latuda. ® See lurasidone, 10.28, 10.30 Levitra, ® 8.42
needle use ketazolam (Anxon ®), 4.36 laudanum (opium), 1.17, 1.22, levo acetyl alpha methado l. See LAAM
Ivo ry® (Soft, Wave, Coast ) , 8.10 ketoconazole (Nizoral ®), 9.68, 10.29 4.6, 4.9 5.3. levo amphetamine (I-amphetamine,
ketone, 5.5, 7.3, 7.8, 7.59 See also opiates/opioids Vick's• ), 3.3, 6.14, 8.52
khat ("qat," "shat," "miraa"), 1.2, 1.8, "laughing gas." See ni trous ox ide levodopa, 9.39
1.14, 1.36-1.37, 3.1, 3.2, 3.4, law enforcement, 8.9 - 11, 8.17 Levo -Dromoran. ® See levorphanol
Jackson, Andrew (U.S. president), 3.6, 3.32- 33, 3.58, 8.41 LAWS and REGULATIONS 1.23- 1.24 levomethady l acetate . See LAAM
1.18 khat paste, 3.32 advertis ing, 8.11, 8.16 levorphanol (Levo -Dromoran ®), 4.6
Jackson, Michael, 4.2, 4.4, 7.3 "K-hole 6.22 alcoho l, 1.14, 1.15, 1.18, 1.21, Lexapro. ® See escitalopram
"JiigerBombs, " 5.7, 5.14 kidneys, 2.6, 5.9, 5.42, 7.6 5.34, 8.3- 5 Lexington Kentucky Narcotics
Jiigermeister, ® 5.7 steroids, 7.19, 7.22, 7.23, 7.24 Amanita mushroom, 6.24 Fann, 9.13
Jamaica, 6.27, 6.32 "kille rs" (OxyContin ®), 4. 7 amphetamine and Lexotan il. ® See bromazepam
James 1 (king of England), 1.16 "kindling," 5.24, 9.69. See also inverse methamphetamine, 1.27, LGBT. See lesb ian, gay, bisexual and
"Jamestown weed." See datura tolerance 3.20, 3.22 transgender community
(jimson weed) Kiowa Indians, 6.2, 6.14 Cannabis, 6.27, 6.29, 6.32, 8.9, 1-glutamine, 9.36
J animine .® See im ipram ine "kit kat," 6.22 8.11 , 8.30-31, 8, 47--49 liability and drunk driving, 5.34
Japan "KJ" (PCP), 6.4 co llege drug use, 8.33 Libritabs. ® See chlord iazepoxide
alcohol, 1.9, 5.7, 5.10, 5.35 Klea r,® 8.53 decriminalization, 1.3 1, 6.25, Librium. ® See chlordiazepoxide
amphetamines, 1.26--1.27, 3.22 Kleber, Herbert D., 9.30 8.15, 9.6 "Libs " (chlordiazepoxide), 4 .36
cell phones, 7.57 "Klond ike bars" (clonazepam), 4.36 designer cannabinoids, 6.33 "lid," 6.32
coffee, 3.40 "klonnies" (clonazepam), 4.36 drunk driving, 5.27, 5.33 Lidone .® See molindone
gambling, 7.33, 7.34 Klonopin .® See clonazepam energy drinks, 5. 7 LifeSkills Training program, 8.30
inhalants, 7.5 "klons" (clonazepam), 4.36 gambling, 7.33, 7.34, 7.35 12-step programs, 9.30
marijuana, 6.36 KMALDH, 2.39 herbal products, 7.28-29 AIDS and HIV, 8.46
opium, 1.7 KMALDH ., 5.41 history, 1.6, 1.7, 1.15, 1.21, 1.22- compu lsive use, 9.62
tea, 1.14, 3.36 "knockout drops" (chloral hydrate), 25, 1.27, 1.29, 1.31, 1.34 family approaches, 9.33 - 34
tobacco, 1.16, 3.50 4.34, 9.39, 9.45 inhalants, 7.10, 7.59 long -term abstinence, 9.21 - 22

pregnant addicts, 8.23, 8.26
recovery; 9.22, 9.42
replacement therapies, 9.43
tertiary prevention, 8.14
treatment, 9.10, 9.15
Liggett and Meyers, 1.23
light beer, 5.6
lighter fluid (inhalant), 7.3, 7.5, 7.6
limbic system, 2.9, 2.22, 3.5, 3.12,
3.26, 4.38, 5.14, 5.38, 6.3,
6.34, 8.35, 8.37, 9.64,
10.21 See also "go " circuit;
old brain
Limbitrol. ® See chlordiazepoxide
Lin, Tse-hau, 1.20
Lions Quest Skills for Adolescents,
8.30
Lion's tail (Leonotis leonurus),
6.4, 6.25
Lioresal. ® See baclofen
lipophilic (fat-soluble) drugs, 2.5,
2.6, 4.38, 7.26
Lipton Tea,® 3.4
liquid chromatography-tandem mass
spectrometry (LC -MS-MS)
method, 8.52
"liquid E" (GHB), 4.43
"liquid ecs tasy" (GHB), 4.36, 4.43
liquor. See alcohol
liquors, 5.6-7, 5.8
lisdexamfetamine (Vyvanse ®), 3.3,
3.29, 3.58
"liss" (khat), 3.4. See also khat
lithium (Eskalith, ® Lithobid ®),
8.40, 10.20, 10.22, 10.27,
10.30, 10.33
Lithobid. ® See lithium
liver, 2.6--8, 3.35, 4.22, 4.25, 4.38-39,
4.41, 4.44
acetaminophen, 4.27, 8.59
age, 5.40
aging, 5.40
aging and, 4.39, 8.55
alcohol, 8.3, 8.15, 8.55, 8.56, 8.58,
9.46
alcohol metabolism, 2.27
alcohol use, 5.12, 5.18-19
cancer, 3.42, 4.22. 4.29, 5.18
cirrhosis, 1.25, 5.17 - 18, 5 .18, 8.3,
8.6, 8.15, 8.55, 4.45
diabetes, 7.47
drug metabolism, 2.6-8
elderly, 8.55, 8.56, 8.57
hepatitis A, B, C, 1.29, 1.33, 3 .14,
3.16, 3.28, 4 .19, 4.22 - 23,
4,45, 5.17, 8.44
inhalants, 7 .6
marijuana, 6.33
metabolism, 2.6-8, 4 .16, 4.23,
4.34, 4.40
naltrexone treatment, 9.68
nutrition, 5.19
opioids, 4.22
Ritalin, ® 3.29
sedat ive-hypnotics, 4.34, 8.57
sports drugs, 7.19, 7.21, 7.23, 7.24
synergism, 4.44, 5 .17
tolerance, 4 .16, 4.34, 4.37, 4.39,
4.44
Lloyd's Cocaine Toothache Drops,
1.22
"loads" (glu teth imide), 4.35-36
Locker Room, ® 7.3
locus coeruleus, 2.29, 4.17, 4.20, 6.8
lofexidine (BritLofex ®), 9.42, 9.66
London Gin Epidemic. See Gin
Epidemic
longevity and smoking, 3.48
long-term abst inence, 9.2 1- 22
long -term memory, 6 .31.
See also memory
long -term potentiation (LTP), 2.16
lookalikes
downers, 1.4 2
stimulants,1.37, 3.32, 4.4
loose- leaf tobacco, 3.42, 3.43,
3.43, 3.59
loprazolam (Dormonoct ®), 4.36
Lorabenz. ® See lorazepam
Lora met. ® See lormetazepam
lorazepam (Ativan, ® Lorabenz, ®
Tavor, ® Temesta ®), 4.21,
4.34, 4.43, 9.67, 10.16,
10.29, 10.30
Lorcet. ® See hydrocodone
Lorillard, 1.23
lormetazepam (Ativan, Loramet, ®
Noctamid, ® Pronoctan ®),
4.31
Lortab. ® See hydrocodone
Los Angeles, 5.44, 9.58, 9.59
gay men, 9.63
Los Zetas, 4.11
losing phase (gambling), 7.38-39
Lotrel. ® See amlod ipine
lotteries, 1.31, 1.4 1, 7.32, 9.49, 9.50
Lotusate. ® See talbutal
LOVE, 8.36. See also sex and drugs
alcohol abuse, 5.20
children of addicts, 9.35
emotions, 8.35
in terven tions, 9.18, 9.19
love addiction, 7.54
ToughLove ® approach, 9.34
"love drug," 6.4
loxapine (Lox itane ®), 10.28,
10.30, 10.33
Loxitane. ® See loxapine
lozenges, nicotine, 9.41
LR. See level of response
LSD (lysergic acid diethylamide), 1.3,
1.4, 1.13, 1.28, 6.6-10
age of first use, 8.18
bad trips, 9.46-47
drug testing, 8.50, 8.52
history 1.3, 1.13, 1.28
mental illness, 1.28, 6.5, 6.6, 6.9
neurotransmit ters, 2.20, 2.20-26
old brain, 2.9 - 10
treatment, 9.46, 9.46-47, 9.47
LTP. See long -term potentiation
1-tryptophan, 9.36
I-tyrosine, 9.36
"Lucky 7," 6.16
Lucretius,1.13, 6.6
"ludes" (Quaaludes ®), 4.40
Ludiom il .® See maprotiline
ludoman ia (gambling disorder), 10.18
Luminal. ® See phenobarbital
Lunesta. ® See eszopiclone
lungs. See also bronchodilation
absorption by, 1.20, 2.3-4, 2.3
alcohol, 2.8, 5.9
alveoli, 2.3, 3.49, 8.25
cancer 3.53, 3.55
cocaine, 3.10-11, 3.18-19
crack lung, 3.19, 3 .57
exc retion, 2.6
inhalants, 7.6
mari j uana, 6.37 - 38
nicotine delivery, 3.43
opioids, 4.8, 4.18, 4.21
quitt ing smok ing 3 .55
smokable cocaine, 3.11, 3.18,
3.19, 3.57
tobacco, 3.5 - 54, 7.21
lupulus, 6.28
lurasidone (Latuda ®), 10.28, 10.30
Luvox. ® See fluvoxam ine
Lyrica. ® See pregabalin
Lysanxia. ® See prazepam
lysergic acid diethy lamide. See LSD
Lysol, ® 7.28
lysophosphatidy l inositol (LPI)
(endocannabinoid
ligand), 6.34
M illega l labs, 1.31, 1.36, 3.20,
"M" (morphine), 4.2, 4.8, 4.19
mace, 6.24
Macedonia, 7.13
Machiavelli, Nicco lo, 1.9
"mad apple. " See datura (jimson
weed)
Mafia, 4.10
Magee, Lawrence, 7.23
"magical thinking," 7.40, 9.50
"magic m int." See Salvia d ivinorum
"magic mushrooms" (psilocybin and
psilocin), 6.4, 6.10-11.
See also Amanita mushrooms;
Psilocybe ("magic ")
mushrooms
magnesium citrate. See blood d oping
magnetic resonance imaging. See MRI
magnetic resonance imaging (MRI),
2.14, 2.17, 2.18, 2.42, 9.3
coca ine, 2 .14
"mahk" (betel nut), 3.4
"ma huang" (ephedrine), 3.36,
7.20 - 21. See also ephedra;
ephedrine
Maine, 1.21, 6.44
"ma inlining," 8.42
main tenance stage, 9.27
maj or depressive disorder, 10.2,
10.4- 9, 10.13, 10.14, 10.15,
10.16, 10.18, 10.19, 10.20,
10.26, 10.27, 10.29, 10.30,
10.32. See also depress ion
Major League Baseball, 7.11- 12, 7.19,
7.21, 7.26-27
stero ids, 7 .17
"major tranquilizers," 10.28.
See also fluphenazine;
prochlorpe razine;
th ioridaz ine
Malaysia, 3.23, 3.35
male -limi ted alcoholism, 5.20
Male Per formance, ® 3.35
males. See also gender differences
ano rex ia nervosa, 7.48
drinking patterns, 5.35
male-limited alcoholism, 5.22
sexual addict ion, 7.54
sexual effects of alcoho l, 5.14
treatment, 9.31, 9.40, 9.55, 9.57,
9.58, 9.69
malnutrition. See also nutrients and
nu trition
alcoholism, 5.18, 5.20- 21, 5.26
amphetam ines, 3.15, 3.27, 3.32,
3.34, (See also anorex ia)
eat ing disorders, 9.51
immune system, 8.43
malt beverages, 5.5, 5.8, 5.8, 5.9
mandrake (mand ragora), 1.13,
6.4, 6.20
Mandrax. ® See methaqualone
mania. See bipolar affective disorde r
manic depression. See b ipolar
affective disorder
Mann, Marty, 1.25
mannito l, 3.16
Manpower, ® 3.4
manufacture of drugs. See also
pharmaceutical industry
acetone, 3. 7, 3.25
INDEX 1.19
alcohol, 5.4, 5.7
amphetamines, 3.22, 3.24-25
crack, 1.30
crimina l organizations, 4.10
fentany l, 4.27
forms of mari j uana, 6.29 - 30
heroin, 1.16-17, 4.9, 4.10 1.19-20
HGH, 19
3.23-24, 4.27, 8.10
look -alikes, 3.32, 3.37
LSD, 6.7, 6.8
methamphetamine, 1.27, 1.31,
3.24-25
I
methcathinone, 3.33, 3.35
op ium ext raction process, 4.8
refinement of opioids, 4 .8
smokable cocaine (crack,
freebase), 3.17 - 18
supply reduction, 8.11
tobacco, 3.55-3.58
unusual substances, 7.27
MAO-B inhibitors. See monoamine
oxidase B (MAO-B)
inhibi tors
MAO inhibitors. See monoamine
oxidase (MAO) inhibitors
maproti line (Ludiom il®), 10.30
mare's milk, 5.5
Marian i, Angelo, 1.21
Marian i W ine, 1.21, 3.9
MARIJUANA, 6.25-45. See also
cannabinoids; Cannabis;
decr imina lization; hash;
medical marijuana; THC
addiction, 6,409.47-48
adolescents, 8.28
adulterants, 7.27, 7.28
aerosol, 1.11
age of first use, 8.18
alcohol and, 5.9, 5.27
alcoholism and, 9.45
anandamide, 2.20, 2.21, 2.22,
2.46, 5.14, 6.33-36,
8.23, 9.48
bhang, 6.27, 6.42
BHO. See butane hash oil
botany, 6.28
brain chemistry, 10.26
buyers' clubs, 6.38
Cannabis-induced disorders, 10.3,
10.21, 10.33
college, 8.27, 8.28-30
dabs, dabbing 6.30-31
decrimina lization, 1.31, 1.34, 6.25,
8.15, 8.58, 9.6
designer cannabinoids, 6 .32- 33
dispensaries, 6.43-45
driving, 6.42-43
drug testing, 2.8, 6.33, 6.42--43,
8.47, 8.52
economic issues, 6.41
effects, 6.33- 34, 7.26
elderly, 8.59, 9.56
emergency rooms, 4.33, 6.28
epidemiology, 6.27 - 28, 6.38
famil ies and, 8.31
gateway drug, 6.35- 36
growers, 6.31 - 32, 6.44-45
hashish, 6.28-29, 6.42, 7.27,
8.18, 8.40
high school, 8.27, 8.28-31
his tory, 1.6, 1.7, 1.10-11, 1.24,
1.25- 1.26, 1.30, 1.33,
1.34, 1.35, 6.26-27
HPPD, 6.10
immune sys tem, 6.38
induced mental disor ders,
10.20 - 21
laws and legality, 6.41-42
 1.20 INDEX
learning, 6.36
long -term effects, 6.37- 38
Marijuana Anonymous, 9.29
Marijuana Tax Act,1 .23,
1.25- 1.26, 6.44
Marinol, ® 2.4, 6.5, 6.32
medical marijuana, 1.34-1.35, 6.1,
6.44-45, 8.10
medibles 6.44
memory, 6.37- 38
mental effects, 6.35, 6.38
Native Americans, 9.61
neurotransmitters, 2.20, 2.20- 26,
6.33 - 34
I
novelty, 6.35-36
pharmacology, 6.33-34
physical effects, 6.33- 34, 6.40
polydrug use, 5.27, 6.42-43
potency,1.34, 6.1, 10.20. See also
below at sinsemilla
pregnancy, 8.24
relapse, 9.22
sex, 8.39
shorMerm effects, 6.34-35
sinsemilla, 1.25- 1.26, 1.34, 6.29,
6.39-40
species, 6.28--29
sports, 7.25- 26
synthetic cannabinoids, 1.3, 1.30,
6.32 - 33, 8.50
"the munchies, " 6.30
tissue dependence, 6.40, 9.47
tolerance, 6.39-40
treatment, 6.40, 9.47, 9.47-48
treatment admissions, 9.16
use by age, 8.18
wax, 6.30
withdrawal, 6.39-40
worldwide laws, 6.42-43
Marijuana Tax Act (1937), 1.23,
1.25- 1.26, 6.27
Marinol ® (synthetic THC).
See dronabinol
marker genes. See genes; heredity
marketing, 7 .28. See also advertising
deceptive advertising, 9.53
eating disorders, 7.44-45, 7.51
herbal supplements, 7.28, 7.60
legal drugs, 8.15-16
new drug development, 9. 70
prescription drugs, 4.4, 4.45
psychedelics, 6.22
Marlboro, ® 3 .55, 3.57
Marplan. ® See isocarboxazid
Martin, Billy, 6.34
"marwath " (ephedra), 3.35
"Mary Jane" (marijuana), 6.4
Marzilli, Lisa, 3.34
masculinization and steroids, 7.16,
7.17, 7.60
Massachusetts, 1.21, 1.34
MAST. See Michigan Alcoholism
Screening Test
masturbation, 7.32, 7.53, 9.53
mataxalone (Skelaxin ®), 4.16, 7.15
mate (tea), 1.11, 3.41
maternal complications, 8.20-21.
See also pregnancy
maternal drinking, 5.28-30
Matrix Model, 9.2, 9.31, 9.39,
9.63, 9.69
maturation, 8.20, 8.27, 8.29 - 30.
See also developmental arrest;
emotional maturation
"Maui wowie, " 6.28
Maxibolan. ® See ethylestrenol
Mayan culture, 1.12, 1.14, 1.16
Mayo Clinic, 3.49
Mazatec Indians, 6.10-11, 6.23
Mazicon. ® See flumazenil
"mazzies" (temazepam), 4.36
McGaugh, James, L., 2.39
McGwire, Mark, 7 .11, 7 .12
McMeens, Dr. R.R., 6.44
McMunn's Elixir of Opium, 1.22, 4.9
MDA (amphetamine analogue), 1.28,
2.20,3.27, 6.1, 6.3, 6.4,
6.15- 16, 8.40, 8.52.
See also MDMA
MDE (amphetamine analogue),
3.3, 6.4
MDM,6.4
MDMA (ecstasy), 1.24, 1.28, 1.33,
3.3, 3.37, 4.38, 6.3, 6.15-19,
10.14, 10.21, 10.29.
See also MDA
age of first use, 8 .18
cost, 6.16
drug testing, 8.54
effects, 6.17- 19, 8.38
marijuana, 6.30-34
misrepresentation, 6.3, 6.19
neurotransmitters, 2.20, 2.20-26,
3.5, 3.17
polydrug combinations, 6 .17- 18
psychiatric problems, 10.14,
10.21, 10.29
sex, 8.35, 8.39
street names, 6.4
treatment, 9.46--47
MDPV,8.10
mead (alcoholic drink), 1.9, 5.2,
5.4, 5.36
Mebaral. ® See mephobarbital
mecamylamine (Inversine ®), 9.41,
9.66, 9.67, 9.68, 10.29
medazepam (Nobrium ®), 4.31
media (television, Internet).
See also advertising;
electronic addictions;
Internet addiction; marketing
Internet addiction, 1.40 - 1.41,
7.55- 56, 9.54-55
sexual addiction, 7.32
shopping networks, 7.32
television addiction, 1.40,
7.5&--57, 7.63
medial forebrain bundle, 2.16
medibles, 6.44
medical management. See also medical
model; medication therapy;
psychophannacology
alcohol detox, 9.45
bad trips, 9.4 7
medication strategies, 9.67 - 70
neonatal withdrawal, 4.21
rapid opioid detoxification, 9.67
sedative -hypnotics, 4.32, 4.37,
9.44, 9.66
medical marijuana, 1.34-1.35,
6.43-45. See also dronabinol
California, 6.32, 6.37,
6.40---41, 6.44
delivery systems, 2.3
laws,8.11
reasons against, 6.45
medical model, 2.36. See also
medical management;
medication therapy;
psychophannacology
detoxification, 9.14, 9.17, 9 .57
medication strategies, 9.67 - 70
mental health, 10.19-33
medical problems
alcohol, 5.43
treatment goals, 9.10
medical review officer (MRO), 8.51
medication therapy, 9.9,
9.20--21, 9.26, 9.50, 9.52,
9.65-70, 10.32, 10.33
See also antidepressants;
psychophannacology
meditation, 9.37
medulla, 2.9
Mellaril. ® See thioridazine
MEMORY, 7 .6. See also dendritic
spines; hippocampus
alcohol, 2.40, 5.19
benzodiazepines and, 4 .3 7
creation of, 2.1, 2. 10-12,
2.40---41, 2.45
drug use, 2.1, 2.10--12,
2.40---41, 2.45
emotions, 2.14, 2.46
environment, 2.38
evolutionary perspective,
2.9-10, 2.45
links, 2.13
marijuana, 6.37, 6.39-40
nootropics, 7.29
old brain -new brain and, 2.1,
2.9-10
PAWS,4.20, 9.23
recovery, 9 .23
sensory input, 2.10, 2.10, 2.12,
2.30
storage process, 2.11 - 12
utilization of, 2.12
memory bumps, 2.12, 2.11.
See also dendritic spines
memory loss. See amnesia; blackout;
brownout; cognitive
impairment
Mendenhall, Andrew, 4.16, 4.17, 4 .19
Men for Sobriety (MFS), 9.31
menstruation
eating disorders, 7.45, 7.48, 7.49,
7.50, 7.60, 9.51
sports, 7.19, 7.48
MENTAL HEALTH and DRUGS,
1.4, 1.39- 1.40, 10.0- 10.33.
See also anxiety disorders;
depression; dual diagnosis;
psychophannacology;
psychosis; schizophrenia
acceptance of problem, 9 .18
ADHD, 3.29-30, 10.6. 10.13,
10.22, 10.25, 10.27
alcohol, 5.12, 5.15, 5.19, 5.37,
5.41, 5.42
alcoholic psychosis, 8.3
assessment, 10. 7,10.11, 10.22,
10.24
bipolar affective disorder, 5.28,
9.38, 10.13, 10.14, 10.15,
10.29, 10.30 (See also
bipolar affective disorder)
brain chemistry, 10.2 - 3, 10.5,
10.7, 10.8, 10.21,10.22,
10.24, 10.25, 10.31,
10.32, 10.33
chemical dependency and
addiction, 9.2
chronic mentally ill, 5.41
classification, 10.3
cocaine psychosis, 3.6,
3.11.15,10.2, 10.4, 10.14,
10.19, 10.20
cognition, 10.21, 10.22, 10.32
10.33
co-occurring disorders (dual
diagnosis), 9.9, 10 .5- 32
diagnostic process for, 10.9-15,
10.18, 10.22- 27, 10.31,
10.32
disease prevalence, 9.2 - 3
drug abuse as disease, 9.2 - 3
drug-induced psychosis, 3.35,
10.4, 10.14, 10.15, 10.21
eating disorders, 7.47-48
environment, 10.3, 10.4-6,10.9,
10.13, 10.21, 10.22,
10.24, 10.31 10.33
epidemiology, 10.2, 10.6,
10.12, 10.32
factors in mental balance, 10.3 - 5
heredity, 10.3, 10.4, 10.5, 10.21,
10.22, 10.31, 10.33
homeless, 10.8, 10.32
impact of drug use, 10.5
inhalants, 7. 7
LSD, 6.10
marijuana, 6.32, 6.38-6.39,
10.20--21
neurochemistry, 10.5, 10.15,
10.16, 10.22, 10.24,
10.26, 10.29, 10.31
psychedelic use, 6.6, 6.9, 6 .32,
6.39
psychiatric disorders, 10.6-16,
10.18, 10.21, 10.22,
10.24-33
psychiatric medications, 3.9, 3.29,
8.40, 9.20, 9.38, 10.24 - 33
psychosis, 3.28
psychotherapy, 9.14, 9.42,
9.53,10.10, 10.23- 25
schizophrenia, 9.38, 10.3, 10.6,
10.13-14, 10.21, 10.21,
10.27, 10.32
sexual addiction, 7.54
stimulant abuse, 9.38
stimulant -induced mental illness,
10.6, 10.19-20, 10.33
treatment community approaches,
1.39, 9.6,10.9, 10.11- 13,
10.32
treatment goals, 9.10
Mental Health Parity and Addiction
Equity Act of 2008, 9.5, 9.15
mentally ill chemical abuser (MICA).
See dual diagnosis
mental retardation, 3 .14, 8.18, 8.19
alcohol during pregnancy,
5.27, 5.28
Mepergan. ® See meperidine
meperidine (Demerol, ® Mepergan, ®
Pethidine • ), 4.19, 4.31, 7.15
mephedrone, 3.33, 8.10, 8.39.
See also methcathinone
mephobarbital (Mebaral ®), 4.36
meprobamate (Deprol, ® Equinil, ®
Miltown, ® Meprospan, ®
Meprotabs ®), 4.2, 4.34, 4 .36
Meprospan .® See meprobamate
Meprotabs. ® See meprobamate
Meridia. ® See sibutramine
Merry Pranksters, 6. 7
"mersh," 6.26
"mesc" (mescaline), 6.4
mescal, 5.7
mescal bean, 1. 11
mescaline (peyote), 1.11, 6.1, 6.4,
6.13- 15, 10.3, 10.15, 10.34
misrepresentation, 6.21
Mesa -American cultures, 1.11 - 1.12,
6.12. See also South America
mesocortex, 2.9. See also old brain
mesolimbic dopaminergic pathway,
2.13, 4.17, 5.28, 7.51.
See also addictions pathway
Mesopotamia, 1.6, 1.9, 1.10, 4.7,
5.5, 7.34
mesoridazine (Serentil ®), 10.30

message transmission, 5.19
nervous system, 2.10--12, 2.19
mestero lon e (Prov iron ®) , 7. 18
metabo lism, 2.6-8, 2.46.
See also half-life
alcohol , 5.8-10, 5.14, 5.40, 8.56,
9.40, 9.68, 9.69
barbitura tes, 2.7, 4.38, 4.40
cocai n e, 3.1- 12
defined, 2.6---8
eating disorde rs, 7.46, 9.52
eld erly, 9.56
factors affec tin g, 2.6-8
fetal, 8.21 - 22, 8.26
first -pass, 2.4
heredity, 2. 7
liver, 2.4, 2.6---8,4.26, 5.10, 8.52
me thadone, 4.26, 4.29
modula tion, 9.68
opia tes, 4.26
stimulants, 3.5, 3.30,3.419.39
Valium, ®4.34
metabo lism modulation, 9.68
metabolites, 2.7, 3.10, 3.11, 3.23,
4.23, 4.28, 4 .34, 5.17, 6.33,
8.24, 8.50, 9.44
Metadate CD.®See methylphenidate
metall ic p ain ts, 7.3, 7.5, 7.6
Metandren. ® See m ethyltestosterone
me t-enkephalin, 2.20, 2.37, 5.14
me tformin (Glucop hage ®) , 9.52
"meth, " 3.3. See also
metham p hetam in e H CL;
methamphetam in es
me thadone, 4.29, 8.14, 8.23
me th adone (Dolo p hine, ® Meth adose, ®
Tussol, ®Adanon ®), 9.9, 9 .20,
9.41, 9.66. See also harm
reduction
alternatives to, 9.43
classification, 4.2, 4.6
con tro versy over, 4.28, 9.42-43,
9.67
cross -dependence, 4.19, 4 .2 1, 4.44
cross tolerance, 2.28
development of, 4 .28, 4.44
drug mixing, 2.33, 4.25
drug testing, 8.50, 8.52
effectiveness, 9 .67
half-life, 2.6
harm reduction, 4 .28-29
opioid detox ificati on, 4.29, 9.42,
9.66, 9.69
overdose, 4.4, 4.5, 4.18, 4.26, 4.38
poly -dru g comb in ations, 3.15,
3.19, 4.20-21, 4.29
pregnancy, 4.20- 21, 4.29, 8.22 - 23
time -release, 9.69
treatment using, 4.29, 4.33, 4.43
withd rawal, 4.25, 8.24 - 25
me thadone main tenance, 9.1, 9.6,
9.10, 9.13, 9 .14, 9.15, 9.42,
9.43, 9.65, 9.67
METHALiz, ® 9.69
me tham p hetamine HCL (Desoxyn, ®
Meth edrine, ® Pervitin ®) , 3.3,
3.21 , 10.28, 10.30
me tham p hetamines, 1.2, 1.3,
1.26-1.27, 1.31, 7.20.
3.20-28, 10.6, 10.7,
10.14, 10.20, 10.21, 10.30
See also amphetamines;
dextromethamphetam ine;
psycho -stimulants
age of first use, 8.18
am ph etam in e analogues an d
(MDMA,MDA,
MMDA,MDE), 6.15
current use, 3.23, 9.38
damage to brain, 9.64
depressants, 4.21, 4 .34
discovery, 3.21
drug co mbina tions, 4 .25
drug test in g, 8.54
elderly, 8.59
eme rgency room vis its, 9.38
epidemiology, 9.38
"go" circuit, 2.1, 2.10, 2.13 - 17,
2.39, 2.4 1, 2.45--46
high schoo l, 8.28
history 1.26-1.27
manufacture,1.31, 1.36, 3.21 - 23,
7.21, 7.27
mental hea lth , 10.9, 10.18, 10.20
meth labs, 1.31, 1.36
methods of use, 2.5, 2.4 4 , 3.24-25
military use, 8.51
neona tal effects, 3.27
neuro transmitters, 2.20, 2.20-26
n itri tes, 7 .9
overdose, 9 .3
physical effects, 2.27, 2.28, 2.28,
2.30, 2.3 1, 2.32, 4.16,
9.23, 9.25
po lydrug abuse, 4.24--25, 5.27,
6.15, 7.9, 10.26
pregnancy, 8.23, 8.2 4
prescrip tion u se, 3.21
relapse, 9.4
sex, 8.36, 8.38
smokable ( "crys tal meth, " "ice"),
3.23, 9.63
smuggling, 4 .5
sports, 7.20, 7.24, 7.26, 7.6
synthetic methamphetam ine, 1.2,
1.30, 1.34
treatment, 9.2, 9.4, 9.16, 9.19,
9.36, 9.39, 9.66, 9.68,
9.69
methamphetamine sulfate .
See "crank "
methandrosteno lone (Dianabol ®) ,
7.18
methano l. See methyl alco hol
methaprylon (Noluda r®), 4.31
metha qualone (Mandrax, ® Optimil, ®
Parest, ® Quaalude, ®
Soper, ® Somnafac ®), 4.40,
4.43--44, 9.61
antihistam in e, 4.44
sex, 8.39
"meth bugs," 3.15
methcathinone (me phedrone,
M-KAT3.34
"meth dancing, " 3.15
Meth edrine, ® 3.22.
See methamphetamine HCL
methenolone (Primobolan ®), 7.18
metheno lone enanthate (Primobolan
Depot• ), 7.18
meth labs, 1.31, 1.36, 3.21, 3.24
"meth mouth," 3.27
methocarbamol (Robaxin ®), 4.3, 4.4,
4.23, 4.38, 7.15
METHODS OF USE. See also contact
absorpt ion; inhalat ion;
injection; mucous membrane
absorp tion; needle use; or al
in gestion
contact absorption, 2.2, 2.4, 3. 11
drug absorption, 2.2-4, 2.5
historical d evelo pm ents in,
1.20-1.21
how drugs get to the br ain,
2.2--4, 2.45
ingestion, 2.2, 2.4 2.45, 3.7,
3.9- 10, 3.25, 3.36, 4.8
inhalants, 7.5-6, 7.27
injection, 2.4-5, 4.9, 8.14, 8.43-46
insuffiation (snorting), 4 .9- 10
me tho hexi tal (Brevita l®), 4.31
methyl alcohol (me th anol), 5.5, 7.3,
7.8, 7.27
methyl but yl ketone (MBK), 7.3, 7.8
methyl chloride, 7.3
methylene chloride, 7.3
methylenedioxyam p hetam in e (MDA).
SeeMDA
methylenedioxyme tham p hetamine .
SeeMDMA
methylenedioxypyrova lerone
(MDPV), 1.2, 3.4, 3.34, 6.18
methyl ethyl ke tone, 7.3
Methylin. ® See methylpheni date
Methylme thcathinone (4-M MC)
methylphen id ate (Conce rta, ® Ritalin, ®
Methylin, ® Metadate, ®
Metada te CD,® Datrana
Patch • ), 3.2, 3.6, 3.29-31,
6.16, 9.67, 10.24, 10.25,
10.26, 10.30, 10.34. See also
at tent ion deficit hyperactivity
disorder
methyltestosterone (Androi d ,®
Metan dren, ® Testred, ®
Virilon ®), 7.18
metryptamine (alph a-methyl -
tryptam ine), 6.4
metyrapone, 9.68
Mexicana (Cannabis), 6.28
Mexican Americans, 5.18, 9.59-60.
See also Hispa n ics
"Mexican brown" (heroin), 4 .7, 4.11
Mex ican drug cart els, 1.31, 1.32,
1.36,3.19, 3.20, 3.25,
4.10 - 12, 4.31. 6.31
"Mexican tar," 1.32,4.5, 4 .10, 4.31.
See also heroin
Mexico, 4.5, 4.11 - 12, 4.31, 5.40, 6 .31
alcohol, 5. 7
amphe tamines, 1.27, 1.31, 3.22,
3.24, 9.38
an ti-drug efforts, 8.10
Aztecs, 1.17
cartels, 1.32, 4 .10-12
chocola te, 1.14, 1.17
cocaine, 1.32, 3.8, 3.20
dru g-trafficking organ izations
(DTOs), 3 .24, 6.31
drug wars, 1.5, 1.30
ephedrine, pseu d oephedrine ,
3.21 - 22, 8.11
fentanyl, 4.27
he roin, 1.32, 4.10-12, 4.13,
4 .14.6, 4.42
marijuana, 1.25, 1.34, 6.36,
6.31 - 32, 6.41
methamphetamine, 1.30,
1.31, 1.36
mushrooms, 1.12, 6.10-11
pre -Co lu m bi an, 1.14, 6.10
seda tive-hypno tics, 4.5, 4.31
smo kin g, 1.16
smuggling, 4.5
U.S. an ti-drug policies, 8.10
MFS. See Men for Sobriety
mibo lerone (Cheque ® drops), 7.18
mic. See microgram
MICA (mentally ill chemical abuser).
See dual diagnosis
mice stu dies
alcohol, 2.37, 2.43--44, 2.47
qigong, 9.37
Mich igan, 6.24 , 6.44, 8.10
Mich igan Alcoho lism Screen in g Test
(MAST), 9.11 - 12, 9.57
MAST/AD, 9. 11
"Mickeys " (chloral hyd rate),
4.34, 4.36
microgram (mic), 6.7
INDEX 1.21
midazolam (Domicum, ® Hypnovel, ®
Versed®) , 4.31, 9.67
midbrain, 2. 9
Middle Ages, 1.12- 1.14
Middle East , 1.9, 1.31, 1.32, 3.32,
3.33, 3.58, 5.7, 6.26, 6.29.
See also Arab
Midol, • 3.37
Midwes t , 1.36, 3.23, 3.33, 6.8
"mih i" (ayahuasca), 6.4
milieu-limi ted alcoholism, 5.20
military and su bstance use, 4.21 - 22,
7.13, 8.50-51, 8.64
alcohol, 5.38, 5.44, 8.49
I
am ph etam in es, 1.23,
1.26-1.27, 8.49
drug testing, 8. 49
heroin, 1.27 1.29
kha t, I.II
nutrition, 7.43
opia te/op ioid addiction, 4 .26
prescription drugs, 8.49
prevention programs, 8. 49
tobacco, 1.23, 3.41, 3.42, 8.49
Vietnam, 1.29, 4 .10, 4.25 - 26
war time, 1.23, 1.26, 1.27, 1.29,
4.8, 4 .9, 4 .23
zero tolerance, 8.51
milk thi stle (Silybu m marianum),
9.37
Miltown. ® See meprobama te
mindfulness meditation, 9.37
minerals, 7.23
minimal br ain dys fun ction, 3.21
Mini mum Drin kin g Age Act.
See Na tiona l Minimum
Drinking Age Act
Min ipress. ® See prazos in
minori ti es. See ETHNIC
CONSIDERATIONS
"minor tr an quilize rs," 4.2, 4,34,
10.29, 10.30, 10.31. See also
alprazolam; benzodiazepines;
diazepam; meprobama te;
sedative -hypnotics
"miraa " (khat), 3 .33-34. See also khat
mi rt azap in e (Remeron ®) , 9 .39,
10.26, 10.30
miscarriage. See also pr egnancy
alcohol, 5.28
anorexia, 7.49
caffeine, 3.42
cocaine 3 .13
heroin and opioids, 4.18, 8.23
Miscellaneous Discon tinuation
Syndromes, 9 .11
"Miss Emma" (morphine), 4.6
missionaries, 1.12, 1.15
Missouri, 1.36
misuse and diversion, 8.11, 8.57,
9.17, 9.41, 9.63. See also
diversion of lega l drugs
Mitchell, George, 7.12
Mit chell Report on baseball, 7.12
mi tochondria, 2.0, 2.22, 2.27
"Mitsubishi doub le-stack " (PMA), 6.4
mixe d drinking cu ltu res, 5.36
mixing, See p olydrug use and abuse
"M-KAT." See methcath inone
MK-ULTRA program, 6.6
MMDA (amphetamine ana logue), 6.4
MMORPGs (massiv ely multiplayer
online role -playing games),
7.56
Mohan .® See molindone
mobile phone ad dic tion, 7.54,
7.57- 58, 7.63
modafinil (Pro vigil ®), 3 .4, 7.24,
7.29, 9.39
MODCRIT, 9.11
 1.22 INDEX
mo dified ciliary neuro trophic factor
(CNTF, Axokine ®), 9.52
Mohamme d (Prophe t), 1.14, 6.26.
See also Islamic countries
"moj o" (mari juana), 6.4
mo lindone (Mohan, ® Lid one ®),
10.28, 10.30
"Molly," See MDMA
Monase, ® 6.12
monasteries, 5.6
money, an d craving, 9.25
money -laun d ering activi ties, 8.8
mon itoring (follow -through ) , 9.48,
9.64--65
I
Mon itoring the Fu ture Survey
alcoho l, 5.13, 8.32
mari juana, 8.17, 8.26, 8.28
MDMA, 8.28, 8.40
methamphetam ine, 8.27, 8.27
tobacco, 8.28, 8.29, 8.33
monoamine oxi dase B (MAO -B)
inhib itors, 9.39, 9.51,10.30
monoamine oxidase (MAO)
inhib itors, 2.40, 6.11, 9.39,
9.5 1, 10.24, 10.26, 10.30,
10.33
monoamines, 2.20
Monroe, Mari lyn, 4.41
Monstar ,® 7.20
Montana, 6.44
Mon tezuma, 1.17
mood diso rders, 10.2, 10.7, 10.13,
10.17- 24, 10.29, 10.30
d own regu lation, 6.17
p re-exis ting, 10.11, 10.13,
10.21, 32
substance- induced,10.7, 10.11,
10.18, 10.32, 10.33
mood sw ings, 9.23
"moonflowe r." See da tura (jimson
weed)
morali ty, 2.2, 2 .17. See also spirituali ty
h istoric drug p olicies, 1.27
"mo re" circui t. See "go " circu it
Mo rmons (ep hed ra tea), 3.35
morn ing glory, 6.4, 6.12, 6.20
"morph" (morphine), 4.6
morph ine (Avinza, ® Infumorph, ®
Kadian, ® MS Cantin, ®
Roxano l®), 2.4, 2.5,
2.20, 2.28
drug testing, 8.52, 8.54
hypodermic needle, 3.10, 4 .8-9
refinement of, 1.7, 1.19, 1.34,
4.8-9
routes of adminis tr ation, 2.2, 4.26
sp orts use, 7.13, 7.15
morph ine supp ository, 2.4
morph ing, 2.33
MORTALITY
AIDS and HlV,4.23, 8.43, 8.44
alcoho l-related, 1.18, 5.26,
9.3, 9.45
anorex ia, 9 .51
binge drinking, 5.37
chil d abuse, 8.22
coca ine, 9.3
college, 8.33
d elirium tremens, 5.26
d rug war, 4 .11
d runken -driving dea ths, 5.44, 8.4
female alcoholics, 5.9, 5.28, 5.37
heroin, 9.3
inhalants, 7.5
methamphetam ine, 9.3
methadone 4.27 - 29
motor vehicle fatalities, 5.21 , 5.44
muscle relaxants, 7. 16
N,0, 7.10
nicotine, 9 .3
opiates 4.18, 4.4.24--25, 4.27 na lmefene (Revex ®), 9 .50, 9.66,
prescri p tion 4 .3 9.68, 10.26
mos to, 5.35 Na lone. ® See naloxone
"mother's litt le hel p er " na loxone (Nalone, ® Narcan, ®
(me p robama te), 4.35 Narcant i®) , 4.6, 4.7, 4.24,
motiva tional enhancement the rapy, 4.30-32
9.42, 9.48, 9.48 na loxone (Na rcan ®), 4.6, 4.22, 4.30,
motiva tional in terv iewing, 7.51, 9.53, 4.32, 9.4 1, 9.42
10.11 Na lt rel, ® 9.69
motiva tional treatment app roaches, Nalt rel.® See na ltrexone
10.11, 10.24 na ltrexone (Depade, ® Nalt rel,®
motor impairment Revia, ® Trexan, ® Vivitro l®),
inha lants, 7.6, 7.10 2.5, 4.6-7, 4.21, 4.28-29,
op ioids, 4 .16 4.32 - 33, 9.9, 9.20, 9.21,
PAWS, 9.23 9.39, 9.4 1, 9.42, 9.46, 9.66,
Motrin. ® See ibupro fen 9.68, 10.29
Mountain Dew,® 3.4, 3.37 time -release, 9.69
Moun t Vernon, 1.19 NAMI (Nat iona l Alliance on Men tal
movies an d ciga rettes, 8.38 Illness), 10.2, 10.6
"MPPP " (meperidine), 4.6 nandro lone (DecaDurabolin, ®
MRI, fMRI (magnetic resonance Du rabolin ®), 7.18, 7.19
imaging), 2.14, 2.17, 2.18, Narcan. ® See na loxone
2.42, 3.25, 3.25, 3.28, Narcanti. ® See naloxone
5.30-31, 7.6, 7.30, 9.3, 9.64 narcole psy, 3.5, 3.21, 3.23, 3.28,
MRO. See med ical review office r 3.35, 3.57, 3.58, 4.43, 7.25,
Mrs. W ins low's Sooth ing Syrup, 8.40, 9.39
1.21, 4.9 neurotransmit ters, 10 .29
M-SAPS, 9.11 - 12 narcotics law, 4 .10
MS Con tin. ® See morphine Narco tics Anonymous (NA), 6.36,
MSN Inves tor, 7.56 9.13, 9.29, 9.42, 9.44
mucous membrane absorp tion, Nard il. ® See phenelzine
2.2, 2.4, 2.45, 3.10. See nasa l mucosa. See snorting
also "sniffing"; snorting; nasal sep tum, 3.10
sublingua l absorp tion; nasal spray, 2.3, 2.4, 3.55, 4 .33
su pp osi tories nicot ine treatmen t , 9.41
Muj ica, Jose (Uruguay p residen t), opioids, 4.10, 4.29
6.42 Nat iona l Alliance on Menta l Illness
Mu ltidiscip linary Associa tion for (NAM!), 10.2, 10.6
Psychedelic Stud ies, 6. 7 Nat iona l Baske tball Associat ion
multi -disciplinary integrate d (NBA), 7.27
treatmen t, 9.51 Nationa l Cente r on Addictions an d
mult ip le diagnoses,10.8, 10 .12, 10.18, Substance Abuse, 9 .17
10.32, 10.33. See also dua l Nat iona l Co llegia te Ath letic
diagnos is Association (NCAA), 7.15,
multiple scleros is, 6.32, 6.45 7.16, 7.19, 7.21, 7.22, 7.24,
mu rece p tors, 4.13, 4 .19 7.25, 7.26
"Murphy " (morphine), 4. 7 Nationa l Cou ncil on Alcoholism, 5.23
muscarine, 3.36 NCA CRIT (Cri teria for Diagnosis of
muscimole, 6.4, 6.23 Alcoholism), 9. 11
muscle bu ilding. See steroi ds Nat iona l Footba ll League (NFL), 7.21,
muscle dysmorph ia, 7.24 7.22, 7.23, 7.25, 7.26
muscle relaxants. See skeleta l muscle Nationa l Gambling Commission
relaxants Study (NORC), 7.33-7.43
"muscling, " 2.4, 4 .9, 8.45 Nat iona l Guard, 8.49
musculoskeleta l sys tem an d alcohol, Nationa l Highway Traffic Safety
5.20. See also sports and Adm inistration, 5.33
drugs Nationa l Hockey League (N HL), 7.27
mushrooms and fungi, 1.11- 1.12, Nationa l Househo ld Survey on Drug
1.28. See also Amanita Abuse . See Househol d Survey
mushrooms; ergot; p eyote; on Drug Abuse
Psilocybe mushrooms Nat iona l Institute of Mental Health
music clubs. See rave clubs (N l MH), 6.7, 10.9
Mu slims. See Islamic countries Nationa l Institute on Alcoho l Abuse
Myanmar (Burma), 3.22, 3.24, and Alcoholism (NIAAA),
4.11, 4.42. See also 5.11, 9.16
Go lden Triangle Nationa l Insti tu te on Drug Abu se
Mylostan. ® See tet razep am (NIDA), 2. 11, 2.38, 2.43,
myopathy, 5. 19 4.37, 8.18, 8.19, 8.43, 9.39
myrist icin, 6.4. See also nutmeg HCV, 4.22, 4.29, 8.42
Household Survey on Drug Abuse
N (See Househol d Survey
on Drug Abuse)
N-arachi donoy l dopamine (NADA) NMASSl ST, 9. 12
(endocannab inoid ligand), prevent ion programs, 8.30
6.34 treatment principles, 9.8-10
NA. See Narco tics Anonymous Nat iona l Institutes of Health (NIH),
nabilone (synthetic THC), 6.4 3.30, 7.32, 8.19, 9.70
Naguib Ad-Din, 1.14 Nationa l Institute of Men tal Health
nail po lish remover, 7.2, 7.4 7.32
National Min imum Drinking Age
Act,8.6
National Registry of Evidenced -Based
Programs and Pract ices
(NREPP), 8. 7, 8.30, 9.4--5
Web site, 8.6
National Schoo l Lunch Prog ram, 7.45
National Science Foundation, 4.40
National Survey of Substance
Abu se Treatment Services
(N-SSATS), 9.8, 9.8, 9.15
National Survey on Drug Use and
Health, 8.20, 8.23, 9.5
Native American Church of North
America, 6.14 - 15
Native Americans (American Indians),
5.9. See also Alaskan Natives
alcoho l, 5.9, 5.42, 5.44
in Cen tral and South America, 6.12
FAS, 5.30
inhalan t u se, 7.2, 7.4, 7.6, 7.7
peyo te, 6.14 - 15, 9.6 1
ritua l use of psychedelics, 6 .10--15
tobacco, 3.44, 3.450
treatmen t, 9.61--62
triba l m igrat ion, 1.8
na tural stimulants. See epinephrine;
norepinephrine
nature video, 2.14, 2.15
nausea . See also bu limia nervosa;
vom iting
2CT-T-2 and, 6.19
alcoho l wi thdrawa l, 5.14,
5.23, 5.24
DMX, 6.24
DMT 6.13
hangove r, 5.16
inhalants, 7.5
marijuana, 6.34, 6.38
MDMA,6.16
morn ing glory 6 .12
mushrooms, 6.10
nu tmeg6.24
opio ids, 4.13, 4.18-19, 4.27
peyo te, 6.14
psycho -stimu lants 6 .19
seda tive-hypnotics, 4.40--43
Navane. ® See th iothixene
Navy Alcoho l and Drug Abuse
Preve n tion (NADAP), 8.49
Nazca people, 1.11
"Nazi spee d" (ya ba), 3.2, 3.3, 3.22,
3.24, 3.57
NCAA. See Nat iona l Collegia te
Athletic Associat ion
NCA CRIT. See Nationa l Counci l
on Alcoholism Cri teria for
Diagnos is of Alcoho lism
NDRis (norepinephrine-dopam ine
reuptake inhib itors),
10.26, 10.30
NE. See norepinephrine
Neande rthal man, 1.8, 6.2
"nebbies" (pen tobarbital), 4.31
necro tizing fasciitis (flesh -eating
bac teria), 4.23, 8.45
need le exchange, 4.23, 8.14, 8.15, 9.6
NEEDLE USE. See also AIDS and
HIV; injection; intramuscu lar
inject ion; intravenous drug
use; subcutaneous inj ection
abscesses, 2.4, 4.12, 4.11, 4.23,
8.44--45
co tt on fever, 4.24, 8.44-45
dirty needles, 1.33, 4.22 - 24, 8.15,
8.45--46, 9.38, 9.63
diseases, 4.23, 8.43--44, 8.58
endocardit is, 4.22, 8.43
epidemiology, 8.41
harm reduction, 8.46

hazards from, 8.42
hepatitis, 1.29,1.33, 2.5, 3.14,
3.16, 3.28, 4,22 - 23,
8.42, 10.12
history, 1.20, 4.22 - 24
HIV disease, 2.4, 3.14, 3.16, 3.20,
3.24, 3.28, 4 .22- 24, 8.45
infections, 4.23, 4.29
laws, 8.8
methods of u se, 2. 4
needle exchange, 4.23, 8.14,
8.45, 9.6
opioids (heroin), 4,5 4 .9- 10, 4.22
outr each programs, 8. 44
prevention, 8.1 4 , 8.45
sexually transmi tt ed diseases
(STDs), 8.42-44
shared needles, 4.23
sports drugs, 7.2
steroids, 7.17
"tracks," 4.22 - 23
nefazodone (Serzone ®), 9.39,
9.68, 10.25
negative reinforcemen t, 2.29, 4.21
Nembutal. ® See pentobarb ital
neocortex. See new brain
Neolithic era, 1.8-1.9, 1.11
neonatal com plic ations, 4.21,
8.20-21, 8.24
neonatal narcotic withdrawa l
syn dro me, 4 .21, 8.24
neonates. See pr egnancy
Nepal, 9.43
nepenthe (Homeric opium mix ture),
1.10
nerve cells (neurons), 2.0, 2.2, 2.5,
2.8, 2.11, 2.11, 2.12, 2.18,
2.19, 2.22, 2.46
neural connections, 2.16
neuroanatomy, 2.18, 2.18-20,
2.42, 2.46
neurotransmitters, 2.20, 2.20-26
number of, 2.12
nerve degeneration, 5.18, 5.21
nerve impulses, 2.18, 2.19
NERVOUS SYSTEM, 2.8-25, 2.45-46.
See also br ain; central
nervous system; sympa thetic
nervous system
alcohol abuse, 5.19
am p hetam in es, 7.20
inhalants, 7.10
neural connections, 2. 16
neuroanatomy, 2 .18, 2.18-20,
2.42, 2.46
Nestler, Eric, 4 .19
Netherlands, 1.34, 4.12, 8.45
mari j uana, 6.27, 6.41 -4 2
psycho stimulants 6.19
neurasthenia, 1.22
neuroanatomy, 2 .18, 2.18-20,
2.42, 2.46
NEUROCHEMISTRY, 10.26.
See also neuro transmitters;
psychopharmacology
action potential, 2.20, 2.23
alcoholism, 5.17, 5.24
am p hetam in es, 3.25
cocaine , 3.11
dopamine 4.17, 4.19, 4.34, 4.38
eating disorde rs, 7.45-46,
7.47, 7.50
GABA, 4.38
heavy drinking, 5.26
mari j uana, 6.33 - 34
mental health, 1.31, 1.39, 10.3,
10.4, 10.5, 10.8, 10.20,
10.22, 10.26, 10.31, 10.32
mice stud ies, 2.37, 2.43-44, 2.47
neural transmission process, 2.24
nico tine addic tion, 3.48-50, 9.40
relapse and, 9.21
research on me d ications and, 9.3
youth, 6.32
neuro feedback, 9.37
neuro leptic drugs, 1.38, 9.39, 10.22,
10.24, 10.27 1.5, See also
antipsychotic me dications
neuron. See nerve cel ls
Ne u ron tin .® See gabapentin
NEUROTRANSMITTERS, 10.26,
10.27. See also acety lcho line;
adenosine; anandam ide;
cor tico trophin; d opamine;
dynorphin; endorphin;
enkephalins; ep inephrine;
GABA; glutamate; glycin e;
norepinephrine; receptor
sites; serotonin; substance
"P"; entries for specific
neurotransmitters
acupuncture, 9.36
aggression, 5.30
alcoho l, 5.14, 5.17, 5.23, 5.24
amphetamines, 3.2, 3.5
cocaine 3.11
craving, 3. 14, 9.21
disruption of, 2.25
dopamine,3.15, 3.25, 3.26, 4.17,
4.19, 4.34, 4.38,10.3,
10.4, 10.24, 10.25, 10.26,
10.28, 10.29, 10.30
first and second messengers, 2.4 7
gambling addic tion, 7.3 7
group in gs, 2.21
homeostas is, 9.36
imaging, 9.3
imbalance of, 2.21
marijuana, 6.33-34
mental health and drugs and, 10 .1
message tr ansmission, 2.23
op ioid receptors, 4 .13
pain, 4.13
pleas u re , 4.7. 4.9, 4.12, 4 .17
psilocybin, 6.10
psychedelics, 6.5
psychiatric medicat ions, 10.24 - 33
psychoac tive drug rela tionships,
2.20
reabsorption of, 2.21, 2.25, 3.5,
3.12, 3.57
sexua l addic tion, 7.5 4
Nevada, 6.38, 7.32, 7.33, 7.35, 7.36
New Age, 6.16, 7.29
new brain (neocortex), 1.7, 2.9- 10,
2.9, 2.15, 2.17, 2.18, 2.44,
5.12. See also prefrontal
cortex
New Guinea, 3.35
New Hampshire, 7.35
Newmeyer,John, 8.16
New York (sta te), 8.10
DTAP stu dy, 9.5
ethnic po pul ations, 9.60
New York City, 3.13, 3.17, 3.56,
3.59, 8.9
HIV infec tion rate, 8.45
methadone maintenance, 9.42
New Zea land, 3.58, 7 .60
nexus (2C -B), 6.4, 6.18-19.
See also CBR
NFL. See Na tiona l Foot ball League
NGB-2904, 9.67
N-hexane, 7.7-8
NIAAA. See Na tiona l Ins titut e
on Alcohol Abu se and
Alcoholism
n iacin (vitam in B3), 8 .53
Nichols, Dave, 6 .15
Nicoderm, ® 9.40
Nicore tt e Gum, ® 9.21, 9.40-4 1, 9.66
N icot,Jean, 1.16
Nico tiana tabacum, 1.16, 1.18, 3.43
nico tine, 3.42 - 58, 8.26-27. See also
tobacco
absorp tion, 2.3, 2.4
addiction, 2.40, 3.45-47, 3.51
ad d iction -associate d genes,
2.39-40
age of first use, 2.33
approved medications, 9.66
botany, 3.46
d rug tes ting, 8.54
elderly, 8.55
freebase, 3.4 7
neurochemical changes, 2.4 7
neurotransm itt ers, 2.21, 2.41
off-label medica tions, 9.66
pharmacology, 3.46
pregnancy,3.5 4, 8.25- 26
sex, 8.38
substance -induced d isorders,
2.35, 2.47
titr ation, 2.3
to lerance, 2.27, 3.45
treatment, 9.37, 9.40-41, 9.66,
9.67, 9.68, 9.68
vaccines, 9.67
wi thd rawal, 2.29, 3.48-49
nico tine gum. See Nicorette ® Gum
nico tine lozenges, 9.41
nico tine patches (N icoderm, ®
ProStep• ), 9.9, 9.21, 9.40,
9.41, 9.66, 9.68
nico tine replacement the rapy, 9.9,
9.40-4 1, 9.66
nico tinic receptors, 3.48
Nico trol ,® 9.40
N icVAX,® 9.67
NIDA. See National Institute on
Drug Abuse
N iemann, Albert, 1.21, 3.9
N ieto, Enriq u e Peiia (Mexico
Pres ident), 4.11
n ifedipine (Adala t,® Procar di a®), 9.68
N igeria, 4 . 12, 6.27
nightshade plan t family, 1.12,
1.13, 6.20
NIH . See Na tional Institutes of Health
N ilex. ® See norethandrolone
NIMH. See National Institute of
Mental Health
nimod ipin e (Nimotop ®) , 9.68
90/90 contract, 9.46
N intendo DSi,® 7.56
N irvana, ® 3.37, 7.29
ni tri c oxide (NO), 2.21, 2.22
ni trit es. See volatile ni tri tes
ni troglycerin, 7.1 4
ni trosamines, 5.12, 7.9
ni trou s ox ide (N 20; "laughing gas"),
1.19, 2.22, 7.3, 7.3, 7.4, 7.5,
7.9- 10, 7.59, 8.40
ecstasy an d , 6.18
Nixon, Richard M. (U.S. president),
1.5, 1.6, 1.29
Nizora l.® See ketoconazo le
NMASSIST (Modified Alcohol,
Smoking and Substance
In volvement Screening Test),
9.12
NMDA receptors, 5.14
Noble, Ernest, 7.32
N obrium. ® See medazepam
N octamid. ® See lormetazepam
Noctec. ® See chlora l hydrate
No-Doz,• 3.37, 8.56
Noludar. ® See methaprylon
non -app roved substances, 7 .24
INDEX 1.23
nonconfrontational strategies, 9.27,
9.55, 9.61, 9.71. See also
motivational enhancement
therapy
non-dependent users, 8.2, 8.12, 8.13.
See also recreational drug use
nonpurposive w ithdrawal, 2.30
non sequ iturs, 6.8
nonsteroidal anti -inflammatory
drugs (NSAID S; ibuprofen,
Aleve, ® Clinor il®), 4.38,
7.16, 8.25, 9.42. See also
aspirin; celecoxib; ibuprofen;
indomethacin; nonsteroidal
I
anti- infl ammatory drugs;
phenylbutazone; rofecox ib;
su lindac
"noodlelars" (methaprylon), 4.31
nootropic drugs, 7.30, 9.37, 9.69
noradrenaline. See norepinephrine
NO RC. See National Gam blin g
Comm iss ion Study
Norco. ® See hydrocodone
norepinephrine (NE, noradrenaline),
2.20, 2.21, 2.23, 2.24, 3.5-6,
3.25, 3.29, 3.34, 3.35, 3.56,
4.17, 4.23, 4.29, 4.33, 5.12,
7.54, 9.36, 10.4, 10.20,
10.24, 10.25, 10.26, 10.27,
10.29, 10.30, 10.33
cocaine, 2.20, 2.25, 2.42, 3. 11,
3.12, 3.14, 6.30
eating disorde rs, 7.30, 7.44
gambling, 7.32, 7.56
MAO inhibitors, 10.26, 10 .30
nicotine, 2.41
opioids, 4.17, 4.23, 4.29
psilocybin, 6.11
psychiatric medications,
10.24- 10.33
sex, 7.54, 8.37
SSRls, 7.54, 10.24-26, 10.29- 3 1,
10.33
stimulants, 3.5, 3.5-6, 3. 11- 12,
3.14, 3.25- 26, 3.29, 3.35-
36, 10.20, 10.25, 10.26,
10.27, 10.33
withd rawal, 4.17
norepinephrine -dopamine reuptake
inhibitors (ND Ris), 10.26,
10.30, 10.33
norepinephrine reuptake in h ibitors
(NRls), 3.29, 4.23, 10.26,
10.27, 10.30. See also
atomoxe tin e; reboxetine
norepinephrine -serotonin modulators
(NRls),10.26, 10.30.
See also mirtazapine
normative assessment, 8.33-34, 9.56
normative educa tion strategy, 8.31
Norp ram in .® See desipramine
No rth America, 3.56
nortriptyline (Aventyl, ® Pamelo r®),
9.66
Norvasc. ® See am lodipine
Norway, 5.33, 6.43
"nose candy" (cocaine), 3.3
novelty, 2.22, 2.33, 8.39
CYP2D 6 *2 gene, 2.39
marijuana, 6.35 - 36
novelty cen ter, 9.25
NQD, , 2.39
NREPP. See National Regis try of
Evidence d-Based Programs
an d Practices
NRis. See norepinephrine -serotonin
mo dula tors
NSAIDs. See nonsteroidal an ti-
inflammatory drugs
 1.24 INDEX
N-SSATS. See Na tional Survey
of Substance Abuse
Treatment Services
nu cleus, 2.0
nucleus accumbens (NAc), 2.12,
2.13, 2.14, 2.15-16, 2.39,
2.42, 2.45, 2.46, 4. 17, 7.18,
7.30, 7.46
alcoholism, 5.22
eat ing disor ders, 7.48
mari juana 6.34
stimu lants, 3.7, 3.12, 3.14, 3.44
"nugget" (mar ij uana), 6.4
Numorphan. ® See oxymorphone
I
nu rsing homes, 5.37
nursing mo the r. See breas t m ilk
nu tmeg, 6.4, 6.24
nu trien ts and nut ri tion, 6.23, 8.19,
8.20, 22. See also eat ing
disorde rs; malnutri tion
alcoho l, 2.44, 5.15, 5.18,
5.18, 5.19
amphe tamines, 3.5 3.27
cravings, 9.24
d emen tia an d , 10.17,10.19
eating d isor d ers, 7.42, 7.4, 7.48,
9.5 1
khat, 3.33
pregnancy, 3.26, 8.19, 8.20
ris k of addiction, 2.36
smok ing, 3.48
treatment, 9.39, 9.68
nu trit ional supplements, 7.23, 9.3,
9.68. See also herbal products
nystagmus, 5.34
Nyswander, Marie, 9.42
Ny tame l.®See zo lpidem
Ny tol,®4.3, 8.56
0 addiction, 4.5-6, 4.10
Obama, Barack (U.S. p resident), 1.5,
1.40, 6.1, 8.2, 8.9
mari juana policy, 6.36, 6.37, 6.38
Oben ix. ® See phente rmine HC L
obesity, 3.29 3.32, 7.45-46, 7.48
diabe tes, 1.5, 1.31, 1.35, 1.40
global rates of, 1.31, 1.41, 1.42
me dical consequences of, 7 .49
pharmaceutica l treatments,
9.52-53
Obetrol. ® See d,l amphe tam ine
Obetrol ® (amphetam ine), 3.22, 3.32
O-BOAT. See office-base d opiate
ad dict ion treatment
obsessive-compuls ive d isorder
(OCD), 2.43, 7.55, 10.6,
10.13, 10.16, 10.18, 10.21
10.25,10.26, 10.30 10.31
defin ition, 2.43, 7.30, 10.16, 10.25
drug treatment, 10.25, 10.26,
10.30, 10.31
obsessive compulsive p ersona lity
disorde r, 2.43, 10.13,
10.14, 10.18
OCD. See obsessive-com pulsive
disorder
"oceans" (oxycodone), 4.6
"o'coffin" (oxyco d one), 4.6, 4.28
"ocs" (oxyco done), 4.6, 4.28
Odyssey, 1.10
office-based opiate addiction
treatment (O-BOAT), 9.14
Office of Nat iona l Drug Control
Policy (ONDCP), 6.27,
8.9, 8. 14
budge t, 8.3, 8.4, 8.9, 8.10, 8.11,
8.12, 8.13, 8.14, 8.15,
8.17, 8.23, 8.56
Oj ibwe Indians, 6.24
olanza p ine (Zyprexa ®), 9.39, 10.28,
10.29, 10.30, 10.33
old brain (p rim itive bra in), 1.4, 2.1,
2.9-10, 2.9, 2.13, 2.15, 2.16,
2.17, 2.17, 2.18, 2.44,
2.45--46, 6.31, 9.4
OLD BRAIN-NEW BRAIN, 2.1,
2.9-10. See also new bra in;
old brain
old er Americans. See elderly
Olmecs, 1.14
"ololiuqui" (morn ing glory seeds), 6.4
Olympic Games, 7.11-12, 7.13, 7.14,
7.16, 7.19, 7.25.
See also Beij ing Olympics;
International Olympic
Comm itt ee; Sidney Olympics
Omni bus Drug Act (1988), 8.10
ondansetron, 9.66
ONDCP. See Office of National Drug
Contro l Policy
One-A-Day We igh tSmart, ® 9.53
OnlineAuc tion, 7.58
on/off switch, 2.1, 2.10, 2.13-17,
2.39, 2.41, 2.45-46. See
also "go" circ u it; addic tions
pathway; "stop" circu it
Op ana. ® See hydromorphone
op iates/opio ids, 8.23, 8.23-24
OPlATESIOPIOlDS, 4.5-29.
See also buprenorphine;
co deine; fen tany l; heroin;
hydrocodone; LAAM;
methadone; morphine;
naloxone; naltrexone;
oxyco d one; en tries for
specific generic drugs
acute withdrawa l, 4.20, 4.31
adulteration, 4.24
agon ists, 7.15 (See also
bu p renorph ine; LAAM;
methadone)
antagon ists, 4.7, 4.46-47, 7.55, 9.67
(See also buprenorph ine; naloxone;
nalt rexone; pentazocine)
approved me dicat ions, 9.66
classifica tion, 4 .6
cost of habit, 4.24
coughing, 4.18
crime, 4.4
defini tions, 4 .6
dep endence, 4.4, 4.13, 4.41, 7.11
designer hero in, 4.27
de tox ificat ion, 4.17, 4.20-21,
4.30, 9.42
diacetylmorphine (See heroin)
diversion of, 4.5, 4.10, 4.29
drug testing, 8.50, 8.52
effects of, 2.29, 4.12-17
elderly, 9.56
ep idemiology,4.4, 4.10
fentanyl (Sublimaze ®), 4.30, 8.50
genes, 2.39
harm reduction (See harm
reduction)
hea lt hcare costs, 4.43, 4.45
his tory, 1.3, 1.7, 1.10, 1.14, 1.17,
1.19-1.20, 1.25, 1.27,
1.28, 1.29, 1.31, 1.32,
1.34, 4. 7-12
iden tifying effects, 4.15-16
immune system, 8.44
initial and long- term abs tinence,
9.42
medical treatmen t stra tegies,
9.67-69
medica tion thera py, 9.20
me thadone, 1.28-1.29, 4.28-29,
9.42--43
me thods of u se, 4.9-10
na loxone, 4.30, 4.32, 9.42, 9.43,
9.67
needle use, 1.17, 2.4-5, 4., 4.9, 4.1
off-label me d icat ions, 9.66, 9.69
op ium extrac ti on, 4.6
overdose, 4.18
oxycodone, 4.16
pain, 4.12-13, 4.14-15
patent medicines, 1.21, 1.2 1-1.22,
3. 7, 3.10, 3.56, 4.9-10,
4.15
pep tides, 2.22
pharmacology, 4.3, 4.6, 4.7,
4.12-17
pleasure, 4.10, 4.12, 4.12, 4.14,
4.14-15, 4.15, 4.16, 4.21,
4.42
poly drug use, 4.1, 4.20-21
poppy opium, 1.9, 1.10, 1.30, 1.31
pregnancy, 8.21, 8.23-24, 8.62
prescri p tion opio ids, 4 .22-29
rapid opio id detoxifica tion, 4.33,
9.67
receptors, 2.22, 2.27, 4.13
recovery, 9.42
rep lacemen t thera p ies, 9.42-43,
9.67
sex, 8.39
sid e effects of, 4.15-17
smoking, 1.20, 4.8
snor ting, 4.10, 4.2 1
sports, 7.13-14
stree t names, 4.6
su bstance "P," 2.21, 2.22, 2.24,
2.25, 4.13
test ing, 8.52, 8.54
tissue d epen dence, 4.1, 4. 16-17,
4.18, 4.22, 4.29. See also
tissue d ependence
tolerance, 2.26, 2.27, 4.19,
4.24-25, 7.14
trade names, 4. 7
treatment, 9.36, 9.37, 9.41-43,
9.66. See also methadone
treatment admissions, 9.16
ultra-rapi d opioid detox ificati on,
9.67
w ithdrawa l, 4.17
op ioi d agon ists, 10 .26
op ioi d analgesics an d the eld erly, 8.55
op ioi d pept ides, 2.2 1, 2.22
opioi d recepto rs, 2.22, 2.27,
4.12-14, 9.50
op ium (laudanum, Pantopon, ®
Paregoric ®), 1.9, 1.10, 1.30,
1.3 1, 4.6-7. See also op iates/
opioids; paregoric
Opium Exclusion Act, 1.20, 4.2, 4.6-8
op ium po ppy, 1.9, 1.10, 1.30, 1.31,
4.2, 4.6, 4.8
Opium Wars, 1.20, 4.8
opportunis tic in fec tions, 8.46
OPRK., 2.39
Op timil. ® See methaqua lone
ora l cancer, 3.50
ora l inges tion, 2.4. See also inges tion
Oranabol. ® See oxymesterone
"orange an d p ink wedges," 6.4
"orange sunsh ine," 6.5
Orap. ® See pimozi d e
orb itofron tal cortex, 2.13, 7.31
Oregon, 6.11, 6.38, 8.15, 9.50
Oreton Propionate. ® See tes tosterone
propionate
organic so lvents. See volat ile solvents
organized crime, 8.4, 8.8
orgasm. See SEX and DRUGS
Orlam. ® See LAAM
orlista t (Xenica l®), 9.52
orn ith ine (amino acid), 7.25
O'Shaughnesy, William, 6.38
Osiris, 1.9
Oslo, Unive rsity of, 3.30
os teop orosis, 7.50
OTC (ove r-the-coun ter) drugs,
8.16-17, 8.24-25
OTHER ADDICTIONS (compu lsive
behaviors), 7.30-42
OTHER DRUGS (inha lants, sports
drugs, etc.), 7.2-29
Ottawa Prenata l Prospective
Study, 8.24
ou tcome and follow-up for
treatment, 9.25-26
"outfits," 8.42
ou tpatien t drug-free programs, 9.14
ou tpatie n t trea tmen t , 9.14, 9.44
men tal hea lth, 10.1, 10.8, 10.12,
10.18, 10.33
ou treach workers and AIDS, 8.45
OVERDOSE, 4.18, 8.23, 8.45
alcoho l, 5.14, 9.3
an tid ep ressan t, 10.26
barbitura tes, 1.27, 4.41-43
benzo diazepines, 1.28, 9.44
caffeine, 3.39
celebri ty deaths, 1.29, 4.1, 4.4,
4.38, 4.22, 4.43
chewed p atches, 2.4
coca ine, 3.15, 3.16, 3.19, 3
crack cocaine, 3.19
dextrome thorphan, 6.24
injection method, 2.4, 4.23
khat, 3.33
MDPV, 3.35
MDMA, MDA, 6.15-18
Me thadone, 1.37, 4.21
mortality rat es, 9.3
opio ids and heroin, 1.19-20,
1.32, 1.39, 2.20, 4.4-5,
4.18,4.21-22, 4.24
protracted wi thd rawal, 2.30, 2.31
respiratory system, 2.15, 2.28,
4.21, 4.25, 4.29
sedative-hypnotics, 4.37 9.44
tobacco, 3.51
vo latile n itrites, 7 .9
Overea ters Anonymous (OA), 7.31,
7.53, 9.29, 9.51, 9.52
ove r-the-counte r (OTC) drugs,
1.21-122, 1.23, 1.27,
1.37, 4.2-3
adverse reac tions, 4.2-3
cost, 4.1, 4.40
dep ressants, 4.3
elderly, 8.55, 8.56, 8.57
in terac tions, 4 .39
p regnancy, 8.23-24
psychedelics, 6.21
sleep-aids, 4.3-4
stimulants, 3.4, 3.31-32, 3.35,
3.58, 3.58
ove r-the-counte r (OTC) me dications
elderly, 9 .56
treatment admiss ions, 9.16
"Owsley's," 6.5
Oxandrin. ® See oxan dro lone
oxazepam (Serax®), 4.6, 10.30
oxca rbazepine (Trilepta l®), 10.27,
10.30, 10.33
"oxies" (oxycodone), 4.6
"oxy" (oxyco done), 4.6
"oxy-80s" (oxycodone), 4.6

oxycodone (Combunox, ®
Endocodone, ® En dodan, ®
OxyContin, ® Oxydose, ®
Oxyfast, ® Perco dan, ®
Percocet, ® Percolone, ®
Tylox• ), 4.2, 4.3, 4.5, 4.6,
4.27 - 28, 6.16
drug testing, 8.52
eld er ly, 8.56
pregnancy, 8.23
side effects, 4 .31
OxyContin. ® See oxycodone
"oxycot ton," 4.6. See also oxycodone
Oxy d ose. ® See oxyco d one
Oxyfast. ® See oxycodone
oxymorphone ( Op ana, ®
Numorphan ®), 4.7
oxytocin, 8.24, 9.36
"ozone" (PCP), 6.4, 6.21
p Par ke Davis Pharmaceut icals,
P3 brain wave. See P300 brain wave
P300 brain wave, 2.40, 5.16
Pacific Islanders. See Asians and
Pa cific Islanders
packaged clinical protocols, 9.69
painkillers. See pain relief
Pain Patien t's Bill of Rights, 4.15
pain relief, 1.37- 1.38, 2.30.
See also opia tes/opioids
age of first u se, 8.18
alcohol, 5.12
Cannabis, l.ll, 4.44-45
henbane, 1.13
hyperalgesia, 1.37
neurophysiology, 4.12 - 15
opia tes/opioids, 1.13, 1.14, 1.19,
1.20, 1.22, 1.27, 1.32,
4.4, 4.8, 4.13
physical disabili ties, 9.62
sports, 7.13-15, 7.24
paint (inha lant), 7.4, 7.5, 7.7-8
pain threshol d , 9 .58
Pakistan, 4.10- 11, 6.29, 6.31, 8.8
paliperidone (Invega ®), 10.28,
10.29, 10.30
Palladone. ® See hydromorphone
Pall Mall ,• 3.4
Pama te.® See tranylcypromine
Pamelo r.® See nortripty line
Panama
mari j uana, 6.28, 6.41
"Panama Red " (marijuana), 6.28
Panax wuinq u efolium (ginseng),
1.36, 3.37, 3.38, 9.37
pancreatitis, 5.18, 5.20
panic attacks and p anic d isord er, 10.6,
10.13, 10.16, 10.18, 10.20,
10.21, 10.24 10.29, 10.30,
10.31, 10.32, 10.33
alcohol, 5.27
be ta blockers and other drugs,
7.22
caffeine, 3.42
drug -induced, 10.21
dual diagnosis, 10.6, 10 .16-18,
10.20, 10.31, 10,32, 10.33
gambling, 7.38
psychiatric me dications, 10.24,
10.26, 10.30, 10.31,
10.32, 10.33
treatment, 10.24, 10.26, 10.29,
10.30, 10.31, 10.32, 10.33
panic focus, 10.20
Pantopon. ® See op ium
Papaver somniferum (opi um poppy),
4.6. See also opiates/o p ioi ds;
poppy opi um
Paracelsus, 1.17, 1.19, 2.25, 4.8
Parafon Forte. ® See chlo rzoxazone
Paral. ® See paral dehyde
paraldehyde (Para! • ), 4.3, 4.30, 4.31,
4.44, 9.45
paramethoxyamphetamine (PMA), 6.4
paranoia, 3.6, 3.11 - 12, 3.28, 3.35
9.38, 10.14, 10.18, 10.21,
10.23, 10.27, 10.32, 10.33
alcoho l, 5.19
amphetamines and coca ine, 3.6,
3.7, 3.11 - 12, 3.1- 16,
3.19, 3.28, 10.27
LSD, 6.9, 9.46---47
marijuana, 6.35, 3.39, 10.21
stero ids, 7.18, 10.14
paranoi d psychosis, 3.15, 3.28, 10.14
parasympathe tic nervous system, 2.9
paregoric (opiu m), 4 .6, 4.7-8, 8.23
Pares t.® See metha qualone
3.10, 3.34
Par ki nson's dis ease, 2.21, 4.2, 4 .31,
7.43, 8.40, 10.28, 10.29
Parlo del. ® See bromocrip tine
Parnate. ® See tranylcypromine
paroxetine (Paxil ®), 8.40, 9.39,
9.52, 9.68, 10.25, 10.26,
10.29, 10.30, 10.31.
See also se lective sero to n in
reuptake inhibitors
partial agonists, 2.24
partial de tox clinics, 9.15
partial fetal alcohol syn drome (PFAS),
5.27. See also fetal alcohol
syndrome
Partne rsh ip For a Drug -Free
America, 8.3 1
party. See rave events (raves)
passion flower (Passiflora incarnate),
9.37
passive smoking. See secon d hand
smoking
passive transport, 2.6
"pasta " (freebase cocaine with
marijuana), 3.3, 3.17
"paste" (freebase cocaine), 3.7,
3.17- 18
Pasteur, Louis, 5.6
patente d me d ical protocols, 9.69
patent me d icines, 1.21, 1.2 1- 1.22,
3.6, 3.10, 3.18, 4.8-9, 6.44
p aternal dri nking, 5.31
pathological gambling, 1.8, 1.41 ,
7.30, 7.32, 7.36---40,7.42,
10.3, 10.18
Asian Americans, 9.61
classification, 2.35
defined, 7.34
PAWS. See post-acute wi thdrawal
syndrome
Paxil. ® See p aroxetine
Paxipam. ® See halazepam
PBIS. See Positive Behavioral
Interventions an d Sup ports
PCP (phencycl idine hydroch lori de;
Sernyl • ), 3.19, 4 .33,6.21 - 22,
7.9, 7.27, 9.46, 10.14, 10.17,
10.29
age of first use, 8.18
bad trips, 9.47
drug testing, 8.50, 8.52
marijuana, 2.33
physical effects, 6.21
treatment admissions, 9.16
PDYN, 2.39
"peace pill" (STP and PCP), 6.4
"peanut butt er meth"
( dextrometham p hetam in e),
3.3, 3.22
"p early ga tes," 6.4
pedemon tana, 6.25
pedophilia, 7.56
"peep" (PCP), 6.4
peer groups, 9.28, 9.30, 9.50, 9.52,
9.62. See also 12-ste p
programs
behavioral addictions, 9.49
targeted popu lations, 9.62
young people, 8.11, 9.56
peer pressure, 8.30, 8.31
"pellets " (methylphenidate), 3.3
p elvic inflamma tory disease (PI O),
8.42
pemoline (Cylen • ), 3.3, 3.30,
3.32, 9.67
pentazocine (Fortwin, ® Talacen, ®
Talwin NX®), 4. 7, 4.28, 4.43
pentobarbi tal (Nembutal ®), 4.34,
4.36, 8.53
Pen tothal. ® See th iopental sod ium
pentoxifylline (Trental ®), 9.69
P en-tsao (her bal encycloped ia), 1.11
Pe p cid, ® 5.44
Pepper, Bert, 10.23
"pe p pills" (d,l amphetamine), 3.3
Pepsi, ® 3.4, 3.37
pe pt ides, 2.21, 2.22
perception of reality, 6.2
Percocet. ® See oxycodone
P ercodan, ®4.37. See also oxycodone
"percs" (oxycodone), 4.6
performance-enhancing drugs and
techn iques, 1.4, 1.27, 1.31,
1.38, 1.39, 7.15- 26. See also
steroi ds; entries for spe cific
drugs an d drug categories
amphe tamines, 7.20
anabolic-an d rogenic stero ids,
7.17- 20
andros tene di one, 7 .22
beta blockers, 7.22 - 3
blood doping, 7.23
caffeine, 7.21
DHEA, 7.22
ephedrine, 7.21 - 22
EPO, 7.23
GHB, 7.24
he rb al products, 7 .24
H GH, 7.20-21
miscellaneous drugs and
techniques, 7.25
soda doping, 7.24
stimulants, 7.21
weight loss, 7.24-25
pergolide, 9.66, 9.68
Pe riac tin. ® See cyproheptadine
perina tal, 8.19, 8.21
peripheral nervous system, 2.8, 2.45
acupuncture, 9.36
alcohol, 5.15, 5.18
ni trous ox ide, 7.9
Permax. ® See pergolide
P ermi til. ® See fluphenazine
peroxetine (Paxil ®), 2.21
perpetrator of vio lence, 5.31 - 33
perphenaz ine (Trilafon, ® Etrafon ®),
10.30
pe rsecu tion. See parano ia
pe rsonality disorde rs (antisocial,
borderline), 5.28, 10.6,
10.13, 10.14, 10.18, 10.33
compu lsive behaviors, 7.18,
7.30--60
co -occurring disorders and, 10.6,
10.13, 10.14, 10.18, 10.33
INDEX 1.25
inhalants, 7 .2
steroids, 7.18, 7.11
Pertofrane. ® See d esipramine
Peru, 1.7, 1.8, 1.11, 1.12, 1.15, 1.32,
3.7- 9, 6.12
Pervitin. ® See methamphetamine HCL
"Pe rze" (heroin), 4. 7
PESQ (Personal Experience
Questionnaire), 9.12
"pestillos" (smokable coca in e), 3.3
Pethi di ne .® See meperidine
PET (positron em iss ion tomography)
scan, 2.14, 2.22, 2.42, 2.42,
3.6, 3.12, 3.33, 3.40, 7.46,
I
9.3, 9.4, 9.22
eating disorders, 7.45
neurotransmitters, 2.22
pet therapy, 9 .3 7
peyote (mescaline), 1.3, 1.11, 1.28,
2.20, 6.1, 6.4, 6.13- 15,
8.40, 10.2, 10.14.
See also mescaline
peyotl. See peyote
pharmaceutical industry
marketing, 7.28
new drug d evelopment, 4.35, 4.37,
4.45 9.52 - 53, 9.69 - 70
pharmacodynamic tolerance, 2.24,
2.27, 4.37, 5.24, 5.25, 6.34
pharmacogenomics, 10.22
pharmacokinetics, 2.2, 2.46
pharmacology. See also
psychopharmacology
benzodiazepines, 4 .38
caffeine, 3.41
Cannabis, 6.33-35
harm reduction, 9 .15
nicotine, 3.46
obesity, 9.52 - 53
opiates/opioids, 4 .3, 4 .6, 4.7,
4.12 - 17
pathological gambling, 9 .50
psilocybin, 6.10
psychiatric me dications, 10.24-26,
10.29- 31
smokab le cocaine, 3.17 - 18
treatment medica tions, 9 .65-70
pharmacotherapy, 9.44
food interactions, 9.38-39
initial abs tinence, 9 .38-39
marijuana depen d ence, 9.48
stimulants, 9.38-39
"pharm parties," 4 .2, 4.41
Phelps, Michael, 7.25
Phenazine .® See phen termine resin
phencyclidine hydrochloride . See PCP
phendimetrazine (Ad ip ost ,® Prelu-2, ®
Preludin, ® Bon tril ®), 3.3
phenelzine (Nardil ®), 10.24,
10.26, 10.30
phenethylamine, 6.4, 6.15 - 19
bromo -dragonFLY, 6.21
phenethylline. See fenethylline
phenobarbital (Lum inal ®), 1.27, 4.2,
4.34-35, 4.41, 9.66
detox ification, 4.18, 8.26,
9.20, 9.39
testing, 8.5 4
"phenos" (phenobarbital), 4.36
phenothiazines, 9.4 5, 10.28,
10.30, 10.34
phentermine H CL (Adipex, ®
Banobese, ® Fastin, ® Obenix, ®
Zantril ®), 3.3, 3.31, 9.52
phentermine resin (Bontril, ®
Ionam in ,® Phenazine ®),
3.3, 9.52
phenylalanine (d ,1-phenylalanine),
9.21, 9.36, 9.39, 9.68
 1.26 INDEX

phenylalky lamine psychedelics.
See MOMA; peyote
phenylbutazone (Butazo lidin ®), 7.16.
See also nonsteroidal
anti -inflammatory drugs
phenylephrine, 3.4
phenylpropanolam ine (Accutrim, ®
Dexatrim ®), 3.4, 3.24, 3.32,
3.35, 3.37. See also lookalikes
phenytoin (Dilantin ®), 8.24, 8.25,
9.44, 9.67, 9.68
pheromones, 8.40
Philip Morris, 3.47
Philippines, 3.22- 23, 3.55, 6.3 1, 7.5
psychoactive drugs, 2.5, 8.20
tobacco, 8.25
placenta l separation, 3.13, 3.28, 3.54,
4.18, 4.26
Placidyl. ® See ethchlorvyno l
plant food, 3.4, 3.34, 8.11, 8.10, 8.39
plant stimulants (miscellaneous),
3.4, 3.33. See also caffeine;
cocaine; psychoactive plants;
tobacco; entries for specific
plants
arecoline (areca, betel nut ) , 3.4,
3.35-6
cath inone, cathine (khat bush),
"pos itive reward/reinforcement action dive rsion, 4.1 , 4.5, 4 .5, 4 .10,
of drugs, " 2.1 4.25, 4.26
positron emission tomography. elderly, 8.56, 8.56, 9.56
See PET scan as epidemic, 4.3
post -acute withdrawal syndrome healthcare costs, 4.44-45
(PAWS), 2.12, 2.31, 4.17, marketing, 8 .15
4.20,4.42, 9.23, 9.45 military personnel, 8.49
post.synaptic neuron, 2.19, 2.20 opioids, 4.3, 8.23, 8.27, 8.45, 8.54
LSD flashback, 6.10 pharmaceutical industry and,
medications, 10.30 4.44--45
potass ium ions, 2.23 physical disabilities, 9.62-63
potency of marijuana, 1.34, 6.38, pregnancy, 8.23
10.20. See also sinsemilla psychiatric medications, 10.29,
powde r cocaine, 8.9 10.30, 10.31

I
philosopher 's stone (plant), 6.14
phosphorus, 3.23, 3.24
PhRMA, 4.40
physical dependence.
See tissue dependence
physical disabilities, 9.62-63
physicians
diagnosis of addiction, 9 .17
office -based treatment, 9.14, 9.43
older patients, 8.56
PHYSIOLOGY. See also
brain; metabo lism;
neurotransmit ters; tissue
dependence; tolerance;
withdrawal
aging, 8.55
blood -brain barrier, 2.6-7
circulation, 2.8, 2.46
cross -tolerance , 2.28, 7.11
drug distribution, 2.4-8
metabolism, 2.6, 2.6-8
nervous system, 2.8-25, 2.45-46
neuroanatomy, 2. 18, 2.18-20,
2.42, 2.46
neuro tr ansmitte rs, 2.20, 2.20-26,
10.2, 10.4, 10.24, 10.25, 10.26,
10.28, 10.29, 10.31, 10.33
pharmacokinetics, 2.2
psychological dependence, 2.26,
2.28-29, 2.30, 2.37, 2.46
regulation, 2.22
responses to drugs, 2.26--31
routes of administ ration, 2.2-4,
2. 4 . See also methods
of use
susceptibility to addict ion, 8. 7
tissue dependence, 2.26, 2.28,
2.29, 2.30, 2.31, 2.37,
2.46
to lerance, 2.37
withdrawal, 2.37. See also
withdrawal
PIO (pelvic inflammatory disease),
8.60
Pilgrims. See colon ial America
Pills Anonymous, 9.44
pilsner, 5.5, 5.8
pimozide (Orap ®) , 10.30
"pinang " (be tel nut), 3.4
pinazepam (Dama r®), 4.31
pindolol (Visken ®) , 10.30
"pink hearts, " (phendimetraz ine), 3.3
"pink wedges " (STP/LSD), 6.4
pinpoint pupils. See under pupil size
piperacetazine (Quide ®) , 10.30
piperazines, 10.30
Pipe r methysticum (kava), 7.28
pipes. See also smoking
pipe tobacco, 3.4, 3.41, 3.42, 3.43,
3.59. See also tobacco
piracetam (Nootropil ®) , 7.30, 9.69
pituitary peptide, 2.22
placebo, 7.29, 9.46, 9.50, 9.68, 9.70
placental barrier, 2.5, 2.45, 8.20, 8.25
alcohol, 5.8
opioids, 4 .21
3.4, 3.33-35
ephedra, 3.4, 3.36-37
khat, 3.33-34
methcath inone (synthetic),
3.4, 3.33
yohimbe, 3.36
plaque, 3.52, 5.11
plasticity. See synaptic plas tici ty
Plato, 1.6, 1.10, 1.27, 2.18
PlayersOnly, 7.55
PMA (paramethoxyamphetam
6.4, 6.16, 6.19- 20
pneumocystis carinii pneumonia, 8.45
Pocahontas, 1.18
Poe, Edgar Allen, 4.9
"points, " 8.44
poker machines, 1.2, 1.8, 2.29, 2.42,
7.31, 7.32, 7.35, 7.37, 7.39,
9.49, 9.50, 10.18
politics. See also geopolitics;
government; laws and
regulations; taxes on drugs
drug laws, 4.8, 4.10,4.40
pharmaceutical costs, 4.41
POLYDRUG USE and ABUSE
with alcohol, 5.27
with amphetamines and cocaine,
3.6, 3.15-16, 3.19
cross -tolerance and cross
dependence, 4.40
drug metabolism, 2.6---8
gambling, 7.37
genes, 2.26, 2.36-40, 2.46-47
GHB, 8.38
heroin, 4.20-21
inha lants, 7.2, 7.4, 9.49
marijuana, 6.43
with MDMA, 6.17 - 18, 8.40---41
muscle relaxants, 7.15 - 16
opioids, 4.21 - 22, 4.25
reasons for, 5 .25
sedative -hypnotics, 4.22,
4.44, 9.44
sports, 7.15, 7.20
synergism, 2.8, 4.39--40
treatment, 9.38
Polynesia, 3.45
Pondimin. ® See fenfluramine
pons, 2.9
pontikka, 5.33
"popcorn coke" (pemo line ) , 3.3
"poppers " (volatile n itri tes), 7.3, 7.9
poppy opium, 1.9, 1.10, 1.30, 1.31,
4.2, 4.6-7
poppy seeds, 8.50, 8.52
poppy straw, 4.6
population subgroups, and alcoho l,
5.37--42
pornography, 7.32 7.33, 7.55, 7.56
porter, 5.5
Portugal, 6.36
trade, 1.15, 1.20
Positive Behavioral Interventions
and Supports (PBIS)
method, 8.33
PPA. See phenylpropanolamine
practice -based interventions,
9.4 - 5. See also Alcoho lics
Anonymous; Narcotics
Anonymous; 12-step
programs
Pravaz, Charles Gabriel, 1.20
prazepam ( Cent rax, ® Lysanx ia®),
4.36, 10.29, 10.30
prazosin (M in ipress ®), 10.30
ine), Precepts of Ani, 1.9
precontemplation stage, 9.27
precursors, 8.9. See also GBL
amphetamines, 1.24, 1.42,
3.23, 3.24
to GHB, 4.5
laws, 1.24, 1.27, 8.09, 8.10
load ing, 9.35, 9.68
smuggling and, 3.21, 4.5
steroids, 7.22
predic tors of drug use, 9 .55
alcoho l, 5.21- 22, 5.39--42
pred isposition to addiction, 2.26.
See also env ironment;
heredity
alcoholism, 2.38, 5.21 - 22
compulsive behavio rs, 7.32, 9.49
prednisone (corticosteroid), 4.23,
7.17, 10.29
pre -existing mental illness, 6.39,10.2,
10.6 10.7, 10.8, 10.11, 10.13,
10.18, 10.21, 10.28, 10.32.
See also bipolar affective
disorder; major depress ive
disorder; thought disorder
prefrontal cortex, 2.13, 2.16--17, 2.46,
3.5, 3.14,5.35, 6.5, 8.13,
9.56, 9.64
pregabalin (Lyrica• ), 4 .3, 4.31, 4.31,
4.32, 4.37, 4.44, 8.39, 10.29
PREGNANCY, 5.1, 8.18-27. See also
placental barrier
abruptio placenta, 8.22, 8.23
acceptance of problem, 9 .18
AIDS and HIV, 8.20, 8.23
alcohol, 5.28-31, 8.21 - 22
prehistory, 1.8-1.19
Prelu -2. ® See phendimetrazine
Preludin. ® See phendimet razine
premature births, 8.22
prenata l care, 8.9, 8.20, 8.26, 8.58.
See also pregnancy
prescribing practices, 4 .43
children, 4.2
iatrogenic addict ion, 4.4, 4.9, 4.16
inappropriate, 4.4, 4.5
opioids, 4.5, 4.12- 13, 22- 23, 4.36
pain control, 4.22 - 23, 4.43
pharmacists and, 4 .5
prescript ion drugs, 1.21 - 22,
1.28, 1.32, 8.24 4.21.
See also opiates/opioids;
psychopharmacology;
sedat ive-hypnotics
abuse, 1.32, 1.37, 8.56
alcoho l, 5.36
sedative -hypnot ics, 4.2, 4.33 - 34
state monitoring, 8 .10
workplace drug use, 8.4 7
Presley, Elvis, 4 .41
presynaptic neuron, 2.20, 2.22, 2.24,
9.69, 10.24
prevention, 8.26--27
PREVENTION, 1.29- 1.30.
See also harm reduct ion;
laws and regulations
adolescents, 8.30-32
AIDS and HIV, 8.45--46
alcohol, 5.26, 5.34, 5.41, 8.3-7,
8.11, 8.21, 8.26-28,
8.30 - 34, 8.49
alcohol -related fatalities, 5.32
Amethyst Initiative, 8.4
approaches to, 8.2 - 3
bleach distribution, 8.14
challenges, 8.15-16, 8.50
college, 8.32- 33
competency building, 8.6
concepts of, 8.3-8, 8.61
coping skills, 8.6, 8.11, 8.12
costs, 8.4, 8.11, 8.46 (See also
costs of abuse)
as cradle -to-grave effort, 8.60
demand reduction, 1.6, 1.7, 1.27,
1.29, 8.11 - 14
disagreement about drugs and
drug policy 8.58
drug dive rsion programs (drug
courts),1.24, 1.31, 1.42,
8.12, 8.13, 9.5, 9.64
drug information programs, 8.5-6
drug testing, 8.49 - 54
education, 8.4-5, 8.10-11,
8.12, 8.33
effect iveness, 8.27, 8.27 - 28, 8 .32,
8.45, 8.48
elderly, 8.58-59
emotional matura tion, 9.55
env ironment, 8. 7
ethnic considerations, 9.1,
9.57-62
evidence -based practices, 8.30-31
family approach, 8.7, 8.12 - 13,
9.32 - 35
funding, 8.16
goals of, 8.2
harm reduction, 1,29, 8.15 - 16,
9.6, 9.15, 9.23, 9.67
high school, 8.5-6, 8.28-31 ,
8.31 - 32
history, 1.6, 1.24, 1.27, 1.29, 1.35,
1.36, 8.3- 7
impediments to, 8 .59
indica ted, 8.11
inhalants, 7.11
legal drugs, 8.15-16
long -term programs, 8.2
medicat ion to prevent relapse, 8.2,
9.67-68
methadone maintenance,
1.28-1.29, 4.17, 4.20,
4.25 - 26, 4.27, 4.28, 8.15

methods, 8.2- 3, 8. 7- 15
military programs, 8.50
needle exchange, 4.23, 8.14,
8.45, 9.6
normative assessment, 8.12,
8.33-34
pace of change, 8.16
pregnancy, 8.26-27
prescription drugs, 4.45
primary, 8.11- 12
principles of prevention, 8.12
prisons. See drug courts; prisons
and jails
programs for youth, 8.30-32
prohibition, 4.8, 4.10, 8.4-5
promising approaches in, 8.58
protective factors, 8.6, 8.12
public health model, 8. 7
relapse, 9.22 - 26, 9.48, 10.9, 10.11,
10.12, 10.22, 10.23
relapse prevention, 8.14
resiliency programs, 8.6-7
risk factors, 4.37, 8.6, 8.7,
8.11 - 13, 8.30
safe sex, 8.28, 8.34
scare tactics, 8.5-6
school -based programs, 8.30- 32
secondary; 8.13
selective, 8.12
self -esteem, 8.30
skill -building programs, 8.6-7
STDs, 8.35
strategies, 8.2
supply reduction, 1.6, 1.29, 1.42,
8.2, 8.3, 8.7- 11
support systems, 8.6, 8.7, 8.13,
8.31 - 32
target groups, 8.15
temperance, 1.10, 1.14, 1.15, 1.21,
1.23, 5.4, 8.3, 8.3-4
tertiary, 8.2, 8.13 - 14, 8.30,
8.32, 8.34, 8.49.
See also treatment
tobacco laws and regulations,
1.46-1.47
tobacco and smoking, 3.50, 3.58
treatment, 9.40
universal, 8.12
war on drugs, 8.15
youth, 8.30-32
Priestly,Joseph, 1.19, 7.9
Primagen, ® 7.24
primal brain. See old brain
primary alcoholics, 5.20
primary prevention, 8.2, 8.30 - 32,
8.34, 8.49
primitive brain. See old brain
"primo" (freebase cocaine), 3.3,
3.19, 9.24
Primobolan Depot. ® See methenolone
enanthate
Principles of Drug -Abuse Treatment
for CJS Populations, 9.9
Principles of Prevention, 8.11,
8.12, 8.13
prisons and jails
adolescents, 8.28
alcohol and, 5.32, 5.33
alcohol programs, 9.46
costs of imprisonment vs.
treatment, 9.8, 9. 70
drug abuse within, 6.21, 9.17
drug -related incarcerations, 3.20,
3.22, 8.10, 8.11
drugs abused in, 6.21
drug use by arrestees, 3.20, 3.22,
9.8, 9.10
marijuana and, 6.25, 6.36-37
mental health, 10.2, 10.6
narcotics violations, 4.10
NIDA principles for treatment in,
9.9- 10
psychedelics, 6.21
secondary prevention, 8.12 - 13
sentences, 8.9
testing, 9 .10
trafficking offenses, 6.14, 6.36-37
treatment, 9.5, 9.8, 9.9 - 10, 9.13,
9.15, 9.46, 9.65, 9.70
problem drinking, 5.32, 5.37, 5.41 ,
9 .12. See also drunk driving
problem gambling, 7.36-38, See also
gambling, compulsive
procaine, 3.11, 3.16, 3.32, 8.42
Procardia. ® See nifedipine
prochlorperazine ( Compazine ®) ,
10.27, 10.33
prodrug, 2.6, 3.3, 3.23, 4.34, 4.39
professional gamblers, 7.37
Prohibition era (U.S.) , 1.7, 1.9, 1.14,
1.15, 1.18, 1.21, 1.23, 1.25,
5.4- 5, 8.5, 8.61, 9.28
prohibition vs. temperance, 1. 7, 8.3-4
alcohol, 5.45
opiates, 4.8, 4 .10
tobacco, 1.16
project success, 8. 7
Project Towards No Drug Abuse, 8.30
prolactin, 9.36
Prolixin .® See fluphenazine
Frometa ®protocol, 9.69
promethazine, 9.42
Pronoctan. ® See lormetazepam
proof, 5.8
Propacet. ® See propoxyphene
propane, 7.4, 7.5, 7.7, 7.8
propanol alcohol. See isopropyl
alcohol
propofol (Diprovan, ® anesthetic), 4.3,
7.2, 7.9, 9.66
propoxyphene (Darvon, ® Darvocet
N,® Propacet, ®Wygesic ®) ,
2.28, 7.15, 8.54, 8.57, 9.42
propranolol (Inderal ®) , 7.22, 9.41,
10.30, 10.31
propyl alcohol. See isopropyl alcohol
ProSom. ® See estazolam
prospective memory, 5.21
Prostep, ® 9.40
protease inhibitors, 8.45-46
protective factors, 8.7, 8 .13, 8.30
protracted withdrawal, 2.30, 2.31,
4.20, 4.40, 4.42. See also
environmental triggers
Provigil (modafinil), 3.3, 7.25, 9.39
Proviron. ® See mesterolone
Prozac .® See fluoxetine
pseudoephedrine (antihistamine),
1.31, 1.36, 3.21, 3.25, 3.32,
3.34, 3.36, 7.20
meth manufacture, 3.23, 3.24
psilocybin (ingredient ) , 6.3-11
psilocin (ingredient), 6.11 - 12
Psilocybe cubensis, 1.11, 1.12
Psilocybe ( "magic ") mushrooms,
I.II, 1.12, 6.3- 12
history, l.ll - 1.12, 1.28, 6.9- 10
mental health, 10.15
sex, 8.41
psoriasis, 5 .19
psychedelic mushrooms.
See mushrooms
PSYCHEDELICS (ALL-AROUNDERS),
See also LSD; marijuana
active ingredients, 6.4
Amanita mushrooms, 1.11 - 1.12
bad trips, 9.46-47
cannabinoids, 5.37, 8.52
chemical structure, 6.10, 6.12
classification, 1.3-1.4, 6.1, 6.3, 6.4
dmx4.33
drug testing, 8.52
epidemiology, 9.46, 9.46
flashbacks, 2.12, 2.30, 6.10,10.5
history, 1.10-11, 1.11- 13, 1.26,
1.28, 1.33-1.34
HPPD, 6.10
ketamine, 4.38, 6.21- 22, 9.46, 9.47
legality, 6.3, 6.7, 6.18, 6.20, 6.21,
6.24, 6.25, 6.26, 6.29,
6.37 - 38
LSD, 1.3, 1.13, 1.28, 4.33, 6.6-10,
9.46, 9.47
marijuana, 1.10-11, 1.24, 1.25-
1.26, 1.30, 1.33, 1.34,
1.35, 6.25-46
MDA, 2.20, 3.2, 3.22
MDE,3.2
MOMA, 2.20, 3.21, 3.37, 4.38,
6.15- 19, 9.46, 9.47
mental effects, 1.3-1.4
mental health, 10.2, 10.5, 10.14,
10.15, 10.16
mescaline (peyote ) , 1,3, 1.11,
6.13 - 15,10.2, 10.14
mushrooms, 1.11 - 1.12, 6.4, 6 .10-
6 .11 (See also Amanita
mushrooms; Psilocybe
mushrooms)
PCP, 2.20, 4.33
peyote, 1.11, 1.24, 2.20, 2.44, 10.14
physical effects, 1.37
psilocybin, l.ll - l.12, 8.39, 8.50,
10.14
psychiatric disorders and, 10.2,
10.5, 10.14, 10.15, 10.16
schizophrenia, 9.46
street names, 6. 4
toad secretions, 7.28, 7.29
tolerance, 9.4 7
treatment, 9.46-47
treatment admissions, 9 .16
usage trends, 6.2
psychiatric disorders. See also mental
health and drugs
pre -existing disorders,10.2,
10.6---8,10.11, 10.13,
10.18, 10.21, 10.28, 10.32
substance -induced disorders,
10.7-8, 10.11, 10.14,
10.18
treatment, 10 .18-31
psychiatric medications, 1.27- 1.28,
4.35, 4.44, 10.29- 30.
See also psychopharmacology
ADHD, 3.2&-30
detoxification, 9.20
elderly, 8.55
neurotransmitters, street drugs,
mental illness and (table),
10.28, 10.29
by psychiatric conditions (table),
10.29-30
sex, 8.39
psychic conversion reaction, 2.30
psychoactive drugs. See also entries
for individual drugs and
categories of drugs
in ancient civilizations, 1.6-1.12
classification of, 1.1- 1.5
current impacts and trends,
1.30- 1.42
definition, 1.3-1.4
discovery of, 1.8-1.9
Enlightenment and, 1.17- 1.22
historical themes regarding,
1.7- 1.8
industrial revolution and,
1.17- 1.22
INDEX 1.27
Middle Ages and, 1.12- 1.14
natural counterparts, 2.20
prehistoric use, 1.8-1.9
Renaissance period, 1.14- 1.17
toxicity, 1.13-1.14
twentieth century developments,
1.22- 1.30
psycho-active drugs
illusions, 6.11, 6.12, 6.15
psychoactive plants, 1.8, 1.14.
See also ayahuasca;
belladonna; betel nut; coca
leaf; cocoa; coffee; ephedra;
ibogaine; kava; khat;
I
mace; magic mushrooms;
mandrake; marijuana;
morning glory; nutmeg;
opium; peyote; Salvia
divinorum; tea; tobacco;
yage; yohimbe
psychedelics, 6.4-5
stimulants, 3.32-45
psychodynamic psychotherapy, 9 .53
psychological dependence, 2.26,
2.2&-29, 2.30, 2.37, 2.46,
6.16, 7.11, 7.59
psychological inoculation, 8. 7
PSYCHOPHARMACOLOGY,
10.22- 24, 10.33.
See also entries for specific
drug classes and specific
generic drugs
ADHD, 3.29- 30
antidepressants, 4.16, 4 .18, 4.35,
4.40, 4.44, 9.39, 9.51,
9.68
antipsychotics, 4.2, 4.38, 8.41
anxiety disorders, 10.28, 10.29,
10.30, 10.31, 10.33
anxiety treatment, 9.44, 10.30
bipolar affective disorder, 8.40,
10.28, 10.29, 10.30
brain chemistry, 2.13, 2.16, 2.28,
2.36, 2.37, 2.38, 2.40,
2.41, 2.43, 2.45, 2.47
children and, 1.39
classification, 10.30
compliance, 10 .31
depression, 10.25-27, 10.29, 10.30
detoxification, 9.20-21, 9.36-37,
9.39, 9.42-43, 9.44, 9.45,
9.65-68
eating disorders, 9 .52
effects on neurotransmitters,
10.24 - 25
MAO inhibitors, 9.39
medications by illness (table),
10.30
medication therapy, 9.65-70
(See also methadone;
psychopharmacology)
neurotransmitters, street drugs,
and mental illness (table),
10.25 - 30
panic disorder drugs, 4.36-38,
4.42
prescribed vs. street drugs, 10.25,
10.29
psychoses, 10.20, 10.26, 10.33
sex, 8.35-41
SSRI (selective serotonin reuptake
inhibitor), 9.20,
10.25 - 26, 10.29-33
substance -abuse treatment, 10.24,
10.26, 10.27, 10.32
tertiary prevention, 8.13
tricyclic antidepressants, 8.40
psychosis, 1.40
alcoholic, 5.24, 5.20, 5.41, 8.3
amphetamine, 1.6, 3.11, 3.28, 3.31
 1.28 INDEX

cocaine, 1.6, 3.11, 3.15, 3. 19,10.4,
10.14, 10.19, 10.20, 10.26
co-occurring disorders, 10.6,
10.13, 10.29, 10.33
dopamine, 10.4
HIV, 10.13
marijuana, 6.39,10.21
stimu lant abuse, 1.6,10.6, 10.19,
10.20, 10.26, 10.33
substance-in duced, 3.6, 3.11, 3.15,
3.19, 3.28, 3.31, 3.36,
6.6, 10.6, 10.14, 10.20,
10.26, 10.33
psychosocia l therapy, 9.26
"railing," 4.18 alterna tive and complementary cocaine, 3.14
"rainbows" (Tuina l®), 4.6, 4.44 p rograms, 9.35-37 cognitive deficits, 9.23
Raleigh, Sir Walte r, 1.16 amphetamines, 9.38-40 co-occurring disorder, 5 .26
Ralgro. ® See Zeranol; zeranol anorexia, 9.51 eating d isorders, 9.52
ram elteon (Rozerem ®), 4.42, cogni tive impairment, 9.64 env ironmen tal triggers, 2.30, 8.33
8.39, 10.30 cognit ive skills, 9.64 (See also environment)
random testing, 8.33, 8.49, 8.51, compulsive gambling, 7.39, gambling, 9.49, 9.50
8.52, 8.64 7.41--43 long-term memory, 9.46
rape, 5.19, 5.31, 7.26, 7.56, 8.34, dua l diagnosis, 10.10, 10.11, methamphetamines, 9.4
8.36, 8.42, 9.53. See also date 10.23, 10.25 nicotine, 3.45, 3.51, 9.40, 9.4 1
rape; sexual assault eating disorders, 9.50-53 opioids, 4.22, 9.41
rapid-eye-movemen t (REM) sleep, life-long process, 9.15, 9.46 PAWS, 2.31, 4.20, 9.23
5.11, 10.19, 10.20 manual-based process, 9.31 prevent ion, 8.13, 9.2 1-25, 10.11,
rapid opio id de toxification, 4.33, marij u ana, 9.48 10.13, 10.21, 10.23

I
detoxification, 9.21 9.42, 9.67 medical model, 9.14, 9.57 protracted withdrawal, 2.30, 2.31,
gambling, 9 .50 RAPS4 (Rap id Alcoho l Assessment medications, 9. 1, 9.4, 9.9, 4.20, 4.40
psycho-stimulants (d esigner Screen), 9.12 9.20-21, 9.39--40, slips, 9.22, 9.23, 9.26, 9.64, 9.69
psychedelics), 3.2, 6. 14--17. rasaqiline (Azilec t®), 10.28, 10.30 9.42--44, 9.46, 9.66-67 strategies for p revention of,
See also MDA; MOMA Rational Recovery (RR), 9.30-31 men vs. women, 9.55 9.24-26
drug testing, 8.52 "rave" (MDMA), 1.33-1.34, 6.4, 6. 19 methamphetamine, 8.46 triggers, 9.24
psychotherapy Ralgro See Zeranol; zemo l nicot ine ad d iction, 9.40 relationship addic tion, 7.56
ketam ine and, 6.22 ram elteon (Roze rem ) 4.42, 10.30 opioids, 9.41-43 rel igio u s/ri tua l use. See sp iritualit y
LSD in, 6.6, 6.9 random testing, 8.32, 8.47, 8.49-51 partial, 10.10, 10.32 Remeron. ® See m irtaza p ine
MOMA use in, 6.14 rapid-eye-movement (REM) sleep, phases, 9.19-26 Remforce ® ( GBL). See GBL
substance-abuse disorde rs, 10.23, 5.11, 10.19 psychosocial support, 9.25 Reminy l. ® See galantam ine
10.24, 10.25 rapid opioid de toxification, 4 .33, restrictive environmental REM (ra p id eye movement) sleep,
psychotic disorder, alcoh ol-induce d , 9.42, 9.67 stimu lation therapy 5.13, 10.19, 10.20
10.14, 10.19, 10.33 RAPS4 (Rap id Alcoho l Assessment (REST), 9.37 Rena issance, the, 1.14-1.17
psychotropic medica tions. Screen) 9.12 sedative-hypnotics, 9.44 ReNew, ® 9.36
See psychiatric medica tions rasquqiline (Azilect) 10.28, 10.30 sexua l addic tion, 9.53-54 "ren t part ies," 6.27
PTSD. See p osttraumatic stress Rational Recovery (RR) 9.30-31 smoking, 9.40-441 replacemen t therapies, 9.14, 9.15.
disorde r rave events (raves),1.33-34, 1.37, social model p rograms, 9 .14 See also harm reduct ion;
puberty, 2.33, 3.30, 8.35 4.18, 4.33, 6.19 sp iritua lity, 9.29-31 me thadone
pubic lice, 8. 4 2 Razwyck, Glen, 7.10 s timu lants, 9.38-40, 4.69 d etoxification, 9.42
publ ic health model of reabsorpt ion of neurotransmitters, test ing, 8.9 medica tions, 9.42-43
preven ti on, 8.59 2.21, 2.25, 3.11, 3.12, 3.57 treatment management, 9.9 nicotine, 9. 40-4 1
Pueraria lobata (kudzu), 9.36 Reagan, Ronal d (U.S. presi d ent), 1.5 recreational drug u se, 2.33 stimu lant abuse, 9.39
Puerto Rico, 1.35, 9.59, 9.60 1.42 rea lity therapy , 9.26 alcoho l, 5.11, 5.11-12 reproductive system and alcoho l , 5.20.
"pumpkin seeds," 4 .7 reasons for drug use, 2.38, 2.47. athletes, 7.25-26 See also p regnancy; sexual
pupil size See also environment; food, 1.42 dysfunction/per formance
constricte d (pin p oint) pup ils, 1.3, heredity gambling, 7.38-39 Rescue, ® 9.36
1.13, 2.28, 2.31, 4.18 rebo u nd respiratory depression, 2.15 history, 1.12, 1.19, 1.25 RESEARCH. See also genes; imaging
dilated pupils, 1.13, 2.29, 4.16, reboxetine (Edronax, ®Vestra ®), inhalants, 1.19, 7.9 techn iques; pharmaceutica l
4.17, 6.8, 6.20, 7.7 10.27, 10.30 marij u ana, 1.25, 1.31, 1.34 indus try; twin studies
Pure Food and Drug Act, 1.22, 1.23, rece p tor sites, 4.13, 5.12. opioids, 4. 9 alcoholism, 5.2 1-23, 5.24,
4.10, 8.10 See also dopamine receptors; rectal absorpt ion, 3.11. See also 5.26-28
purging (anorex ia and bulim ia), 7.24, endorphin recep tors; mu mu cous membrane alcohol use, 5.38
7.50, 7.51, 7.52 rece p tors; serotonin receptors absorp tion; supposi tories brain effects of violence, 5.33
purity. See adulteration/ alcohol, 5.26, 5.45, 9.46, 9.66 Red Bull,• 3.39--40, 7.20, 8.15 breas t cancer, 5.20
contamination; dilution behaviors, 7.2 "Red Bull Wings," 5.8 compu lsive buying, 7.30,
of d rugs beta, 7.22 "red devils," 4.36 7.43, 7.44
Purkin j e cell , 2.11, 2.19 caffeine, 3.42 Redman ® (chewing tobacco ), 3.4 d extrome thorphan, 6.2 1
"puro" (heroin), 4. 7, 4. 11 cocaine, 3.11, 3.13, 3.14 red phosphorus (me th manufacture), env ironmen tal causes, 5.36
"purple drank," 1.34, 4.18, 6.18 dopamine, 3.5, 9.4, 9.39 3.24--25 fetal alcohol syndrome, 5.29
purple fungus. See ergot fungus down regu lation, 2.24, 2.24, 2.46, "reds" "re d devils" (secobarb ital), hear t disease, 5.12
purposive withdrawal, 2.30, 4.18 3.6 4.36, 9.44 he redity, 5.23
"puta" (heroin), 4.6, 4.11 DRD 2A 1 Allele gene, 7.32, 7.47 Redux. ® See dexfenfluramine inhalants, 7.6
PVC cement, 7.3 eating disorde rs, 7.47, 9.50 "ree fer " (mari ju ana), 6.4, 6.24, 6.35 issues in, 9.1, 9.3-6
gene tics, 2.26 Reefer Madness (film), 6.24, 6.35 ketam ine, 6.22
glutamate, 9.39, 9.68, 9.69 refinement of subs tances LSD, 6.3, 6.5, 6.10
Q ketamine, 6.22 cocaine, 1.20-1.21, 1.33, 3. 7, marijuana 6.33-35, 6.38-40
"Q" (metha qualone), 4.44 mari j uana, 6.33-35 3. 17-18 MDMA,6.17
qanneb, 1.10 neurotransmitters, 2.20, 2.20-26, food, 7.43, 7.45, 7.46, 7.47, 7.53 methadone maintenance, 9.43
"qat" (khat). See khat 3.2 in history, 1.22 neurotransmitters, 2.20,
qigong, 9.37, 9.37 nicotine, 3.46, 3.48, 3.55 opioids, 1.19-1.20, 4.7-8 2.20-26, 5.26
Qu aalu d e.® See metha qualone opioids, 2.22, 2.27, 4.2, 4.13, 434, "regs," 6.29 patterns of drinking, 5.38
quazepam (Doral ®), 4.36, 10.30 4.38, 6.20, 6.21, 9.25, regulation of drugs. See laws and psilocybin 6.11
quetiapine (Sero qu el®), 9.39, 9.43, 9.50 regulations relapse, 2.17-18
10.25,10.27, 10.28, 10.30, psychedelics, 6.8 re info rcement. See reward/ roots of ad dict ion, 1.6, 1. 7
10.31, 10.33 relapse, 3.14, 3.26, 4.32 rein forcemen t center steroids, 7.18-19
Quide. ® See p iperacetazine se dative-hypnotics, 4.35 re inforcing pro tective factors, 8.6 violence, 5.31
qunubu, 1.10 synaptic plas ticity, 2.26 relapse, 2.17-18, 3.26, 8.2, 8.13, research and dev elopment
Qu r'an, 1.14 treatment, 9.39, 9.43, 9.50, 9.66, 8.32, 8.45, 8.48, 9.6. See pharmaceutical industry, 4.45
9.67 also prevent ion; recovery; resi d ential treatmen t programs, 9.7,
R recovery; 9.22. See also relapse; treatment 9.13, 9.14--15
treatment; 12-step programs alcoho l, 9.46 resiliency, 8.6
Radio Immunoassa y (RIA), 8.50, 8.51 abs tinence, 9.6 amphetamines, 3.14, 3.26 resiliency-focused prevention, 8.30
radio trace rs, 2.22 African American, 9.57-59 anhe donia, 9 .38 resins, in marijuana, 6.28-30
Radix pue ra tiae (kudzu), 9.36 alcohol, 9.46, 10.19 brain chemistry, 9.21 resistance, 9.27
Raid,• 7.28 caffeine, 3.40 resistance skills tra ining, 8.31

respiratory system. See also asthma;
bronchodilation; inhalants;
lungs; oxygen insufficiency
alcohol, 4.44, 5.1, 5.15, 5.19, 5.35
cocaine, 3.15, 3.19, 3.56, 3.57
drug inhalation, 2.4
drug overdose emergencies, 2.15
ephedra, 7.21
GHB, 7.23
heroin overdose, 4.21
inhalants, 7.5-6, 9.48
marijuana, 6.37-38, 8.25
opioids, 4.18, 4.21, 4.25, 4.27-29,
4.32, 4.44
sedative-hypnotics, 4.43, 4.44
tobacco, 3.47, 3.48-49, 3.54, 3.59,
7.21
yohimbe, 3.35
responsible use education, 8.16
REST. See restrictive environmental
stimulation therapy
restoration of homeostasis, 9.58, 9.65
Restoril. ® See temazepam
restrictive environmental stimulation
therapy (REST), 9.37
reticular formation, 6.3
retrograde amnesia, 5.24, 6.21
retrospective memory, 5.21
retrospective studies, 2.38-39
reuptake ports, 2.23, 3.12
reverse tolerance , 2.27, 4.39, 5.26
Rev ex. ® See nalmefene
Revia. ® See naltrexone
Revivarant ® (GBL). See GBL
Revivarant G® (GBL). See GBL
Revolutionary Armed Forces of
Colombia (FARC), 3.8
Revolutionary War. See American
Revolution
"reward chemical." See dopamine
alcoholism, 5.28
compulsive behaviors, 2.17
dopamine, 2.21
imaging, 9.3
marijuana, 6.34-30
morality, 2.17-18
nucleus accumbens, 2.16
opioid peptides, 2.17
opioids, 4 .17
react ivation, 2.14-16
stimulants, 3.1, 3.6, 3.12,
3.45, 3.56
tobacco, 3.46-47
reward deficiency syndrome, 2.39
reward -reinforcement circuit.
See "go" circuit
reward -reinforcing action of
drugs, 2.29
Reynolds, John Russell, 6.39
Reynolds, R.J.(company), 1.23,
3.4, 3.44
Rhazes (Arabian physician ), 1.14
rhinoceros horns, 8.40
Rhode Island, 6.44
Rhovane. ® See zopiclone
RIA. See Radio Immunoassay
rice wine, 1.9, 5.6, 9.61
"rigs," 8.44
Rig-Veda, 1.ll, 6.21
right inferior parietal lobe, 2.17, 3.26
right insula, 2.17, 3.26
RIID (res tless, irritable, isolated,
discontented), 9.24
Rilamir. ® See triazolam
riluzole (Rilu tek ®), 9.68
rimonabant (Acomp lia, ® Zimulti, ®
SR141716A), 6.35,
9.48, 10.26
risk factors (prevention ), 4. 16, 4.23,
8.6, 8.7, 8.ll-13, 8.30
risk-focused prevention, 8.30
Risolid. ® See chlordiazepoxide
Risperdal. ® See risperidone
risperidone (Risperdal ®), 9.39, 10.28,
10.29, 10.30, 10.33
Ritalin. ® See methylphenidate
ritanserin (Tisterton ®), 9.39
rivastigmine (Ex elon ®), 10.29
Rivotril. ® See clonazepam
Ro 15-45 13. See
imidazobenzodiazepine
"roachies " (flunitrazepam), 4.36
Robaxin. ® See methocarbamol
Robins, Lee N., 4.25
"rob in's eggs" (phentermine HCL), 3.3
Robitussin A-C. ® See codeine
Robitussin DM® (dextromethorphan ),
4.18, 6.4. See also
dextromethorphan
"robo, " 6.4
Roche Laboratories, 4 .35
"rock" (freebase cocaine), 3.3, 3.11,
3.18, 3.19, 3.22, 3.56. See
also "crack " cocaine
Rockefeller, Nelson, 8.10
Rockstar, ® 3.4, 3.37, 7.20
Rodriguiz, Alex, 7 .11
Roger's Cocaine Pile Remedy,
1.21-1.22
Rohypnol. ® See flunitrazepam
"raid rage," 7.18
"ra ids " (steroids), 1.37, 7.15.
See also steroids
Rolfe,John, 1.18
"rolling, " 6.16
Roman Empire, 1.9, 1.10
Roman gladiators, 7.13
Romazicon. ® See flumazenil
Rome, ancient, 1.10, 6.26
Romilar. ® See dextromethorphan
"roo fies" (flunitrazepam), 4.31
room odorizers (nitrites), 7.4, 7.9
Roosevelt, Franklin Delano, 1.5
rosacea, 5.19
routes of administration, 2.2-4, 2.4,
3.9-10, 4.7-10 2.5.
See also methods of use
Roxanol. ® See morphine
Rozerem. ® See ramelteon
rubber cement, 7.3
rubbing alcohol (isopropyl
alcohol), 5.5
rue herb. See ayahuasca;
Syrian rue herb
"ruffies " (flunitrazepam), 4.36
"rufus " (hero in ), 4.6
rum, 1.15, 1.18, 1.19, 1.21, 5.4, 5.7,
5.7, 5.38
Runge, Friedlich, 1.14
rush
amphetamine, 3.28, 8.37
behaviors, 7.55
cocaine, 2.20, 3.10-12, 3.17-18,
8.43
gambling, 7.39, 7.41
heroin, 4.9
inhalants, 7.9, 7.59
lVuse, 2.4,4.13,4.17
online, 7.58
opioids, 4.2, 4.12, 4.28
tobacco, 3.47, 3.53
Rush, Benjamin, 1.21, 5.22, 8.3
Rushmore.com, 7.58
Russia
AIDS, 8.46
alcohol, 5.2, 5.18, 5.30, 5.36-37
Crime 4.8, 4.10
fentanyl incident, 4.27
Internet, 7.57
methcathinone , 3.33, 3.58
synthetic marijuana 6.33
tobacco, 1.16
Russian Mafia, 4.10
Ruth, Babe, 7.21
rye mold. See ergot fungus;
ergotism; LSD
s LSD and, 6.9-10, 8
SAAST (Self-Administered Alcoholism
Screening Test), 9.12
Sabina, Maria, 6.10, 6.10
Sabril. ® See vigabatrin
saddhu, 1.11
safe sex, 8.34
safety margin
barbiturates, 4.34
benzodiazepines, 4. 40
buprenorphine, 4.30
chloral hydrate, 4.34
sedative-hypnotics, 4 .3 7
"sage." See Salvia divinorum
Saint AnthonyS Fire, 1.9-10
"Saint Anthony's Fire" (ga ngrenous
ergotism), 6.6
Saint John 's wort (Hypericum
perforatum), 9.36, 9.37
St. Mary's Hospital, 1.20
Saint Paul, 1.14
sake (rice wine), 1.6, 5.5, 5.7,
5.9, 9.61
saliva testing, 8.51
"Sally-D." See Salvia divinorum
Salvia divinorum (sa lvinorin A), 6.4,
6.21-23
SAMe,• 7.29
SAMHSA. See Household Survey
on Drug Abuse; Substance
Abuse and Mental Health
Services Administration
SAMI (substance abusing mentally
ill ). See dual diagnosis
Sandoz Pharmaceuticals, 1.28, 6.6
San Francisco, 3.22. See also Haight
Ashbury Free Clinics
African Americans, 9.58
AIDS, 8.47, 10.13
Asian Americans, 5.43
drug -induce d symptoms, 5.28
homeless, 5.41
marijuana, 6.40
meth, 9.38
prevention, 8.45
slot machines, 7.34, 7.37, 7.42
Soma ® abuse, 4.3
steroids, 7 .12
treatment, 9.58
San Pedro cactus, 1.8-9
San Salvador, 1.15
Saphris. ® See asenapine
Saraf em. ® See fluoxetine
sarpa salpa (fish species), 7.28
satiation switch. See "stop " circuit
Sativex ® (semisyn thetic THC), 6.5,
6.32. See also synthetic
marijuana
saturated adhesive patches, 2.4, 4.18,
4.26, 4.26. See also adhesive
patches; nicotine patches
Save Our Selves. See Secular
Organization for Sobriety
scabies, 8.42
scare tactics, 8.5, 8.5
scheduled drugs, 1.38--39, 6.29, 9.14,
9.52. See also classification
of drugs
schizophrenia, 9.38, 10.2, 10.3, 10.6,
10.7, 10.13, 10.14-15, 10.19,
10.27-29 10.32. See also
psychosis; thought disorders
INDEX 1.29
amphetamine/cocaine-induced,
3.6, 15, 3.28
antipsychotics, 10.27- 10.30
dopamine, 2.21
dual diagnosis, 10.7, 10.13 - 14,
10.19, 10.21, 10.32
heredity, 10.3, 10.4, 10.21, 10.22
marijuana and, 6.32, 6.38, 10.6,
10.14, 10.21
misdiagnosis, 10.14
neurotransmitters, 3.28, 10.4,
10.25, 10.28, 10.29
psychedelics, 9. 46
I
treatment, 10.21 -23, 10.25,
10.27 -30, 10.32
school and youth. See adolescents;
elementary schools; high
school; youth
"schwag, " 6.29
"scoo p" (GHB), 4.38
scopolamine, 1.12, 1.39, 6.4, 6.20
sleep aids, 4.2-3
scotch, 5.8
Screening, Brief Intervention, Referral,
and Treatment (S-BIRT), 8.14
"script docs," 8.10
Scythians, 1.11
secobarbital (Seco nal ®), 4 .41
treatment, 9.44
Seconal. ® See secobarbital
secondary amine tricyclics, 10.30
secondary prevention, 8.2, 8.12-13,
8.31, 8.48, 8.57-58
secondary terminal, 4.13
secondhand drinking, 5.36, 5.44
secondhand smoking, 1.36, 1.42,
3.53-55
second messenger system, 2.23, 2.25
Secular Organization for Sobriety
(SOS), 9.31
SEDATIVE-HYPNOTICS.
See also barbiturates;
benzodiazepines; entries for
specific generic drugs
age of first use, 8.12, 8.18
Asian Americans, 9.61
barbiturates, 1.27, 2.26, 2.27,
4.33-4
benzodiazepines, 1.28, 1.39, 4.3,
4.33-34, 8.24, 8.25, 8.38,
8.50, 8.52, 8.56, 8.58,
9.44, 1.28, 10.29, 10.30
buspirone, 4.31, 4.32, 4.36, 4.42,
10.30, 10.31
classification, 4.2, 4.6
dependence, 4. 4 2
detoxification, 9.39, 9.44
diversion, 4.5, 4.28
drug interactions, 4.39, 4.44
elderly, 8.57, 8.56
emergency room visits, 4.2-3,
4.48, 4.42
GABA, 4.38, 10.24, 10.25, 10.29,
10.30
history, 4.30--32
memory impairment, 4. 46
mental health, 10.3, 10.24, 10.25
other sedative-hypnotics, 4.2
overdosing, 4.18
pregnancy, 8.24-25
Quaalude, • 4.3, 4.31, 4.36,
4.39, 9.61
sedatives (de fined ), 4.37
sex, 8.38--39, 8.40
sports use, 7.25
tissue dependence , 4 .33
tolerance , 4.39-41
toxic effects, 10.29
treatment, 9.44
 1.30 INDEX
withdrawal, 4.39, 4.41--42,
10.24, 10.29
Z-hypnotics, 4.32, 4.37 - 38
seed less. See sinsemilla
"seizure focus, " 10.20
seizures, 2.15. See also convulsions;
drug seizures
alcohol, 5.20, 5.26
cocaine use, 3.15
GHB, 9.47
inhalant withdrawal, 9.48
medica tions, 9.66
selective prevention, 8.13
selective sero tonin reuptake inh ibitors
I
(SSRls), 1.28, 1.41, 7.54,
9.68, 10.24, 10.25-26, 10.29,
10.30, 10.31, 10.33. See
also fluoxet ine; paroxetine;
sertraline
ADHD,3.30
for anx iety, 9. 44
anxiety disorders, 10.29,
10.30, 10.31
buspirone and, 4.37, 4.42,
10.30, 10.31
care in stopping,10.30, 10.31
depression treatment, 4.37 - 38,
10.25-26, 10.29, 10.30
detoxification, 9.20
neurotransm itters, 10.24-26,
10.29
replacement therapies, 9.67
serotonin syndrome, 10.21, 10.26
sex,8.4 1
street drugs and,10.25, 10.26,
10.29
treatmen t with, 9.20, 9.39, 9.44,
9.5 1, 9.67, 9.68, 10.25-
26, 10.29, 10.30
Selective Severity Assessment
(SSA), 9.11
select tolerance, 2.27, 4 .37, 5.23
selegiline (Eldepry l• ) , 7.29, 9.39,
9.68, 10.26, 10.29, 10.30
self-disclosure, 9.32
self-efficacy, 9.27, 9.30, 9.52
self-esteem, 7.48, 7.58, 9.23, 9.51
self-help groups (SHG), 7.45, 9.13,
9.28-31, 9.40 , 9.42, 9.44,
9.49. See also 12-Step
Programs
self -medication, 2.31, 10.6, 10.7,
10.19, 10.25
"sens " (sinsemilla marijuana ) , 6.4
sensory confusion. See synesthes ia
sensory deprivation, 9.37
sensory distortions 6.9, 6.19, 6.24,
6.35, 6.37
sensory percept ion/deprivation an d
psychedelics, 6.5, 6.15,
6.18, 6.19, 6.30. See also
ha llucinations; hallucinogen
persis ting perception
disorder; illusions
Sentencing Clarification Act
(2010), 8.09
Sention, ® 7.29
September 11 terrorist attack, 3.8
Serax. ®See oxaze p am
"serenity" (STP), 6.4, 6.20
Sereni ty Praye r, 9.62
Serentil. ® See mesoridazine
Sernyl® (phencyclidine
hydrochloride ). See PCP
Seromycin. ® See cycloserine
Seroquel. ® See quetiapine
serotonin, 2.21, 3.5, 9.36. See
also selective serotonin
reuptake inhibitors;
serotonin modulators;
serotonin -norepinephrine
reuptake inhibitors; tricyclic
antidepressants
ADHD, 3.30
alcohol, 2.20, 5.12, 5.30
cocaine, 3.11 - 12
depression 10.20
eating disor d ers, 7.24, 7.25, 7.32, 7.44
effects of drugs on, 2.24
energy and, 3.2
MDMA, 6.17, 8.39, 8.53
psychedelics, 6.3, 6.5, 6.19
psychiatric medications, 10.24-26,
10.29, 10.30
receptors, 2.21 - 22, 3. 7
sedative -hypnotics, 4.35,
4.38, 4.42
sex, 7.54, 8.37, 8.41
SSRI ant idepressants, 3.29, 7.56
tricyclic antidepressants, 8.4 I,
10.26, 10.30
violence, 7 .44
withdrawal, 5.24
serotonin modulators, 10.26, 10.30,
10.31
serotonin -norepinephrine reuptake
inhibitors (SNR!s) , 10.26,
10.29, 10.30, 10.31
serotonin recep tors 6.17
5HT,A, 6.5, 6.8
down regulation, 3.6, 6.5, 6.8,
6.17, 6.36
LSD, 6.3, 6.5, 6.11
MDMA neurotoxicity, 6. 12
psychedelics, 6.1, 6.5, 6.8, 6.15
tolerance, 6.8
serotonin recep tors (5HT 1 to 7),
2.22, 2.23
serotonin reuptake inhibitors (SSRis) ,
2.24, 3.29, 9.20, 9.39, 9.44,
9.51, 9.67, 9.68, 10.25-26,
10.29, 10.30, 10.3 1
sex, 7.54
serotonin syndrome, 10.21, 10.26
sertra line (Zoloft ®), 3.29, 4.35, 8.40,
8.55, 9.11, 9.20, 9.39, 9.44,
9.52, 9.68,10.24, 10.25,
10.26,10.29, 10.30, 10.31
Serturner, Frederick W, 1.16,
4.8, 4.23
serum hepatitis, 8.42
Serzone .® See nefazodone
set and setting, 8.38, 8.39
"sets " or "setups " (codeine and
glutethimide ) , 4.35 - 36
"7-Up ," 6.19
7-hydroxym itragynine (Kratom), 4.29
"7th Heaven, " 6.19
severi ty of abuse or dependence , 9.11
assessment, 9.20
Sexaholics Anonymous (SA) , 7.53,
7.54, 9.29, 9.53-54
Sex and Love Addicts Anonymous,
7.55, 7.56
SEX and DRUGS, 8.31--45, 8.59--61.
See also AIDS and HIV;
date rape; hepatitis; love;
sexual addiction; sexual
dysfunction/performance;
sexually transmitted diseases
adolescents, 5.35, 8.28
AIDS and HIV, 1.33, 8.33-36, 8.41 ,
8.43--46
alcohol, 5.12- 13, 5.18, 8.35
amphetamines, 3.23, 3.25, 3.27,
3.57, 8.36, 8.36, 8.40
antidepressants, 8.39
aphrodisiacs, 8.39-41
cocaine, 3.12, 3.19 - 20, 8.34, 8.36,
8.40, 8.43
college, 5. 14, 5.40, 8.58, 8.60,
8.61
crack, 3.19, 3.20, 3.57
date rape, 8.35, 8.41
ecstasy, 8.36, 8.35, 8.39
epidemiology, 8.41
general sexual effects, 8.34
GHB, 8.38
hepatitis, 1.33, 8.42
high-risk behavior, 1.33, 3.12,
3.19- 20, 3.57, 5.14,
8.34, 9.53
inhalants, 7.62, 8.39
L-dopa, 8.40
LSD, 8.39
marijuana, 6.30, 8.38
MDMA and MDA, 6.15, 6.16,
40-41
medications, 8.33 - 35
mephedrone, 8.39
meth use, 3.23
nicot ine, 3.44, 3.45, 3.52
n itrites, 7 .9
n itrous oxide, 8.39
opioids, 8.37
PCP, 8.39
pheromones, 8.40
prevention of STDs, 8.34, 8.61
psychiatric medicat ions, 8.39
sedative -hypnotics, 8.39-40
sexua l assault and rape, 4.40, 4.43,
5.31 , 5.40, 8.40, 8.63,
10.4, 10.17, 10.18
steroids, 7. I 7
stimu lants, 3.6, 8.36
testosterone, 5.18, 5.43, 6.30 ,
8.34, 8.35, 8.37
tobacco, 8.36-37
trading sex for drugs, 8.41
transmission of HCV, 8.42
volatile nitrites, 8.39
yohimbe, 3.36
"sextacy, " 6.18
sexua l addiction, 7.1, 7.55-57
classifica tion, 7.55 - 57
cybersexual addiction, 7.1 ,
7.55, 7.58
diagnosis, 7.55, 9.53
treatment, 7.55, 7.56, 9 .53- 54
sexua l assault, 4.40, 4.43, 5.31, 5.40,
7.56, 8.40. See also da te rape;
domestic violence; rape
sexua l dysfunction/performance, 3.12,
3.27, 3.35, 3.56, 8.35, 10.7,
10.12, 10.19, 10.33
alcoho l, 5.20
medications, 8.34
opioids, 8.39
sedative -hypnotics, 8.37
stimu lants, 8.38
substance -induced, 2.35, 10.7,
10.12, 10.19, 10.33
sexually transmitted diseases (STDs) ,
5.14, 8.20, 8.36, 8.43,
8.43--46, 8.63. See also
hepatitis
sexua l minorities. See gay community;
lesb ian, gay, bisexual and
transgender communi ty;
lesb ians
sexua l preda tors, 7.52
"shabu " ("ice ") . See smokable
methamphetaminek i
shamans, 1.11, 1.13, 1.16, 1.8, 3.5,
3.11, 6.2, 6.10, 6.22
"shat. " See khat
"shattered glass, "
Shen Nung, Emperor, I. 7
"Shermans, Sherms " (PCP ), 6.4, 6.21
sherry, 5.8
SHG. See self-help groups
"shi t" (hero in), 4.6, 4.11
Shiva, Shivites, 1.11, 6.23, 6.24
shochu, 5.33
Short Michigan Alcoholism Screening
Test- Geriatric Version
(S-MAST-G), 9.57
short -term memory, 2.40, 6 .31
"'shrooms. " See Psilocybe mushrooms
Shulgin, Alexander and Ann 6.15,
6.18-19
Siberia, 1.11, 6.24, 6.29
sibutram ine (Merid ia®) , 3.4, 9.52
Sicily, 4.12
side effects, 2.2 1, 2.31, 2.47
caffeine, 7.20
HGH abuse, 7.19
modem medications, 7 .29
natural vs. drug -induced
sensations, 2.20
SIDS. See sudden infant death
syndrome
sildenafil citrate (Viagra ®) , 6.18, 7.9,
7.55, 8.34, 8.40
Silkworth, William 0., 2.2, 2.16, 2.45
silver mines, 1.15, 3.9, 3.56
Silybum marianum (milk thistle ) , 9.37
simple phobia, 10.13, 10.16
Simpson, Wallis, 7.46
Sinaloa (Mexican drug cartel), 4.11
Sinemet ® (carbidopa wi th levodopa),
9.39
sinensis, 3.41, 6.28
Sinequan. ® See doxepin
Singapore, 6.37
single -photon em ission compu ted
tomography (SPECT).
See SPECT scan
sinsemilla, 1.25, 1.26, 6.4, 6.27, 6.34,
6.35, 9.47
6-(2 -am inopropyl, benzofuran or
6APB, fury)
6-APB (benzo fury)
"sizzurp, " 1.34
"skag " (heroin ) , 4.7
Skelax in. ® See mataxa lone
skeletal muscle relaxants (Soma ®
Robaxin • ) , 7.15- 16, 9.44,
9.61. See also baclofen;
carisoprodol; chlorzoxazone;
cyclobenzaprine; dantrolene;
me thocarbamol; tizanidine
Asian -American use, 9.61
classification, 4.2
pain control, 4. 2- 3, 44.2, 4.22
sports use, 7.15-16
treatment, 9.44
skill -bu ilding p revention
program, 8.11
skin condit ions and alcoholics, 5.21
skin patches. See adhesive patches
"skin popp ing, " 2.4, 4.9, 8.43
"skittles, " 6.4
Skoal,• 3.4, 3.42
Skunk ® (synthetic cannab inoid),
6.5, 6.29
"skunk weed " (sinsemilla or Cannabis
indica), 6.4, 6.26
"slamming, " 2.4, 8.42, 9.63
slavery, 1.15, 1.18, 1.19, 5.4, 6.24
sleep -aids, 4 .3, 4.4, 4.38, 4.39, 4.44,
5.13, 8.37. See also GHB;
insomnia; sedat ive-hypnotics
sleep apnea, 5.11
sleep disorders, 9. 44. See also
insomnia; narco lepsy; sleep
disturbances
medications, 4.38, 10.19, 10.26,
10.28, 10.29, 10.30

substance-indu ced, 3.6 , 10.2, 10.7 ,
10. 15, 10.17-20
sleep disturban ces
PAWS, 9.23
treatment , 9 .39
Sleep- Eze,'" 4.3 , 8.56
slips, 9.23
slot machi nes, 7.33, 7.36, 7.37,
7.38, 7.42
Slovenia , 5.18
"smack" (hero in), 4.6
small int estine, 2.3, 2.4 , 9.52
alcoho l, 5.8, 5.18
"smart dru gs"
treatment using, 9.69
smart drugs and smart drin ks,
7.29-30
smart shops, 6.16--17
SMAST-G, 9.12
Smith , Anna Nicole, 4 .43
Smith , Bob, 1.25, 9 .28
Smith, David E., 2.36
SMOKABLE COCAINE (crack,
freebase), 1.30, 3.16
addiction , 3.17
cocaine vs. amphetamines , 3.20
compu lsion , 3.20
consp iracy theory, 9.59
dru g gangs, 3.17- 20
eco nom ics, 3. 19
effects, 3.20
ep idemic, 3.7, 3 .17
history, 1.30
neonata l effects, 3. 13- 14, 8.21-23
overdose , 3 .19
pharmacology , 3. 17- 18
polydru g abuse, 3.19
respirato ry effects, 3.19
sex, 3. 19, 3.20, 8.43
socia l consequences, 3.20
withdrawa l, 3.14
smoka ble methamph etam ine ("crys tal
meth ," "ice"), 1.30, 3. 1,
3.3 , 3.7, 3.2 1, 3.23, 3.25 ,
8.38, 9.63
Smoke® (synth etic cannabin oid),
6.4, 6.28
smok eless tobacco (snuff, chewing
tobacco), See chewin g
tobacco
smokin g,1.22- 1.23, 4.8.
See also lun gs; mar ijuan a;
ni cotine; opiates/op ioids;
pipes; respiratory system;
smoka ble cocaine; smoka ble
me thamp hetamin e; tobacco
smuggling, 1.25, 8.8-9
alcohol, 1.25, 8.4
amph etamin es, 1.27, 1.36, 3.22,
3.24 , 3.2 1
cocaine , 1.21, 1.32,6 , 8 .8 3 .7
heroi n, 1.25, 4 .10
khat, 1.37, 3.33
precursors, 4.5, 8.9 , 8.9
prescrip tion drugs, 4.5
"smurf dope, " 3.3
SNCA, 2.39
"sniffing," 4.9, 7.2, 7.3, 7.5
snorting, 1.26, 2.4, 4 .9
amp hetamines, 3.20
cocain e, 1.30, 3.10
DMT, 6.12
hero in ,1.37, 3. 19, 4.10
MOMA, 6.15
meth amphe tam ine, 3.20
PCP, 6. 18, 6.4 1
tobacco , 1.12
"snot" (freebase me tham phe tamine) ,
3.3
"snow" (co caine), 3.3
SNRls (serot onin -nore pinephrine
reuptake inhib itors ), 10.29,
10.30 , 10.31
snuff , 3.4 , 3.4 1, 3.42-43, 3.43, 3.49 ,
3.50 , 3.59. See also smoke less
tob acco
psychedelic, 6.2 , 6. 12
sobering stations , 9.15, 9.45
sobe r-living treatm ent programs , 9.15
sobe r mice, 2.43-44, 2.47
sobriet y. See abst inence
social drug use. See recreational
drug use
social gamblers, 7.38
social impacts of ab use, 1.30.
See also costs of abuse
social-mod el program s for detox and
recovery, 9.5 , 9.13, 9.14,
9.20, 10.10, 10.32
social network app roach , 9.34
social phob ia, 10.5, 10.13 , 10.30
social side effects, 2.32
Socrates, 4. 7
soda do ping, 7.24
sodium ion channel bloc kers, 9.68-69
sodiu m ions , 2.23
sodium oxyba te. See GBH
soft drink s, 1.36, 3.37
Solana ceae (night shade family), 1.12
soldier's disease, 1.20
solvents . See volat ile solvents
Soma."' See carisoprodo l
Soma (Ama nita mushroo m), 1.11,
6.6, 6.24
soma (cell body), 2.18
soma (e rgot fungus) , 6.6
soma (Aldous Huxley), 1.27
Somalia, 3.33-3 4, 3.58
Somaliu m.®See broma zepam
somatic ner vous system , 2.08
somatic psychology, 9.37
somatofo rm di sorders, 10.16 ,
10.17 , 10.33
Sombul ex .'" See hexoba rbital
Sominex,®4.2, 8.56
Somnafac.® See meth aqualone
Somn os® (chlora l hydrat e).
See chlora l hydrat e
Sonata."' See zaleplon
Sonora n dese rt toad , 6.4, 6. 11, 7.28
Sons of Male Alcoholics (SOMAS),
5.20
Sony PlayStation 3 ,'" 7.56
Soper.®See methaq ualone
"sopers," "sopes ," 4.31.
See also methaqualone
Sophidone.®See hydromorphon e
sophora seed, 1.9
SOS. See Secular Organization
for Sobri ety
Sosa, Sammy, 7.11, 7.12
South Africa, 1.3, 4.44, 5.2, 6.25,
8.21, 9.53. 1.6, See also
Sub-Saharan Africa
South Amer ica, 1.11, 1.12, 1.16, 1.32,
3.7 , 3.8, 3.9, 3.17, 3.38, 3.41,
3.56, 3.58, 6.10- 12
South east Asia, 1.31, 1.32, 7.28, 7.53
South Korea, 3.23, 5.36, 7.55
South Oaks Gambling Screen
(SOGS), 9.49
South west Plains Indi ans , 6.13
Sovie t Union. See Russia
"space basing," 3. 19
Spain , 5.16 , 7.14, 7.46
choc olate, 1.14, 1.17
coca, 1.15
ma rij uana, 6.42
opium , 1.10
salvia 6.23
tobacco, 1.17, 1.18- 1.19
Spanish Conqu istadors, 1.1, 1.7, 1.15,
3.9 , 3.56 , 6.14
Span ish fly (canth aradi n), 8.40
Sparks ,'" 5 .8
spas molytics, 7.16
Special Amino Acids and Vitamin
Entera l (SAAVE), 9.36
"special K" (ketam ine), 6.4 , 6.22
SPECT (single-photon emission
comp ut ed tomography) scan ,
2.22, 2.40 , 2.42, 2.42 , 3.28,
5.28 , 9.3, 9.3, 9.64
"speed," 1.2, 1.26, 1.29, 1.33, 1.36 ,
3.3 , 3.4, 3. 15, 3.20 , 3 .21,
3.22 , 3.23, 3.26, 3.31, 3.57
"speedball," 1.38, 2.33 , 3. 15 4.25,
4.31 , 6.16
speed of action. See also duratio n of
actio n
contact absorpti on, 2.2
ingestion , 2.2
inha lation, 2.2- 3
injection, 2.4
meth od of use, 2. 2-4
muco us membranes, 2.4
"speed run ," 3.15, 3.26, 10.8 .
See also amph etam ines
sperm , 5.29
Spice'" (Gold , Silver, Diamond ), 8. 10
Spice® prod ucts (synth etic
can nabinoid), 6.5, 6.32-33
Spike Shoote r, 3.3 7
sp ina l cord, 4.2, 4.13 , 9.62 , 9.63. See
also central nervo us system
CNS and , 2.5, 2.8 , 2.8-9
fluid barrier, 2.6
neurotr ansmitt ers, 2.20 , 2.20-26
"spirals" (methtryptamin e) , 6.4, 6.12
spirit ual bypas s, 9.29
spirituality. See also religious/ritual use
adolescents, 8 .30
African-American co mmunit y,
9.59
cravin gs, 2.10, 2.12 , 2.14
genes , 2.39
Hispanic comm unities, 9.60
historical develo pment of, 1.6, 1.8,
1.11, 1.25
recovery an d, 5.4, 7.43, 9.29- 31,
10.11
sac red/ritual use of psychedelics,
6.1, 6.10- 15, 6.24, 6.26
substance ab use treatm ent , 10.11
treatmen t goals an d, 9.10-11
treatment proce ss, 9. 19
sp it toba cco . See smokeless toba cco
spontaneou s abort ion. See miscarri age
Sports book.com , 7.58
SPORTS and DRUGS, 1.27, 1.31,
1.38-1.39 4.38, 7.13- 27. See
also performan ce-enhancing
dru gs and techniqu es;
steroids
alcohol , 7.26
am phetamines, 7.21
anab olic-an drogenic stero ids. See
be low a t stero ids
analgesics, 7.11- 16. See also
op iates/o pioids
androste ned ione, 1.4, 1.27,
7.22, 7.24
anti -inflam matory dru gs, 7.15- 17
asthma medi cat ions, 7.11, 7.16
benzod iazepin es, 7.16, 7.28
be ta blocke rs, 7.22- 23
blood doping, 7.23
caffeine, 7.21
catego ries of drugs, 7. 11
INDEX l.ll
chewing tobacco , 7.2 1
cocaine, 7.11, 7.12 , 7.13, 7.20,
7.25
commer cialization, 7.14
cost, 7. 19
creat ine, 1.4 , 1.27, 7.23
depressants, 7. 15, 7.25
diuretic s, 7.14 , 7.18, 7.24, 7.25,
7.51
dru g ba ns and policies, 7.21,
7.25-26
eating di sorders, 7.45
ephedrin e and ephedra , 7.13 ,
7.20-21
I
epid emiology, 7 .13, 7 .14
erythropo ietin (EPO) , 7.14,
7.23, 7.25
ethi cal issues, 7.27
gambling , 7.3 1, 7.36
GHB, 4.43
healing process, 7.16
HGH (human growth hor mon e),
7.19-20
history, 1.27
history of use, 7.13- 14
marijuana , 7.11, 7.24, 7.25
muscle relaxants, 4., 7.11,
7.15-16, 9.44, 9.66
natura l highs, 9.25
NCAA survey, 7.15
other performanc e-enh ancing
drug s, 7.22-26
pain , 7.2, 7.11, 7.15, 7.16
performance-en hanci ng drug s,
1.4, 1.27, 1.31, 1.38,
1.39, 7.11-2 1
"ro id" rage, 7.18
seda tive-hyp notics, 7.25
soda dop ing, 7.24
stacking and cycling, 7. 17
stimu lants , 7.13, 7.16, 7.20,
7.24 , 7.26
street/ recreational drug s , 7.26--28
test ing, 7.26--27. See also drug
testing
thera peutic drugs , 7.11 , 7.13-1 5
tobacco , 7.12, 7.2 2
volatile nitri tes, 7.9
weight loss, 7.2 1, 7.24-2 5
spot remo ver, 7.5, 7.7
spray cans, 7.2, 7.29
"spraying ," 7.5 , 7.28
"Squirr el" (qu etiapi ne), 4.31
SR141716A (THC ant agonist;
rimonabant ), 6.35, 9.48
SSA. See Selective Severity Assessme nt
SSRls. See selective sero tonin reupt ake
inhi bitor s
stackin g, 2.32, 7. 17
Stadol.®See buto rphanol
stages of change model, 9.27, 9.71
stammt isch drink ers, 5.22
Stamoc. ® See zaleplon
stanozo lol (Winstro l,'" Winstrol-V'"),
7.18
"state depen dence, " 3.50
state policies on marijuana, 6.26--27
See also ent ries for specific
sta tes
sta tistics . See epidemio logy
stay-stopped circui t , 2.17- 18, 2.45 ,
2.46 , 9.4
STDs. See sexua lly tra nsmitt ed
diseases
steady endoge nous sympt omatic
dri nkers, 5.22
"stealth marijuana ," 6.4
Stelazine® (trifluoperazine), 10.30
 1.32 INDEX
STEROIDS (a nab olic-androg en ic) ,
1.4, 1.27, 1.31, 1.38,
1.39, 7.1-20. See also
corticosteroids
ad diction , 7.18
classification, 1.4
college sports use , 7.15
compu lsive use, 7.18
cost, 7.19
dosage , 7.14 , 7.17
drug testing , 7.26
effectiveness, 7.18-19
effects, 7.17-18
epidemiolog y, 7.16- 19
no t U.S. ap proved, 7.18
I
sex, 8.34, 8.40
slang terms for, 7.17
sports use, 7.12- 13, 7.14, 7.15
stacking and cycling , 7.17
trade names , 7.18
use by ath letes, 7.16-19 , 7.21
veterinary procedures , 7. 11
Stevenson, Robert Louis, 3. 10
Stewart , Pablo , 10.1, 10.6, 10.22
stillbirth , 8.26
stim ulant alkaloids , 1.12. See also
caffeine; coca ine ; nicotine
stim ulant-indu ced menta l illness,
3.7, 3. 15, 3.57 , 10.7,
10 .19-20 , 10.33
STIMULANTS (UPPERS), 1.2-1.3 ,
1.12, 1.36- 1.37, See also
amph etamines; cocaine ;
MOMA; nico tine; entr ies for
specific subs tances
ad diction , 3.6 , 3.9 , 317,3.21,3.24,
3.31, 3.42, 4.48-50, 3.55 ,
10.8, 10 .14, 10.16, 10.19,
10.20 , 10.21
ADHD, 3.24 , 3.28
ad ulterat ion , 3.16
am ph etamines , 1.26- 1.27, 3 .20-32
ane rgia, 3.1 2, 3.14,3. 27, 9.38
anhedon ia, 3.12, 3.14, 3.27, 9.38
card iovascula r effects, 3.5-6 ,
3.13, 3. 16, 3.24, 3.27-28,
3.32, 3.36, 3.4 2, 3.46,
3.51 ,53-54
classificatio n, 1.2, 3.3-4
cocaine, 1.15, 1.20- 1.21, 3.6-3 .20
cras h, 3.5-6, 3.12, 3. 14, 3.16, 3.34
di et pills, 1.3, 3.22, 3.32, 7.20,
9.52
elderly, 8.56, 9.56
euthymia 3.14
genral effects 3.6
group therapy, 9.27-28, 9.3 1
ibogain e, 6.10
khat, 1.14 , 3.33
malnutri tion, 3.15, 3.27,
3.32 , 3.34
manufactur e of, 1.31, 3.21,
3.24- 25
m edical use, 9.52
m ent al disord ers, 3.14- 15, 10.6 ,
10.19- 20, 10.33
mental effects, 1.3
neur otra nsm itt ers, 2.24, 3. 11- 12,
3.14, 3. 16, 3.21 , 3.25- 28,
3.30-36 , 3. 46
overdose, 3.15, 3.19, 3.26, 3.39 ,
3.47 , 3.56, 3.57, 3.66
parano ia , 3.6, 3. 11, 3. 12- 13, 3.14,
3.15- 16, 3. 19, 3.33,
pe rsonality change, 3.0
phys ical effects, 1.2- 1.3
pregnan cy, 3.13- 14, 3.26, 3.38,
3.39, 3.50, 3.56 ,
3.59 , 8.26
reward/reinforcement pathway,
3.12
sex, 8.34 , 8.36
smart drugs , 7.29
sports use, 7. 12, 7.20-21 , 7.23
tolerance , 3.6 , 3.27-28, 3.42
treatment , 9.27-28 , 9.37 , 9.38-40,
9.66
treatment admissions, 9.16
weight loss , 1.41- 1.42, 3.6 , 3.22,
3.31 3. 19 , 3.22 , 3.27
withdrawal, 3.5-6
xant h ines, 3.4, 3.41, 8.27
"stinkw eed." See datura (j imso n
weed)
Stoll, Arthur, 6.6
Stone Age, 1.8, 1.9
"stop " circui t, 2.14, 2.17- 18
disabling of, 2.16
eating disorde rs, 7.45, 7.50, 7.51
stop sw itch. See "stop " circuit
stout , 5.6, 5.7
STP (DOM; 4 meth yl 2,5 dimethoxy-
amphetam ine), 3.22, 6.4,
6.20
STP'" (fuel add itive) , 7.4
STP-LSD combo, 6.4
Strauera '" (atomoxe tine) , 3.4 , 3.30,
3.32, 10.27 , 10.30
street dru gs. See amp hetam ines;
hero in; LSD; "magic
mushrooms"; mar ijuana ;
MOMA; methca thinone;
PCP; peyote ; ent ries for other
spec ific drugs
street labs. See illegal drug labs
street people , 5.38
"street spee d," 3.3 , 3.4, 3.2 1,
3.22, 3.3 1
stro ke, 2.26, 3.6 , 3.13, 3.15, 3.19 ,
3.27 , 3.28,3.52 7.2 1, 8.22.
See also heat stroke
alcohol , 5.12-3, 5.19, 5.29
stryc hnin e, 7.13, 7.14, 7.29
"stunn a," 6.4
"sub" (bu preno rphin e), 4.7
subcu taneous injection, 2.4, 2.45,
3.10, 4.23 , 4 .27, 8.42
Sublimaze.®See fentan yl
subli ngua l absor ption , 2.4.
See also mucous membr ane
absorpt ion
Suboxone ® (bupreno rphine
with naloxone) .
See buprenorphine
Sub-Saharan Africa, 1.33, 4.23 , 5.4
HIV, 8.43
substanc e abuse (DSM, DSM-lV-R
category), 2.33, 9.11, 10.3
Substance Abuse an d Mental Health
Services Administra tion
(SAMHSA), 9.4. See also
Household Survey on Drug
Abuse
substance-abuse treatment , 8.26
substance abusing menta lly ill
(SAM]). See d ual di agnos is
substan ce depe nden ce, 2.36, 7.11
alcohol , 5 .26
DSM-IV-R category, 9.11, 10.2,
10.18
home less population , 10.9
treatment , 10.20- 27
substa nce-indu ced ment al d isorders,
2.35, 10.1, 10.3, 10.6, 10.7,
10.11, 10.14, 10.18-21 ,
10.31. See also psychosis
alcoho l, 5 .22- 3, 10.18- 19
amp hetami ne, 3.16, 3.28, 3.31
cocaine, 3. 11, 3.15- 16, 3.19
DSM-IV-TR category, 2.35, 5.23 ,
9.11
marijuana , 10.20-22
MOMA, 10.19-21
pan ic disorder , 10. 18-21, 10.29
psychedelics , 9.46
stimulants, 3.6, 10.19-20, 10.21
substance "P," 2.21 , 2.22, 2.24, 4. 13
substa nce-rela ted disorde rs
classificat ion, 2.35 , 10. 1-3, 10.5 ,
10.8, 10.13, 10.14 , 10.17 ,
10.18
ment al health di sorders and, 10.1,
10.2 , 10.3, 10.5, 10.6-13 ,
10.15, 10.17- 25, 10.28 ,
10.29
substance use disorder (SUD),
2.35 , 8.6, 10.1-3 , 10.5-11 ,
10.2 1-24
alcohol, 5.26, 5.38
approved vs. off-label med ications ,
9.66-67
co-occurring disorders, 10.5- 18
DSM categor y, 5.23
hom eless and , 5.41
treatment , 10.9-11
substitution therap y, and sedative-
hypn otics, 9.44.
See also cross-to lera nce;
har m reduct ion
Subu tex.'" See bupr eno rphine
SUD. See substan ce use diso rder
Sudafed, '" 3.4
sudden infant death syndro me (SIDS),
3.13 , 3.28, 3.54, 8.22 ,
8.23 , 8.25
Sufenta.'" See fentany l
sufenta nil, 4. 7. See also fentany l
"sugar cube ," 6.4
suicide, 8. 14, 8. 18, 8.28
alcoho l, 5.35, 10.18
assisted suicide, 4 .7
bi polar patients, 10.15
depression, 10.26
eating disor ders, 7.52
gamb ling , 7.40, 7.42
risk in alcoholics, 9.46
teenage rs, 8. 28
treatment , 8.15, 9.65
sulfu ric acid, 3.17, 8. 10
sulindac (Clin oril'"), 4.23, 7.16.
See also nonsteroidal
anti-inflammatory drugs
Sumerians , 1.9, 1.10
"Summer of Love," 1.27, 3.22
"sunshi ne (LSD)", 6.4
"super-K" (ketamine) , 6.4
"super kus h" (synthetic marijuana )
supernatural, 1.8, 1.11 , 1.14
Supertoot, '" 3.4
suppl y reduct ion, 1.29, 1.42, 8.2-3
activities, 8.8
agencies respons ible for, 8.8
costs of, 8.4, 8.6
federal funcling, 8.3
outcomes, 8. 10-11
prevention , 8.7- 11
support groups. See also 12-step
programs
eating disorders, 7.54
support services, 9.35-37, 9.43
support sys tems, 8.6 , 8.13. See also
family; support groups
elderly, 9.57
hom eless perso ns, 5.38
preventi on, 8.6
recovery, 9. 25
suppositories, 2.4 , 4.19, 4.26
Supreme Court, 3.4 7
marijuana, 6.44
peyote, 6.14
Surgeon Genera l
alcohol, 5.13 , 5.20
drink ing dur ing pregnancy, 5.28
report on tobacco, 1.23, 1.35,
3.42-43, 3.51, 3.54
Surita!.'° See thiamylal sod ium
Surmonti l.®See trimiprami ne
surv ival mechan ism, See also
addiction pathway
surv ival/re inforcement circu it, 2.1,
2.13-16 , 2.18, 2.39 , 2.42-45 ,
7.32, 7.48 , 9.3
suscepti bility. See also environment ;
heredity; relapse
compu lsion, 2.44
genet ic/environm ental factors ,
2.38-4 1
m ice studies, 2.44
relapse , 2.30
Sustiva. ®See efavirenz
"SuzieQ" (quetiapine) , 4.31
sweat lodges, 9.62
sweat collect ion testing, 8.51
Sweden , 2.4, 3.26, 3.38, 5.33, 6. 19,
6.23, 9.51
Switzerland, 1.7, 1.15,4.7, 4.2 7,
5.36, 8.45
Sydney Olymp ics, 7.11, 7.16
Symmetrel.® See ama ntadin e
sympa thetic ner vous system, 2.8.
See also cardiovascular
system
amphetamines , 3.13, 3.21 7.20
be ta blockers, 10.24
hallucin ogens, 6.3 , 6. 16, 6.20
sympa th om imetic agents, 3.20, 7.20
SymTan.'" See hydrocodone
Symtan .'" See hydrocodone
synapse
neuroanatomy , 2.18, 2.18-20,
2.42 , 2.46
synapse, synap tic gap, 2. 11, 2.18-20 ,
2.21, 2.22, 2.24 , 2.25-26 ,
2.26, 2.40 , 2.46
LSD, 6.5
mar ijuana , 6.37, 6.39
MOMA (ecstasy), 6.17
opiates , 4.14
stimulants , 3.12, 3.25
synapti c plast icity, 2.25- 26, 2.46
syne rgism , 2.8, 4.44
synes thesia , 2.25, 6.3, 6.9
synthe tic drugs
ba th salts (coca ine/meth) , 1.2,
1.3 1, 1.33, 134 , 1.37,
8.10 , 8.50
marijuana , 1.31, 1.33, 1.34,
6.2, 6.32-33 , 8 .10- 11,
8.50 , 8.53
opioids and code ine, 4.2, 4.6-7 ,
4.28 , 4.30-31
psychede lics, 6.4-5, 6.12-13, 6.13,
6.18, 6.20
stimulants , 3.4, 3.33 , 8.10- 11
suppl y control , 8.10-11
synt hetic marijuana, 1.31, 1.33, 1.34,
6.4, 6.32- 33
dru g testing , 8.50, 8.5
K2, 1.31, 1.33, 1.34, 6.2, 6.32 ,
8.10, 8.50
trad e names, 1.33 , 6.28, 8.10
syph ilis, 4. 19, 8.4 1
Syrian rue herb, 6.12
syringe. See needle use
 INDEX 1.33

T temperance versus prohibition, th erape uti c communities (TCs), GHB, 9.47

"tab ," 6.6
Tabernanthe iboga shrub, 6.4, 6.11
TA-CD (cocaine vaccine), 9.67
T-ACE, 9.12
tachycardia , 3.6, 3.13, 3.15, 3.33,
5.24, 5.41, 10.16
tachyk inin, 2.22
tachyphy laxis (acute to lera nce),
2.27, 5.24
tacrine (Cog nex'"), 10.26
tadalafil (Cialis'"), 7.55, 8.35
Tafil.'" See alpr azolam
1.21-1.23 , 8.3-4
alcohol, 1.10, 1.15, 1.21, 1.23 5.4
tobacco, 1.16, 1.40
temp ora l disintegration , 6.37
Tenex.'" See guanfacine
Tenorm in.'" See atenolo l
Tenuate.'" See diethylpropion
teonanacatl ("divine flesh"), 6.9
Tepan il.'" See die thylpropi on
tequila , 5.7
term inal (nerve), 2.11, 2.19, 2.19
Terms of Resista nce (10-step
program), 9.59
1.27, 9. 14- 15
therapeutic drugs in sports, 7.11, 7.15
therapeut ic index , 4.40, 4.42
therap y.Seealso cognitive behavioral
therapy ; group therapy ;
psychotherapy ; individua l
therapy
aversion therapy, 2.44 , 9.13, 9.26,
9.39, 9.41
chron ic problems, 10.23
cogn itive behaviora l thera py, 7.44,
9.14, 9.39 , 9.4 1, 9.42,
9.46, 9.53
marijuana , 6.40, 9.47
neonata l effects, 4.21
opioids, 4.19
pain contro l, 4.12-14
physical changes , 2.30 , 2.38
relapse , 2.46
risk factors for addiction ,
4. 16, 4.26
sedat ive-hypno tics, 4.3 , 4.30 , 4.35
sp orts , 7.16
withdrawa l, 2.28
titration , 2.3
tizan idine (Zanaflex'"), 4.16 , 7.16

Taiwan, 1.11, 3.35-36, 10.6 terroris t activities, 1.7, 1.31
Talacen. '" See pentazocine tertiary amine tricyclics, 10.30
talbu tal (Lotusate '"), 4.36 tertiary prevention, 8.2, 8.13- 14,
talcum powder, 3.16, 4.20. 4.24 8.3 1-32, 8.48. See also
Taliban , 1.32, 4.2 , 4.11 treatment
talking circles, 9.62 Teslac.'" See testolactone
Talwin NX.'" See pentazocine Testex.'" See testosterone propionate
taqlA , 2.40 testing. See drug testing
"tar " (hero in), 4.10-11 testostero ne, 1.27, 5.18 , 7.13, 7.17,
tar (tobacco), 3.5 1-53 7.18, 7.19, 7.22, 8.35.
Taractan. '" See ch lorp rot hixen e See also stero ids
Tarahum ara Indians , 6.14 alcohol, 8.36
tardive dysk inesia , 10.28 androstenedione and , 7.22
target grou ps, 9. 18, 9.55-63, 9.72-73 anorexia nervosa, 7.45
prevention programs , 8.13, 8. 14 marijuan a, 6.34-35
tar heroin , 1.32, See also hero in na tural prod uction of, 7.18
TAS2R16, 2.39 tobacco , 8.38
Tashkin , Donald, 6.36-38 testostero ne cypio nate
T-ASI, 9.11 (DepoTestos teron e,'" Virilon
Laurine , 1.36, 3.37, 3.38, 9.21, IM'"), 7.18
9.36, 9.68 testosterone enantha te (Delatestryl'"),
Tavor.'" See lorazepa m 7.19
taxes on drugs, 1.7, 1.27, 3.42 . testosterone propionate (Testex ,'"
See also econo mic factors Oreton Propionate '"), 7 .19
alcohol, 1.10, 1.15, 1.18, 5.4, Testred. '" See methyltestos terone
5.19 , 5.37 tetra chloroethylene , 7.4
cocaine, 1.15, 3.8 tetra hydrocan nabinol. See THC
consumpt ion and, 1.10, 1.18, tetrahydrogestrinone (T HG), 7.13,
5.17, 5.37 7.26, 7.27
gambli ng, 1.41 tetrazepam (Mylostan '"), 4.3 1
government drug policies, l. 10, Texas holdem, 1.41
1.15-1.18, 1.22-1.26, "Texas shoeshin e," 7.7
1.31, 1.35, 1.4 1, 3.9 , 3.42, "Texas tea," 4.18, 6. 18
5.5, 5.42, 6.42-4 4 texting compul sion. See mobile phon e
med ical marij uana , 1.7, 6.41-42 add iction
op ium, 1.10 Thailand , 1.29, 1.36, 4.11
supp ly contro l, 1.10 be tel nu t, 3.4 , 3.35-36
recreational mariju ana, 1.3 1 mariju ana , 6.28, 6.3 1
tobacco, 1.16, 1.22 , 1.31, 1.35, ya ba , 3.3, 3.23
3.42, 3.5 1 3.44-45, thalamus, 2.18 , 4.12
3.55- 56 THC (delta-9-te trahydrocannabinol ,
TC. See therapeutic commu niti es L\9-THC) , 6.3 , 6.25, 6.39.
TCE. See trichloreth ylene See also marijuana
T-cell count , 8.43 absorpt ion, 2.4, 6.34
"TD" (truth drug) , 6.24 brain receptor sites, 6.33-34
tea , 1.10, 1.14-1.15, 1.17, 1.20, breas t milk , 8.24
1.22, 3.33. See also caffeine; cancer , 6.38
herba l produ cts drug testing, 6.29, 6.37
"tea pads," 6.27 half-life, 2.6
techno logical advances , l. 7, hash oil, 6.27
1.14,1.42. See also herba l incense, 8.10-11
refinemen t of substances high conce ntrati on , 6.32,
T EDS. See Treatment Episode 6.40, 9.47
Data Sets me mory, 6.36-37
Teen Challenge , 9.15 misrepresentation , 6.3
Tegreto l.'" See carba mazepi ne receptor s ites, 2.2 1
Telemachus , l. 10 synthetic , 6.33
television addict ion , 1.40, 7.60-6 1 Thea sinen sis (tea) , 1.11, 3.4
television shopping networks , 7.32 thebain e (opiate), 4.6, 4. 7
tema zepam (Restoril'"), 4.36-38 , "the kind " (marijuana ), 6.4
10.29, 10.30 Theobroma cacao (chocolate),
Temesta.'" See lorazepam 3.39 , 3.4 1
Tempera nce Movement , 1.21, 5.4 , 8.1, theobromine , 3.39, 9.53
8.4, 8.5, 9.28 Theophra stus , 1.13
theo phylline , 3.3, 3 .23
theori es of addic tion , 2.36-38
cognitive impa irment and,
10.22, 10.33
cue extinctio n, 8.13, 9.25
drug , 9.9 , 9.42 , 9.46, 9.52 ,
9.66-69
drug replacement therapy
(See buprenorphine ;
methadone )
effectiveness , 3.30-3 1, 7.44, 9.70
family, 8.14, 8.7, 9.33, 9.42,
9.5 1, 9.61
gene therapy , 10.21
group, 9.1 , 9.13, 9.25, 9.26,
9.27-28 , 9.31 , 9.41, 9.51
individual , 9.26, 9.54
motivational enhancement
therap y, 9.41
outpa tient, 9.7, 9.8, 9.12, 9.13,
9.14 , 9.15, 9.17, 9.20 ,
9.21 , 9.37 , 9.44, 9.50 ,
9.51, 9.62 , 9.63
psychosoc ial, 9.21 , 9.26, 9.50
psychotropi c medications in , 10.5,
10.13 ,10.22, 10.24-31
ther iac, 1.1 7
THG. See tetrahy dro gest rinone
th iamylal sodiu m (Surita l'"), 4.3 1
thin layer chroma tography (TLC),
8.50
thiope ntal sod ium (Pentoth al'"), 4.31 ,
4.37 , 4.44
th ioridazin e (Mellar il'"), 8.4 1,
10.27 , 10.30
thiothi xene (Navane "'), 10.30
th ioxanthenes , 10.30
"thizz ," 6.4
Thoraz ine.'" See chlorproma zine
"thornap ple." See datura
th ought disorder. See also cogn itive
disto rtion ; schizop hreni a
abused drugs and , 10. 1, 10.3,10.7,
10.11, 10.14, 10.18,
10.26, 10.32 10.33
pre-existing conditions, 10.2, 10.6,
10.13-15
psychiatric medications , 10.24-33
3C-F LY.See bromo -dragonFLY
3,4-methy lenedioxymethamp heta
mine (MOMA). See MOMA
"thre e-strikes-and- you're-out" law, 8.9
throat and eating disorders, 7.53
thyro xin, 9.36
tiagab ine (Gab itril'"), 9.39, 9.66, 9.69
tim e-release drugs , 2.4, 3.29, 9.69
inject ion, 1.8, 1.37
op ioid an tagon ists , 4.6-7, 9.42
oxycodone, 4.28
Tindal. '" See acetophe nazine
Tippling Act (England), 1.18
"tipsy gene ," 2.38
tissue depend ence. See also tolerance
acu te withdrawal , 4.20
alcohol , 5.24
barbiturat es, 4.39
ben zodia zepine s, 4.39
defined, 4.19
I
TLC. See thin layer chromatography
toad secret ions (bufoten ine , DMT),
6.4 , 6.12, 7.28
TOBACCO. See also nicotine
addiction , 3.44-46
adolescents , 8.38-39
advertisi ng, 3.52-53, 8.16-17
age of first use, 2.33 , 3.50 , 8.18
American Indians 3.43-44
anti-smoking efforts, 3.58, 8.16
cancer , 1.23, 1.35, 3.42-43,
3.50 , 7.2 1
chewing tobacco , 1.36, 2.4, 3.4 ,
3.46, 3.53, 7.21, 9.22,
9.40, 9.41 (See also
smokeless tobacco)
college, 8.27 , 8.28-30, 8.32
in colonial America , 1.18-1.19
companies , 3.47, 3.56
cost , 3.51
craving, 3.47-51
detoxificatio n, 3.50-5 1
effects, 3.46 , 3.48 , 3.49-50 ,
3.53-54
harm reduction , 8.15
high school , 8.27, 8.28-30
history, 1.12, 1.14-1.15 ,
1.18-1.23 , 3.43-44
lawsu its, 1.31, 3.47 , 3.58
longev ity, 3.5 1
marijuana and , 6.37-38
medic inal use, 1.16
m ilitary use, 3.41, 3.42, 8.49
mortali ty, 3.48, 3
movie scenes, 8 .36
Native Americans , 1.15-16
nicoti ne, 1.2, 1.8 , 1.12, 1.17,1.19,
1.23, 1.36, 1.38, 3.3, 3.4,
3.42-59 , 7.21
pha rmacolog y, 3.46-47
pregnanc y, 3.54 , 8.18 , 8.25-26
respiratory effects,3.5 2-53
second hand smoke , 1.36, 3.42-43,
3.51-52, 3.58-59 , 8.25
sen lement , 1.36 , 3.47, 3.58
sex, 8.37-38
side effects, 3.50-5 1
smoke less tobacco (snuff, chewi ng
tobacco), 1.12, 1.15 , 1.16,
3.45-46
smok ing prevention , 1.35- 1.36 ,
3.50, 3.58, 8.7, 8.11,
8. 15- 16, 8.38
spo rts, 7.21, 7.23
Surgeon General's Reports, 1.23,
1.35, 3.42 , 3.51 , 3.59
tolerance , 3.48 , 4. 16
treatment , 3.55, 9.40-4 1, 9.66
use by age, 8.54
withdraw al, 3.48-49
tobacco industry , 1.20, 3.5 1-53,
8. 15- 16
Tofranil.'" See imipramine
 1.34 INDEX
TOLERANCE, 2.27- 28. See also
cross -tolerance
age and, 4.34-35, 5.37
alcohol, 5.24-26, 5.24-25
amphetamines, 3.26, 7.20, 10.27
barbiturates, 4.41
benzodiazep ines, 4.37, 4.39
caffeine, 3. 7, 3.40
cocaine, 3.9, 3.14, 3.20, 3.56
cross tolerance, 4.44
dextromethorphan, 6.24
dispositional tolerance, 4.37
efavirenz, 6.25
elderly, 8.57
I
heroin, 4.44
inhalants, 7. 11
inverse, 3.15, 6.40
ketam ine, 6.22
LSD, 6.5, 6.8
marijuana, 6.39-40, 9.47
MDMA, 6.16--17
opiates/opioids, 4.19, 7.15
peyote, 6.13
pharmacodynamic, 4.37, 6.39
physical changes, 2.6
psychedelics, 9.47
reverse tolerance, 4.39
sedat ive-hypnot ics, 4.1, 4.30, 4.32,
4.33, 4.39
serotonin receptors, 6.17
sexual addiction, 7.54
stimulants, 3.6, 3.7, 10.27
television addict ion, 7.60
tobacco, 3.45, 4 .16
types of, 2.27- 28, 2.47
Toltec Indians, 1.14
toluene (methyl benzene), 3.47,
7.4, 7.5, 7.6, 7.7, 7.8
"toot " (cocaine), 3.3
"tooting, " 3.10
Tootsie Roll, ® 6.16
Topamax. ® See topiramate
topica l anesthetics, 1.21 , 3.3,
3.12, 7.15
topical gel (steroid), 7.18
topic -specific groups, 9.31
topiramate (Topamax ®), 9.9, 9.20,
9.39, 9.46, 9.66, 9.68, 9.69,
10.27,10.29, 10.30, 10.33
TOPS. ® See Take Off Pounds Sensibly
torsade de pointes, 4.26
ToughLove ® approach, 9.34, 9.55
Tour de France, 7.11, 7.14
TouretteS syndrome, 2.39, 3.31 , 7.33
toxicity, 6.3
acute tolerance (tachyphylaxis),
2.27
alcohol, 5.30
Amanita mushrooms, 6.23
anticholinergic psychedelics, 6.20
cocaine 3.15
datura (jimsonweed), 1.13, 6.20
dextromethorphan, 6.21
inhalants, 9.48
ketam ine, 6.21
lookalikes 3.32
MDMA6.16
PCP, 6.21
psychedelics, 6.13, 6.18
select tolerance (tachyphylaxis),
2.27- 28
tryptam ine, 6 .13
tracking abili ty and marijuana,
6.34, 7.26
"tracks " (need le), 4 .18, 4.19, 7.19
trade names, 1.36
amphetamines, 3.3
anandamide antagonists, 9.48
energy drinks, 3.40
GHB, 4.36
ketamine, 6.21
opiates/opioids, 4 .6
phenethy lamines, 6.16-17
sedative -hypnotics, 4.36
steroids, 7.19
stimulants, 3.3-4
synthetic cannabinoids,
1.30-1.34, 6.28
traffic fatalities (alcohol), 5.34, 5.34
trafficking, 8.10. See also drug gangs;
illegal drug labs
colleges, 8.10-11
synthetics, 8.11 - 12
"tragic magic, " 3.19
trailing phenomenon, 6.8, 6.34
tramadol (Ultram, ®Ultracet ®) ,
4.33, 9.67
"tranquility, " 6.4, 6.20
tranquilizers, 1.33, 1.37, 6.22, 7.25.
See also ketamine; "minor
tranquilizers "; sedative -
hypnotics
nasa l spray, 2.3
sex, 8.39
treatment of psychoses, 10.27
transderma l absorption, 2.4, 9.66.
See also adhesive patches;
contact absorption of drugs;
scopolamine
transitional living treatment
programs, 9.15
transport of drugs to brain, 2.4, 2.23
transport pumps, 3.25
transvestic fetishism, 7.56
Tranxene .® See clorazepate
tranylcyprom ine (Pamate ®),
10.27, 10.30
trauma, 2.1, 2.12, 2.26, 2.37, 2.40,
2.41, 2.42, 2.45, 2.47, 7.7,
7.47, 10.4-6, 10.17. See also
post -traumatic stress disorder
LSD use, 6.7, 6.9
needle use, 4.22 - 23
pass ing out, 6.18
traumatic medical procedures, 4.40
trazodone (Desyrel ®), 10.26, 10.30
treatment, 8.27
TREATMENT, 9.1- 73. See also
counseling; detoxification;
diagnosis; harm reduction;
12-Step Programs;
withdrawal
12-step groups, 1.25, 1.30, 2.4, 5.4
acupuncture, 9.36
addiction as brain disease, 9.2 - 3,
9.70
African Americans, 9.57 - 59
alcohol, 1.25, 1.29, 5.2- 26, 5.28,
5.37, 5.41, 9.45-46, 9.66
alternative treatments and
services, 9.35 - 37
amphetam ines, 1.36, 9.38-40,
9.53, 9.66
anorexia, 9.49, 9.50-51
Asian Americans, 5.44, 9.60-61
aversion therapy, 9.13, 9.26,
9.39-40, 9.41, 9.53, 9. 71
bad trip, 9.46--47
beginning treatment, 9.15 - 19,
9.45, 9. 71
behavioral addictions, 9.49 - 53
bulimia, 9.51
buprenorphine, 1.37- 1.38, 4.38,
8.3, 8.14, 8.23, 8.25
child ren of addicts, 9.34-35
cocaine, 9.38-40, 10.20, 10.25,
10.26
compulsive overeating, 9.51 - 52
continuum, 9 .19- 26
cost, 9.14, 9.55, 9.70
counseling, 10.11, 10.23 - 24
cue extinction. See desens itization
current issues, 9 .3-6
DATOS, 9.7
denial, 8.13, 8.27, 8.45, 8.48, 8.53,
9.17- 18, 10.11, 10.23,
10.24
disabled, 9.62--63
drug courts,1.42
drug -induced symptoms, 5.28
drug -specific programs, 9.38-55
drug testing, 8.53
dua l-diagnosis, 1.31, 10.08-13,
10.21- 31
eating disorders, 7.45 - 54, 9.50 - 52
effectiveness, 8.13-14, 9.70
elderly, 9.56--57
electronic addictions, 9 .54- 55
emotional maturation, 5.35 - 36,
8.13, 8.29, 8.29 - 30, 8.34,
9.64, 10.23
ethnic considerations, 9.57-62
family and, 8.32 - 35
federal centers, 4 .10
follow-up, 9.30, 9.64-65
gambling, 7.33, 7.38--39, 9.49 - 50
gay and lesbian, 9 .63
goals, 9.33, 9.65, 9.70
government facilit ies, 9.13
group therapy, 9.27 - 32
harm reduction, 1.29, 8 .14-15,
8.45, 9.6, 9.10, 9.13,
9.15, 9.23, 9.54, 9.67
health problems, 9.18
heroin, 4.29-30, 9.26. See also
methadone; opiates/
opioids
Hispanic community, 5.40,
9.59--60
HIV prevention, 8.45
homeless, 5.39
individual therapy, 9.26-27
infectious disease, 8. 46
inhalant abuse, 9.49 - 50
initial abstinence, 9.38-39, 9.46
Internet addiction, 7.57 - 59
intervention, 8.14, 8.31, 8.47,
8.60, 9.18--19
lack of resources, 8.14-15
long -term abst inence, 9.39-40,
9.46
marijuana, 9.47-48
medication therapy, 9.65 - 70. See
also methadone
mental hea lth disorders, 10.21 - 31
mental health vs. substance abuse
communities, 1.39, 9.6,
10.09- 13
methadone, 1.29. See also harm
reduction
motivat ional approaches, 10.11,
10.21, 10.24
multisystemic therapy, 8.30
neurochemistry, 2.47
obstacles, 8.13-14, 9.64-65
opiates/opioids, 9.36, 9.37,
9.41--43, 9.66. See
also harm reduction;
methadone
outcomes, 8.10, 9.30, 9.64-65
philosophy of treatment, 9.6-8
polydrug abuse, 5 .25
pregnancy, 8.26
psychedelics, 9.46-47
psychopharmacology, 10.24-31
rapid opioid detoxification, 4.33
resources for, 9.65
sedative -hypnotics, 9.44
sexual addiction, 7.55, 9.53-54
spirituality and recovery, 5.42,
9.29 - 31, 10.11
stages of change, 1.4 2
tertiary prevention, 8.13 - 14
tobacco, 1.36, 3.51, 9.40-41, 9.66
withdrawal symptoms, 2.28
women, 9.55
workplace, 8 .50
youth, 9.55- 56
treatment admissions, 9.15, 9.16
alcohol, 9.45, 9.45
cocaine, 9.38
cognitive status examinations,
9.64
by ethnicity, 9.58
inhalants, 9.48
marijuana, 6.40, 9.47, 9.48
men vs. women, 9.55
methamphetamines, 9.38
opioid abuse, 9.41
by source of referral, 9.19
stimulants, 9.38
treatment communities, di fferences
among, 1.35, 9.6, 10.09,
10.11- 13, 10.32
treatment continuum, 9.19 - 26, 9.71
Treatment Episode Data Sets (TEDS),
3.17, 3.23, 6.35, 7.5, 8.23,
9.7, 9.8, 9.65
alcohol, 9.45
ethnicity, 9.58
treatment admissions, 9 .15, 9.16,
9.45, 9 .58
Treatment Research Institute,
University of Pennsylvania,
9.8
tremors, 6. 40
Trexan. ® See naltrexone
triads, 4.10
triazolam (Halcion, ® Rilami r®), 4.36,
4.38, 8.54, 10.30
trichlorethylene (TCE), 7.4, 7. 7
trichloroethane, 7.4
trichomes, 6.30
trichomonas vaginalis, 8.42
tricyclic antidepressants
as medication, 10.26, 10.30, 10.31
serotonin and, 8.41, 10.25 - 27
sex, 8.39
trifluoperazine (Stelaz ine ®), 10.30
triggers
binges, 9.52
environmental, 2.30--31
internal, 2.10
relapse prevention, 9.24
sexual assault, 8 .32, 8.38, 8.40
stimulant craving, 9.39
trihexyphenidyl (Artane ®), 6.4, 6.20,
10.28, 10.29, 10.30
Trilafon. ® See perphenazine
Trileptal. ® See oxcarbazepine
trimipramine (Surmontil ®), 10.30
TrimSpa, ® 9 .53
Triple P (Positive Parenting Program),
8.7
triple diagnosis, 10.12, 10.13
"Tripstacy," 6.4, 6.16--19
trismus (jaw muscle spasm), 6.15
TrophAm ine, ® 9.36
Tropium .® See chlordiazepoxide
Trotte r, Thomas, 5.22
Trujillo coca leaf, 1.22
Trump, Donald, 2.34
"truth serum " (thiopental sodium),
4.31
tryptamines, 6.4, 6.8, 6.12 - 13
tryptophan, 9.21, 9.39, 9.68
 INDEX 1.35

"Ts" (pentazoci ne ), 4.7 ulcers (mouth), 7.6 vasoconstriction, 3.11, 3.42, 6.6 vitamins, 4.40, 7.29. See also nutrients
tuberculosis, 8. 4 3 Ultimate Xphoria, ® 6.17 vasodilation (b lood vessels), 2.20 and nutrition
alcohol, 5.21 Ultracet. ®See tramadol alcohol, 5.19, 5.41 beer, 1.17-1.18, 5.6
marijuana, 6.23 Ultram. ®See tramadol inhalants, 7.9, 7.23 coca leaf, 3.9
opioids, 4.9, 4.19 ultrarapid opioid detoxification nitrites, 7.9 deficiencies, 2.41, 5.16, 5.18, 5.19,
treatment plan, 9.9, 9.10 (UROD), 4.33, 9.42 vasopressin (Catap res ®), 2.29, 7.29 8.56, 10.14
"tuies," 4 .36 Unisom, ®4.3, 8.58 Vedas, 1.10, I.I 1 energy drinks, 1.34, 1.36,
Tuinal ® (secobar bital and amobarbital; United Kingdom. See England venereal disease. See sexually 3.37, 3.38
"rainbows"), 4.36, 4.44 U.S. Coast Guard. See Coast Guard transmitted diseases FDA category, 8.24
Turkey, 1.9, 1.141.16, 1.32, 6.37 U.S. Household Survey on Drug venereal warts, 8. 41 herbal products, 3.37, 7.23
Tussend. ® See hydrocodone Abuse. See Household Survey venlafaxine (Effexor®), 9.39, 9.68, look-alikes, 3.37
Tussionex, ® 8.7 on Drug Abuse 10.26, 10.30, 10.31 pregnancy, 8.25
Tussol. ® See methadone U.S. Olympic Committee (USOC), ventral tegumental area (VTA), sports and, 7.23, 7.24
Tut, King (Egypt), 1.9 7.20 2.13, 4.16 urine tests, 8.53

TV advertising, 4.24
anti-tobacco, 3.58
TWEAK,9.12
"tweak ing, " 2.16, 3.28, 3.58, 9.39
12-STEP PROGRAMS, 1.25, 1.30,
8.13, 9.13, 9.22, 9.24,
9.28-31, 9.35, 9.59
Alcoholics Anonymous, 2.2, 5.4
behavioral addictions, 9. 49
eating disorders, 7 .54
individual therapy, 9.39
sexual addiction, 7.55
twin studies, 2.36, 2.38-39, 3.34
alcoholism, 5.23
anorexia nervosa, 7.51-52
behavioral disorders, 10.3
Cannabis, 6.41
compulsive behaviors, 7.52
polydrug abuse, 9.38
Twitter, 1.42, 7.32
2AG (2-arachidonyl glycerol), 2.20,
2.22
2-AGE (noladin ether, 2-arachidonyl
glycerol ether), 2.22
2C-l,6.4
2C-C, 6.4
2C-B (CBR, dimethoxyphenethyla-
mine), 6.4, 6-15, 6.18
2CB (dime thoxyphene -thylamine),
1.25, 1.36
2C-B-FLY. See bromo-dragonFLY
2C-FLY. See bromo-dragonFLY
2C-T-2 (2,5-dimethoxy-4-ethyl-
thiophenethylamine),
6.4, 6.15
2C-T-7 (2,5-dimethoxy-4-propyl-
thiophenethylamine),
6.4, 6.15
2,5-dimethoxy-4-ethyl-
thiophenethy lamine
(2C- T-2). See 2C-T-2
2,5 dimethoxy-4 methylamphetamine
(STP, DOM). See STP
2,5-dimethoxy-4-propyl-
thiophenethy lamine
(2C-T-7). See 2C-T-7
Tylenol. ®See acetaminophen
Tylenol PM Extra, ®4.3
Tylox.®See oxycodone
Type A and Type B alcoholism, 5.20
Type I and Type II alcoholism, 5.20
tyrosine (amino acid), 9.21, 9.39, 9.68
u valproic acid (De pakene ®), 10.20,
U4Euh (4-methylpemoline), 3.3, 6.4
Ober Coca (Freu d), 1.21, 3.39
uBid, 7.58
UH-232, 9.67
Uhl, G.R., 2.11
Ukraine, 8. 44
ulcers (gastrointestinal), 3.39, 7.16
alcohol, 5.18, 5.44
antihistamines, 4.3
IV drug users, 4.19
U.S. Supreme Court. See Supreme
Court
U.S. Surgeon General. See Surgeon
General
universal prevention, 8.12
universal screening, 8.27-28
University of Virginia, 8.5
unsafe sex, 1.33. See also high-risk
behavior; sex and drugs
ado lescents, 8.29, 8.36, 8.41
alcohol, 5.12, 5.35, 5.44, 8.29,
8.36, 10.18
hepatitis A, 8.42
HIV, 8.41, 8.45, 8.46, 9.63
mental disorders, 10.15, 10.18
meth abuse, 3.24, 9.38
sexual addiction, 9.53
STDs, 8.41
use during pregnancy, 8.19
UPPERS. See stimulants
up regulation, 2.24
Urban VIII, Pope , 1.16
urethritis, 8.41
urinalysis, 3.8, 8.47, 8.50, 8.51,
8.52, 9.40, 9.60. See also
drug testing
test manipulation, 8.51, 8.52, 8.53
UROD. See ultrarapid opioid
detoxification
usabingo.com, 7.55
USOC. See U.S. Olympic Committe
V alcohol, 1.21, 5.14, 5.31-41
vaccines
AIDS, 8.46
antagonist medications, 9.67
cocaine treatment, 9.67
drug abuse treatment, 9.21, 9.67
nicotine craving, 3.55
weight loss, 9.52
vaginal absorption, 3.11
vaginitis, 8. 41
vaginosis, 8. 41
Vaillant, George, 5.21, 9.22
Valeriana officinale (valerian root),
9.37
valerian root, 9.37
Valium. ®See diazepam
Valium• (diazepam), 4.33, 8.30, 8.55
"valley girl" (Valium ®), 4.36
valproate (Depacon ®), 9.69,
10.27, 10.30
10.27, 10.30
"vals" (Valium ®), 4.36
Vanilla Sky,• 8.12
Vaping, 1.36
vaporization technique, 2.3
vaporized nicotine. 1.36, 3.56.
See electronic cigarettes
VaporOne ® (apparatus), 2.3
vardenafil (Levitra ®), 8.36
varenicline (Chantix ®), 3.55, 9.9,
9.21, 9.40, 9.41, 9.66, 10.14
Vermont, 6.38
vermouth, 5. 7
Veronal. ®See barbita l
Versed. ®See midazolam
vesicles, 2.19, 2.22, 2.23, 2.24,
3.25, 6.15
Vestra. ®See reboxetine
veterinary medicine. See also
ketamine; PCP
anesthetics, 7.11
psychedelics, 6.21
Viagra. ®See sildenafil citrate
"Vic" (Vicodin ®), 4. 7
Vick's®inhalants, 6.14
Vick's Inhaler, ®3.3, 6.14. See also levo
amphetamine
Vick's Vapor Inhaler, ®8.50
Vicodin. ®See hydrocodone
Victorian Era, 1.22
video games, 1.42, 2.41, 7.35
video poker, 1.2, 1.41, 2.42, 7.33, 7.42
Vietnam, 3.22, 7.32
Vietnam War, 1.23, 1.41, 4.25
vigabatrin (Sabril®), 9.39, 9.66
vigabatrin/CCP-109 (Sabril ®), 9.69
"vike " (Vicodin ®), 4.4, 4.6
"vilca," 6.11
vinegar, 8.53
"vine of the soul or death " (yage), 6.4
Vin Mariani, 1.21, 3.10
vinyl chloride, 3.47
violence
amphetamines, 3.2-287
bystander witness of, 5.31
cocaine, 3.12-13, 3.17
sex, 8.34
steroids, 7.18
stimulants, 3.6
substance-induced menta l
disorders, 10.18
Vioxx. ®See rofecoxib
Virginia leaf, 1.18
Virginia Slims, ®3.51
Virilon. ®See methyltestosterone
Virilon IM.®See testosterone
cypionate
"virtual novelty," 6.31
virtual-reality graded exposure
therapy, 9.36
"virtual reel mapping' technology,
7.42
viruses
blood-brain barrier, 2.5
needle use, 3.16, 4.22, 4.24, 8.42
(See also AIDS and HIV;
hepatitis (A, B, C))
Visine, ® 8.53
"visionary vine" (ayahuasca), 6.4
Visken. ®See pindolol
Vistaril. ®See hydroxyzine
"vitamin B 12" (calcium pangamate),
7.24
"vitamin K" (ketamine), 6.4, 6.21
"vitamin R" (methylphenidate), 3.30
I
vitamin Bw 5.17, 7.24
vitamin therapy, 9.36, 9.46
vitas vinifera, 5.6
Vivactil. ®See protriptyline
Vival.®See diazepam
Vivarin, ®3.4, 3.42, 7.20, 8.56
Vivitrol. ®See nalt rexone
vodka, 5.7, 5.36-37
volatile nitrites ("po ppers "), 7.2, 7.8.
See also inhalants
with adrenaline, 7 .24
effects, 7.9
sex, 8.39
volatile solvents, 1.19, 7.2, 7.5-6. See
also alcohol solvents; alkanes;
gasoline; inhalants; methyl
butyl ketone; N-hexane;
toluene; trichlorethylene
major abused solvents, 7.6-7
psychiatric effects, 7.8
short- and long -term effects, 7.5,
7.7-8
warning signs of abuse, 7. 7
Volcano ® (ap paratus), 2.3
Volkow, Nora, 2.2, 2.42, 2.43, 3.12,
3.25, 3.29, 7.48, 9.3, 9.4,
9.22, 9.64
Volstead Act, 1.23, 1.25. See also
Prohibition Era
voltage, 2.20
vomiting
beta blockers, 7 .23
caffeine, 3.42, 3.48
eating disorders, 7.1, 7.45, 7.50,
9.51
effects of, 7 .52
hangover (alcohol), 5.16
hepatitis, 8.42
marijuana 6.38
opium/opiates, 2.29, 4.18,
4.20--21, 4.40, 8.23
psychedelics, 6.6, 6.12- 14, 6.19
sedative-hypnotics, 4.4.2-43
tobacco, 3.45
weight loss, 7.231 7.47
voyeurism, 7.56
VTA. See ventral tegumenta l area
(VfA)
Vyvanse. ®See lisdexamfetamine
w
WADA. See World Anti-Doping
Agency; World Anti-doping
agency
Wales, 5.33
"war on drugs," 1.6, 1.29, 8.14,
8.15, 9.6
Wars for Free Trade. See Opium Wars
warts (genital), 8.41
Washington (state), 6.38
Washington, D.C., 8.44
Washington, George (U.S. president),
1.18, 1.19, 6.23
Washingtonian Revival, 9.28
 1.36 INDEX
Wash ing ton Temperance Socie ty, 5.4
Wasson, R. Gor d on, 6.10
water soluble drugs, 2.6
Watson 387 (hydrocodone), 4.6
Watt, James, 7.9
"wedding bells, " 6.4
"we dges, " 6.4
"wee d " (mari j uana), 6.4, 6.21, 6.24,
6.26, 6.32
we ight control, 1.23, 7.46. See also
anorexia nervosa; diet pills;
eating disorde rs; stimulants
eating d isorders, 7.45, 7.51-52
inhalants, 7.6
I
nicotine, 3.85
obesity tr eatment, 9.52-53
sports, 7.24-25
stimu lants, 3.5, 3.22, 3.32
weigh tlifting, 2.32, 7.13
we ight phobia, 7.5 1. See also an orexia
nervosa
Wellbutrin. ® See bupropion
Wepfer, Johann Jakob, 2.43
Wemicke's encephalopathy, 5.19,
10.15, 10.19
West Indies, 1.15
we t drink ing cultures, 5.33
Wet Party (Wets), 5.4
"wets," 8.5, 8.6
WFS. See Women for Sobriety
"whac k," 3.19
Whip- It !,® 7.10
whipped cream propellant, 7 .4.
See also nitrous oxide
"whi p pits" (Wh ip -It!, ® EZWhip ®),
7.3, 7.10
whiskey, 1.7, 1.15, 1.18, 1.21, 1.31,
1.33, 5.7
alcohol content, 5.8, 5.42
Whiskey Rebellion, 1.18
"whi te knuckling, " 9.20
Whites. See also ethnic consi d erations
alcoholism rates, 5.1, 5.43
alcohol use, 2.7, 5.43
birth defects, 5.28, 8.21
diabetes, 7.46
homelessness, 5.39
inhalants, 7.5
law en forcemen t , 8.17
problem gambling, 7.36
psyche d elics, 6.3
rates of drug use, 8.17
tobacco use, 3.57, 8.26
treatment admissions, 9.58
"whi tes" (amphetam ine), 3.3
WHO. See World Health
OrganizationWii, ® 7.3, 7.46
"w ild cat" (khat), 3.4. See also kha t
wild daggha, 6.2, 6.25
"wild hemp," 6.22
Wilkenson, Bruce, 8.46
Williams, Cecil, 9.59
Wilson, Bill, 1.25, 9.28
"w indow pane" (LSD), 6.6
wine, 1.6, 1.9--11, 1.14, 5.6, 8.3,
8.21, 8.26, 8.34, 8.35, 8.36,
8.44, 8.56
alcohol conten t, 5.6, 5.8
wine coo ler, 3.19, 5.6, 5.8
winning phase (gamb ling), 7.38
Winston, ® 3.44, 3.51, 3.52
Winstrol. ® See stanozolol
Winst rol -V.® See stanozolol
wi tchcraft, 6.20
wi tches' berry (be llad onna), 1.13
Withania somni fera (ashwagandha),
9.36
WITHDRAWAL,3.5--o, 3.7.
See also crash; detoxificat ion;
half- life; non purposive
withdrawal; post-acute
withdrawa l syndrome;
protracted with d rawa l;
pu rposive with d rawal;
recovery; treatment; entries
for specific substances
acute, 4.20
alcohol, 5.16--17, 5.20, 5.24--25,
9.45--46
am p hetam ine, 3.27-28
anorexia, 7.49
barbiturate, 4.37, 4.39, 4.41
benzodiazepines, 4.1, 4.32, 4.33,
4.34--36, 4.44, 8.26
betel, 3.34
buprenorph ine, 4 .26-27
caffeine, 3.45
care during, 9.45
cocaine, 3.14
codeine, 4.20
con tinued op iate use and, 4.2,
4.17, 4.21, 4.42
craving, 2.13
defined, 2.29--31, 2.37
elderly, 9.57
emot ional memory, 2.12, 2.14
gambling, 9.49
GHB, 9.47
heroin 4.20
iboga ine, 6. 12
infants, 8.22
inha lants, 7.11
khat, 3.34
Kratom, 4.33, 4.37
LAAM,®4.32
LSD, 6.8
Lunes ta,® 4.34-35
mari j uana, 6.39-40, 8.24, 9.47
medically assisted d etox, 9.20-21
medical mari juana, 6.39
medications, 9.3, 9.11
methadone, 9.43
neonates, 4.21, 8.23, 8.24, 8.25
opioids, 4 .19
physical changes, 2.39
physiology, 2.29-31
post -acute, 4.20, 9.45
pregnancy, 3.54, 8.23
protrac ted, 4.20
purpos ive, 4.22
rapid opioid de toxification,
4.33, 9.67
reeme rgence of symptoms, 9.44
replacement the rapies, 9.42
research and, 4.19
risk factors, 4 .16
sedative-hypnotics, 4.37, 4.38
social mo d el treatment, 9.20
steroids, 7.18
stimulants, 3.5-6
sym p toms of mental illness, 5.28
tobacco, 3.44, 3.45, 3.48, 3.51
treatment, 9.20, 9.39
types of, 2.29--31, 2.48
wolfbane, 6.4
WOMEN. See also domestic vio lence;
eat ing disor ders; lesbians;
menstrua tion; pregnancy
acne, 7.17
African American, 9.58
alcohol, 5.9, 5.19, 5.37-38,
8.35, 8.49
Black women, 5.42-43
blood alcohol level, 2.4, 5.8,
5.9, 5.10
body image, 7.50
cocaine, 3.20
depressants, 4.9, 4.34
eating disorders, 7.50
epidemiology, 8.35
HIV, 3.20, 8.44
inhalants, 7.5, 7.10
opia te addiction, 4 .9
opia te effects on, 4.19
pregnancy, 8.19-27
sex, 8.36
steroids, 7. 15, 7.17, 7.19
treatment, 3.17, 5.38, 9.55
violence against, 5.33
Women for Sobriety (WFS), 9.31
Women's Christian Temperance Union
(WCTU), 1.21
Women's Crusade, 1.21
Wood, Alexander, 1.20
woo d alcohol. See methy l alcohol
Woo dward, Samuel, 9 .13
"woo lies," 3.19
WORKPLACE DRUG USE, 8.47--49
costs, 8.47-49
drug -free workforce gu idel ines,
8.49
drug testing, 8. 48, 8.53
EAPs, 8.48, 8.48---49,8.50
intervention, 8.49, 8.50, 9.17-18
loss of productiv ity, 8.47-48
prevention, 8.59
testing, 8.51-52
"wo rks, " 8.42
Wo rld Anti-Doping Agency (WADA),
7.11, 7.14, 7.21, 7.24, 7.26,
7.59
Wor ld Health Organization (WHO),
3.29, 8.4 1
alcoho l, 1.29, 5.18, 5.23
inhalant abuse, 7.5
In terna tiona l Classification of
Diseases (!CD), 2.36
obes ity, 7.45-47
tobacco, 1.35
Wor ld of Warcraf t,® 7.59
Wor ld War II
amphetamines, 1.26,
3.21-22, 8.49
cigare tt es, 1.23, 3.44
Wright, C. Alder, 1.20, 4.9
Wygesic. ® See propoxyphene
X Zimovane. ® See zopiclone
"X." SeeMDMA
Xanax. ® See alprazolam
"xannies" (a lp razolam), 4.31.
See also alprazo lam
Xanor. ® See alprazo lam
xanthines, 3.4, 3.38, 8.25.
See also caffeine
Xbox 360, • 7.56
"x-boxes " (alprazolam), 4.36.
See also alprazo lam
Xenadr ine EFX, ® 8.56, 9.53
Xenical. ® See orlistat
"XTC" (ecstasy), 6.4, 6.15.
See also MOMA
Xyrem. ® See GHB
y
"yaa baa" ("ya ba," "yaa maa"),
1.36, 3.23
yage. See ayahuasca
Yahoo 1, 7.56
Yakuza, 3.22
Yale Laboratory of App lied
Psychology, 5.20
yeast and alcohol, 3, 5.5, 5.6
yeast infec ti on, 8.42
"yellow jackets," "yellows"
(pentobarbital), 4.36, 4.41
"Yellow peril, " 1.23
"yellow rock" ("ice"), 3.3, 3.23
"yellow sunshine," 6.4
Yemen, 3.2, 3.32-33
yoco, 1.14, 3.40
yoga, 9.37
yoh imbe, 1.2, 1.37, 1.40, 3.36, 8.40
Yohimbe 8,® 3.4
Yohimbe Power, ® 3.36
"yopo" (DMT), 6.2, 6.4, 6.12
young teens, 8.37
YOUTH. See also adolescents
age of firs t use, 3.50, 8.17
alcohol, 5.34, 5.42
energy drinks, 3.37-38
epidemio logy, 8.27-29
food advertising, 7. 44
marijuana use, 6.28, 6.37
marketing and, 8.16-17
maturation, 8.13, 8.29, 8.29-3,
8.34, 10.23
neurochemistry, 6.32
OTC and prescrip tion drug abuse,
4.5, 4.40
peer programs, 8.58
perceptions of ha rmfu lness, 8.28
prescription drug abuse, 1.28, 1.29
prevention, 8.61
res iliency, 8.2, 8.6, 8.3
risk factors, 8.5, 8. 7, 8.11-13,
8.21, 8.30-32
treatment admissions, 9.55-56
youth surveys, 8.2, 8.27-28
Yu, Emperor, 1.10
Yucatan Fi re,® 6.28
Yucatan Peninsula, 1.14
z
zaleplon (Sona ta,® Stamoc ®), 4.2,
4.36, 4.42, 8.38, 10.30
Zaniflex. ® See tizanidine
Zantril. ® See phentermine HCL
zeranol (Ralgro ®), 7.18
zero-tolerance policies, 5.10, 5.34,
8.3, 8.10, 8.15, 8.30
Z-hypnotics, 4.37-38
zidovud ine. See AZT
Zimulti. ® See r imonabant
zinc su lfate, 8.53
ziprasidone (Geo don ®), 9.39, 10.28,
10.30, 10.33
Zoldem. ® See zo lpidem
Zoloft. ® See sertraline
zolpidem (Ambien, ® Nytamel, ®
Zoldem • ), 1.3, 4.2, 4.36,4.42,
8.37, 10.30
zopiclone (Imovane, ® Rhovane, ®
Zimovane ®), 4.36, 4.42
4.37-38, 10.30
Zyban. ® See buprop ion
Zydone. ® See hydrocodone
Zyprexa. ® See olanzapine