Addiction as a Disease of the Human Spirit

 To understand the reality of addiction is to

understand something of human nature.
 The word “spirit” is derived from the Latin
word spiritus, which means the divine, living force
within in each of us.
 In the human, life – spiritus – has become
aware of itself being apart from nature and
others.
 Human Spirit…
 Each person possesses the twin gifts of self-awareness
and self-determination. Each can, within certain limits,
be aware of himself or herself and decide his or her
fate.
 The addicted person is on a spiritual search.. Looking
for something akin to the great hereafter, and they flirt
with death to find it.
 Misguided, romantic, foolish, needful, they think they
can escape from the world by artificial means. And
they shoot, snort, drink, pop or smoke those means as
they have to leave their pain and find refuge. At first it
works. But, then it doesn’t.
 The drugs do not bring on addiction; rather the
individual comes to abuse or be addicted to
drugs because of what he believes to be
important. One expression of this flaw is the
individual’s hesitation to take responsibility for
the “self”. Personal suffering is one way of
owning responsibility for one’s life. Many
people find it difficult to accept the pain and
suffering that life entails.
 Unfortunately, modern society looks down on
the process of individual growth and the pain
inherent in growth. It is preoccupied with
individual happiness, and any pain is viewed
as unnecessary, if not dysfunctional. Further,
modern society advocates that pain
automatically be eradicated through the use of
medications, so long as the pills are prescribed
by a physician.
 Modern Neurosis
 A reflection of this modern neurosis is that
many people are willing to:
go to quite extraordinary lengths to avoid our
problems and the suffering they cause, proceeding
far afield from all that is clearly good and sensible
in order to find and easy way out, building the
most elaborate fantasies in which to live,
sometimes to the total exclusion of reality. (Peck,
1978,p17)
 Diseases of the Mind and Diseases of the
Spirit: The Mind-Body Question

 Diseases of the body are viewed as falling in

the realm of physical medicine, diseases of the
mind in the realm of psychological sciences.
Diseases of the human spirit, according to this
view, are the specialty of clergy(Reiser, 1984)
The problem with this perspective is that the
patient is not merely a spiritual being or a
psychosocial being or a physical being but a
unified whole.
 The Growth of Addiction: The Circle
Narrows
 As one’s addiction progresses, the drug becomes
the “axis” around which the addicts life
revolves. The drug comes to assume a role of
“central” importance for both the addict and the
family. The addicted person will demonstrate a
preoccupation with chemical use and will
protect his or her source of chemicals. It is not
uncommon for cocaine addicts to admit that
when it comes down to a choice, they would
choose cocaine over friends, lovers, or even
family.
 There are many people whose all consuming
interest is themselves. They care for nothing
outside of that little portion of the universe
known as “self” In this sense, chemical addiction
might be viewed as a form of self-love or
perhaps more accurately, as a perversion of self-
love. It is through the use of chemicals that the
addict seek to cheat themselves of the experience
of reality, replacing it with the distorted desires
of the self.
 The Science of Pharmacology
 The Prime Effect and Side Effect of
Chemicals
 Because the brain is so highly integrated
that is not possible to circumscribe
mental function without impairing a
variety of other functions, typically
causing generalized dysfunction of the
brain and mind.
 Science of Pharmacology
 In order to achieve the prime effect of a
compound, the user must endure the side
effects of that compound as well. Some of
the side effects will be relatively minor,
whereas others might be life threatening.
This rule is true for both pharmaceutical
agents prescribed by a physician for a
patient, and for the drugs of abuse.
 Pharmacology. The Method of
Administration.
 One factor that influences the intensity of
the drug’s primary and side effects is the
manner in which it is administrated. The
specific form in which a compound is
administered will have a major impact
on (a) the speed with which that
compound begins to have an effect on
the body.
 (b) the way that the compound is
distributed throughout the body, (c ) the
intensity of its effects, and (d) the speed
with which the individual will begin to
experience any side effects from that
compound. Drugs of abuse are
administrated either by the enteral or
parenteral route.
Enteral Forms of Drug Administration
 Compounds administered by the enteral
route enter the body by the gastrointestinal
tract. Such compounds are usually
administered in oral forms. The most
common of enteral drug administration is in
a tablet form, which is essentially a selected
dose of a compound mixed with a binding
agent that acts to give it shape and hold its
form until it enters the gastrointestinal
tract(GI).
 Parenteral Forms of
Administration
 The parenteral method of drug
administration involves the injection of a
compound directly into the body. The
several advantages to parenteral forms of
drug administration: the drug(s) is not
being exposed to gastric juices; delays
caused by the stomach-emptying
process;
 Parenteral Forms of Drug
Administration
 The danger of being mixed with food in the
GI tract, which might slow absorption by
the body. But the parenteral method of
drug administration also presents a number
of dangers to the user. Depending on the
substance being discussed, parenteral
administration might be the preferred
method of administration, especially when
a rapid onset of effects is desired.
 Parenteral Forms…
 “Skin Popping” Subcutaneous
Administration of a drug just under the
skin. Although the onset of the drug’s
effect is slower than other forms of
parenteral drug administration
subcutaneous drug administration
allows for a reservoir of the drug to be
just under the skin that is absorbed over
time.
 Forms…
 A second method of
administration is (intra-muscular or
IM injection) Muscle tissues have a
good supply of blood, and many
compounds injected into the
muscle tissue will be absorbed
into the general circulation more
rapidly than compounds injected
just under the skin.
 Forms
 There are some compounds…
benzodiazepine chlordiazepoxide that
are poorly absorbed by muscle tissue and
are rarely, if ever administered that way.
 Forms..
 A third method of parenteral drug
administration is the intravenous (or IV)
injection. In this process the compound(s)
of choice are injected directly into a vein,
thus being deposited directly into the
general circulation. Parenterally
administered compounds do not have an
instantaneous effect.
 Other Forms..
 Another method of drug administration,
one that is more frequently used by drug
abusers than in medical practice, is the
intranasal method. In this method of drug
administration, the compound is
“snorted”, depositing it on to the blood-
rich tissues in the sinuses. Both cocaine
and heroin power are occasionally
abused in this manner.
 Other forms
 The process of “snorting” is similar to the
process of inhalation, which is used both
in medical practice with certain
compounds by drug abusers. The process
of inhalation takes advantage of the fact
that the circulatory system is separated
from direct exposure to the air only by a
layer of tissue less than 1/100,000th of an
inch(0.64micron) thick.
 Other Forms
 Each Sub-form of inhalation takes
advantage of the fact that the lungs offer
a blood rich, extremely large surface
area, allowing for the rapid absorption of
many compounds. The amount of the
compound that goes into the system is
highly variable.
 1. The user must inhale the compound(s)
at exactly the right point in the
respiratory cycle to allow the drug
molecules to reach the desired point in
the lungs(2) some chemicals are able to
pass through the tissues of the lung into
the circulation comparatively slowly.
Marijuana is a good example.
 The individual must hold his/her breath
for as long as possible to allow the largest
percentage of the molecules inhaled to
cross into the circulation before the
person must exhale.
 Bioavailability
 To have an effect, the drug must enter
the body in sufficient strength to achieve
the desired effect. This is referred to
bioavailability of a compound. The
bioavailability of a compound is the
concentration of unchanged chemical at the
site of action.
 The bioavailability of a compound in
turn, is affected by the factors of
absorption, distribution,
biotransformation, and elimination.
 Absorption
 Except of topical agents that are
deposited on the site of action, such
as an antifungal cream, most
compounds must be absorbed into
the body to have any effect. This
involves the drug molecules moving
from the site of entry through
various cell boundaries to the
circulatory system, where it is
transported to the site of action.
 Absorption
 Compounds that are weakly acidic are
usually absorbed through the stomach,
whereas compounds that are a weak
base, are absorbed in the small intestine.
The human body is composed of layers
of specialized cells, organized into
specific patterns that carry out
designated functions.
 The cells of the circulatory system are
organized to form tubes(gastrointestinal
tract that are surrounded by blood
vessels) that contain the cells and fluids
collectively called blood. To reach the
circulatory system a chemical molecule
ingested orally must pass through the
cell walls of the intestine and then the
cell wall
and then the cell walls of the cells that form
the blood vessels in order to reach the
circulatory system, a process that will slow
absorption's circulation is separated from
the air in the lungs by a single layer of
tissue(the cell wall of the individual alveoli).
Compounds that are able to cross this one
layer are able to reach in just a matter of
seconds.
 In contrast to this, a compound that is
ingested orally must go through the process
outlined here to reach the circulation. This
inhalation is a more rapid method of drug
absorption than oral ingestion. There are a
number of specialized cellular transport
mechanisms that the body uses to move
necessary substances into/away from the
circulatory system.
 Drug macules can take advantage of
these transport mechanisms to move
from the site of administration to the site
of action.
 The process of drug absorption is
variable, depending on factors, the most
important of which is the method of
administration.
 Another major variable is the rate of blood
flow at the rate of entry. Yet another
variable is the molecule characteristics of
the compound itself. Yet another variable
that influences drug absorption is
whether it is ingested on an empty
stomach or not.
 Still another that influences the
absorption of a chemical ingested orally
is if it does not have to compete with
other drug molecules for admission into
the body.
 Distribution

 The process of distribution refers

to how the chemical molecules
are transported within the
body. Distribution is affected
by such as the individuals age,
sex, muscle/adipose tissue
ratio, state of hydration,
genetic heritage, and health.
There is significant inter-
individual distribution patterns of
 Transport

 Drug molecules are foreign

substances, and their presence in the
body is only tolerated by body until its
natural elimination/defense
mechanisms are able to latch on to and
remove them. Drug molecules must
reach the general circulation, and be
transported to the site of action before
they can be eliminated from the body.
 Transport
 Some chemicals are able to mix freely
with the blood plasma, and as such are
often referred to as water-soluble
compounds. Alcohol is a fine example of
a water-soluble compound: After
absorption the chemical molecules
become intermixed with the blood
plasma and pumped through the body
by the circulatory system.
 Transport
 The process of lipid binding provides a
drug reservoir within the body, allowing
the newly detached drug molecules to
replace those that have been eliminated
from the body. The brain is 50% lipid
molecules, which allows compounds that
are lipid soluble to become concentrated
in the brain.
 Transport
 The ultrashort and short acting
barbiturates are excellent examples of the
process. They are able to form bonds
with blood lipids very rapidly, thus
allowing them to take advantage of the
brain’s constant demand for lipid
molecules to reach the brain rapidly and
take effect. This is what makes these
barbiturates useful as surgical
anesthetics.
 Transport
 If the individual were to take an
unusually large dose of a drug, or if more
of the molecules of more than compound
were competing for the same binding
sites on the protein or lipid molecule,
those binding sites rapidly become
saturated leaving a larger than normal
percentage of drug molecules free in the
blood to have a biological effect.
 Transport
 This is one of the mechanisms through
which pharmaceuticals might have a
synergistic effect. The effects of one
compound reinforce the effects of a second
compound, possibly with fatal results.
Another form of synergism effects is seen
when different drug molecules bind at the
same receptor site, increasing (or
decreasing) the rate at which that neuron
can “fire”.
Biotransformation/detoxification
 Biotransformation/detoxification is
usually carried out in the liver, although
on occasion other organs may be
involved. There are essentially two forms
of biotransformation(a) the zero-order
biotransformation process and (b) the first
order biotransformation process.
 Alcohol is an example of a compound
that is bio-transformed through a zero-
order biotransformation process. If the
drinker ingests alcohol more rapidly than
his or her body can metabolize it, he or
she will become intoxicated.
 The goal of the biotransformation process
is to alter the foreign chemical molecule
until it becomes a compound that can be
eliminated from the body.
The First-Pass Metabolism Effect
 The human digestive tract is
designed not to let any
chemical that is absorbed pass
directly into the circulation,
but to filter them first through
the liver. This is called the
first-pass metabolism effect. By
taking chemicals absorbed
from the GI tract and passing
them through first through the
liver, any toxin in that food or
 Elimination
 The process of biotransformation
changes the chemical structure of a
compound so that the metabolites are
more water soluble so that it can then be
removed from the circulation by the
organs filtering the blood. This
elimination occurs through the kidney,
through the lungs, sweat glands, binary
tract may also be involved.
 Elimination
 Depending on the exact compound under
consideration, the elimination process
might take hours, or in the case of long-
acting compounds such as methadone,
days. The goal of the biotransformation
process is to allow the enzymes to
transform the drug molecule(s) into a
water-soluble metabolite that can be
eliminated from the body.
 Drug Half-life

 Distribution Half-Life-is the

period of time that it takes a
compound to work its way into
the general circulation once it is
eliminated. (a) alpha half-life is
the period following peak
concentration of the drug in the
tissues and (b) beta half-life is the
decline in plasma concentration as
 Therapeutic Half-Life: is a rough measure
of the compound’s duration of effect. The
therapeutic half-life is the time necessary
for the body to inactivate 50% of the
compound.
 Elimination Half-life: this is the time that
the body requires to eliminate 50% of a
single dose of a compound.
 Drug Interactions
In cases where a patient is receiving
multiple medications, there is a very real
danger of these compounds interacting in
ways not anticipated by the user. Serious
drug-drug interactions result in an
estimated 7,000 deaths in this country.
(many more not reported)
 The Effective Dose
 The dose at which 10% of the general
population is expected to have the
desired effect would be identified as
ED10.
The Lethal Dose and Therapeutic Index

 For example 1% of patients with a

blood alcohol concentration of
0.350mg/ml would be expected to die
without medical help.
 Thus, for alcohol the LD01 would be
0.350 mg/ml of blood. By comparing
the effective dose and lethal dose
ratios it is possible to obtain a raw
estimate of the therapeutic window or
therapeutic index of a compound.
Therapeutic Threshold and Peak Effects

 As the drug absorption process

progresses following a single
dose of a compound the
amount of a compound in the
user’s circulation will increase
until it reaches the minimal
level at which that compound
might e effective. As the blood
levels rise over time the effects
will continue to become
 The Site of Action
 The site of action is where the
compound(s)carry out their main effects.
For most of the psychoactive
pharmaceuticals, and the various drugs of
abuse, specific regions of the central
nervous system(CNS) will be the site of
action. The CNS is comprised of 100 billion
neurons, each receiving input from score,
hundreds, thousands of other neurons.
 The site of action
 The neurons are separated by
microscopic spaces called the synaptic
gap. To communicate across the synaptic
void or gap, one neuron will release a
cloud of chemical molecules known as
neurotransmitters.
 The strength of the attraction of the
neurotransmitter molecule in the
receptor site is often called the affinity
that molecule to the receptor. (efficacy)
 The response of the postsynaptic neuron
falls into one of the two categories: the
fast or inotropic response, which usually
involve the downstream neuron altering
the speed with which it can “fire” and
pass the message on to the next neuron in
the neural network.
Neurotransmitter Reuptake/Destruction
 After their release, one of three things
can happen to the neurotransmitter
molecules:
 (a) they can be retrieved by the upstream
neuron through the use of molecular
reuptake pumps for future use, (b) they
can be destroyed by enzymes near the
receptor sites produced by either the
presynaptic or postsynaptic neuron.
 (b) they can diffuse into the surrounding
area and eventually be removed.
 Tolerance/Neuroadaptation
 Tolerance to a compound is defined as “
as a defined duration and decreased
intensity of drug effects after repeated
administration.
 Metabolic Tolerance
This this process, the body becomes more
proficient in the biotransformation of certain
compounds, at least for a limited time. This
is commonly seen in the early stages of
alcoholism. The drinker most drink more to
get the same level of intoxication once
achieved at a lower level.
 Behavioral Tolerance (playing it cool)
The brain effort to maintain normal function
in spite of the presence of foreign molecules.
The individual’s behavior appears almost
normal in spite of the presence of a
compound in their body.
 Cross Tolerance
Alcohol and the benzodiazepines: the
molecules of both compounds bind at a
receptor site for the inhibitory
neurotransmitter know as GABA. As the
neuron adapts to the continual presence of
alcohol by altering the number of GABA
receptor sites it will also become less
sensitive to the benzodiazepines, which use
the same GABA receptors to achieve their
effects.
 Reverse Tolerance
 A poorly understood phenomenon in
which lower does of a compound
produces the same effect as higher does
did when the use of that substance was
initiated. Maybe operant conditioning
contributes.
 Upregulation and Downregulation of
Receptor Sites
 Upregulation and Downregulation of
receptor sites is one process through
which tolerance to a compound
develops.
 Drug Agonists/Antagonists
 A drug agonist is a compound that
activates a receptor sit by being able to
mimic or enhance the actions of a natural
neurotransmitter. Some of these compounds
are able to fit into the receptor site, without
activating it. Such compounds are called
antagonists(or antagonists).
 The drug Narcan functions as a opioid
antagonist, blocking the opioid receptor
sites without activating them; preventing
narcotic molecules from reaching the
receptor sites in the brain.
 Potency..
 The standard conversion formula is that
4 milligrams of pharmaceutical quality
heroin provides the same degree of
analgesia as 10 milligrams of morphine.
 The Blood-Brain Barrier
 The protect the brain from direct
exposure to blood while allowing
necessary nutrients to reach neural
tissues, nature has provided the brain
with a circulatory system in which
endothelial cells are tightly joined
around the capillaries. The closely
packed endothelial cells are part of the
blood-brain barrier(BBB)
 If it is intact the BBB will protect the
brain from invasion from a range of
micro-organisms and toxins in the
environment, that could destroy it.
 The Nature of the Beast
 Why Do People Choose to Use Drugs or Alcohol?
* Blindness to the Compound’s Effect: One side effect
of alcohol, drug of abuse, and some prescription
medications is substance abuse “blindness”. The
abuser will say that he/she feels better, but others
will note that they have generally decompensated in
terms of interpersonal behaviors, ability to handle
finances, ability to maintain cognitive function, and
generally attend to necessary activities of daily
living.
 BEAST…
 Pharmacological Reward Potential: The reward
potential of a compound depends upon its
chemical structure, the individual’s biochemistry,
and the route of administration. Those compounds
that have rapid onset of action or immediacy of effect
and that induce a greater sense of pleasure have
the highest reward potential for abuse. The basic
laws of behavioral psychology states that if
something (a) increases the individual’s sense of
pleasure, or (b) decreases his/her discomfort then
he/she will likely to repeat the behavior.
 Beast…
 In contrast, if a compound were to (c )
increase the individual’s sense of
discomfort, or (d ) reduce the individual’s
sense of pleasure, s/he would be less
likely to repeat that behavior. Arguably,
although the reward potential of the drugs
of abuse might b a powerful incentive for
repeated use, it is not sufficient in itself to
induce addiction to that compound.
 Nature of the Beast..
 Social Learning
The role of social learning is a form of psychological
learning that is developed in individual expectations
for each potential recreational substance.
Individual Expectations: Substance use expectations
begin to evolve in childhood or early adolescence,
and evolve over time as a result of such influences as
peer groups, childhood exposure to advertising,
parental substance use behaviors, and past
experiences.
 Nature of the Beast
 Cultural/Social Influences: Each person lives in a
cultural matrix that both helps to shape his or her
behavior and is affirmed by the person’s
adherence to those norms.
 Legal Sanctions: If the individual should elect to
use a drug(s) whose use is not approved of by
society or a drug that is socially accepted but in an
unacceptable manner, the legal system steps in to
punish this unacceptable behavior. The disease
concept advocated by the health community can
be in conflict with that of the legal system.
 Drug Abuse Cycles..
 Analogous to those seen in epidemics of infectious
diseases: (1) Incubation: The abuse of certain
compounds is infrequent within society: although it
may be more popular with certain subgroups.
(Marijuana was mainly limited to small segments of
society (rebels, nonconformists, some musicians, and
others.), before the 1960s when it entered the second
stage(2) Expansion: The abuse of that compound is
more tolerated and a growing number of people try it
at least once. Some of these users will continue to
abuse that compound on a irregular basis, or go on to
abuse that compound on a regular basis.
 Cycles..
 During stage 3, the abuse of that compound reaches
a plateau, with many former users choosing to
discontinue the use of that compound at about the
same rate that others initiate he use of that
compound. Finally (4), the cycle reaches the stage of
decline, in which the number of people initiating or
continuing the abuse of that compound declines.
There will however always be a small number of
abusers who will use the compound, bringing the
cycle back to stage one – incubation. This pattern
has been seen with virtually every drug of abuse.
 The Continuum of Chemical Use
 People often confuse the terms, substance use, abuse
and addiction. Substance use is a normal learned
behavior that falls on a continuum ranging from
abstinence through limited use to excessive use and
dependence. It is suggested that alcohol users fall
into three categories, which formed a continuum: (a)
normal drinkers (who never exceed the guidelines
used to define normal drinking), (b) “at-risk”
drinkers (persons who exceed the guidelines but
who currently do not have symptoms of alcoholism
and have never met the diagnostic criteria for this
condition), and (c ) persons who meet the criteria
for an alcohol use disorder. (AUD)
 Continuum ..
 This continuum fails to include those
persons who never drink or use illicit
drugs or whether a person may outgrow
a SUD. Substance use disorders are not
static entities, but evolve over time.
Movement up or down the spectrum is
possible as the individual’s substance use
becomes more or- less problematic.
 Continuum
 The various stages are defined as follows:
Level 0: Total abstinence from all recreational chemicals.
Level 1: Rare to social use of recreational chemicals(this
might include the limited experimental use of a drug that
is technically illegal, such as alcohol or tobacco for an
adolescent or marijuana for a young adult.)
Level 2: Heavy social use/early problem use: Although
the majority of substance abusers moderate or control
their abuse of chemicals, some users/abusers fall into a
pattern of substance abuse that is clearly above the social
norm. Little legal, social, medical, or vocational problems.
 Nature of The Beast
 Level 3 – Late problem use/Early addiction:
Individuals in this category may be physically
dependent on a compound(s), and possibly also
experience the classic withdrawal syndrome for the
compound(s) being abused if they should abruptly
stop using alcohol or drug(s) of choice.
 Level 4 – Middle or Late Stage Addiction –
Individuals whose substance use would fall in this
category demonstrate all of the classic signs of
addiction: physical, medical, legal, occupational,
and/or personal problems, as well as physical
dependency on alcohol/drugs.
 What does Addiction Mean?
 There is a wide discrepancy between how
the average person defines addiction and
what a health care professionals mean they
use the same word. Physical dependence
on a substance is one of the traditionally
accepted signs of addiction. Beyond that
there is no universally excepted definition.
The Diagnostic and Statistical Manual of
Mental Disorders, 5th edition is helpful..
 DSM-5
 1. Impaired control over substance use
 2. Multiple attempts to quit/reduce substance use
 3. most of individual’s activities center around
(a)obtaining the substance,(b) using the substance
or (c ) recovering from the effects of the substance.
This includes social, vocational, and legal
consequences of substance use or using a substance
under “risky” conditions.
 4. Pharmacological effects of the drug on the
individual, including “craving” for the substance it
is not actively being used.
 Let’s define terms..
 Social Use: The individual’s culture
defines what is the frequency with and
conditions under which an individual
might use a substance(s). Currently
alcohol and tobacco are the only
products that might be legally used in
certain social settings, although
marijuana use is arguably also, a
“social” compound in certain social
groups.
 Substance Abuse is the term that is used
 Definitions..
 There is no physical dependence on the
chemical(s) in question at this time, and it does not
automatically progress to physical addiction of
that compound.
 Dependence: is said to exist when the individual
meets the criteria for alcohol or drug dependence,
as discussed in the DSM-5.
 Drug of Choice – With the growth of polydrug
disorders the concept of drug of choice has fallen
into disfavor and few clinicians place emphasis on
this concept.
 Definitions
 Addiction/Dependence: Most clinicians
prefer the term dependence to a chemical,
although a large number of health care
professionals still use the older term
addiction.
 Dependence is marked by the development
of a characteristic withdrawal syndrome for
the compound(s) being abused that have
not been prescribed.
 Definitions
 Withdrawal Syndrome: is a phenomenon experienced
when the individual either stops, or significantly
reduces, hos or her intake of a specific compound(s).
The withdrawal syndrome is usually the opposite of
the compound’s effects on the user’s body. Alcohol
acts like a chemical “brake” on the neurons of the
brain. The neuron struggle to compensate, increasing
the number of neurotransmitters to overcome the
inhibitory effects of the persistent alcohol use. When
the alcohol is removed, the neurons in the brain
becomes overactive.
 Definitions
 This is experience by the heavy drinker
as anxiety, withdrawal tremors, and in
extreme cases delirium tremens(DTs).
 Behavioral “Addictions”
 There is little physical evidence at this
time that non-drug-centered behaviors
can result in a physical addiction, and
clinicians are increasingly classifying
these behaviors as “behavioral
addictions” or compulsive behaviors as
opposed to substance abuse or
dependence.
 Many Unanswered Questions..
 1. Are those individuals who seek treatment
the same as those who do not?
 2.Are those individuals who are “chippers”
different in some poorly defined way from
those individuals who go on to become
physically dependent on a drug or alcohol?
 3.Is research carried out on those individuals
who seek treatment through the VA Hospital
system applicable to the general population?
 Unanswered…
 4. How do men and women who have SUDs differ.
Do the same treatment techniques work for each
subgroup?
 5. Are those substance abusers who hold full-time
employment the same as, or different from those
substance abusers who do not hold full time jobs,
and are indiviuals in either group the same as or
different from those who are unemployed?
 6.Are those persons who limit their substance use
to alcohol the same as those who are poly-drug
abusers or addicts?
 Questions…
 7. It is known that the individual’s motivation
for substance abuse varies as a result of his or
her age and past substance use history. How
do these variables affect the processes of
intervention and rehabilitation?
 8. What is the contribution of the individual’s
genetic heritage to the development of an
SUD, and how is this genetic heritage
modified by environmental forces?
 Concepts of Chemical Dependency
 Why Worry about Recreational Chemical Use In the
U.S.
The abuse of drugs and alcohol is intermixed with every
other problem society faces today. The challenge of finding
effective health care has been compounded by alcohol and
drugs
 Approximately 21% of patients admitted to a hospital

Intensive Care Unit are there because of alcohol use.

 The medical treatment of alcoholism and drug

addiction, in combination with the various psychiatric

consequences of these disorders, accounts for up to 60%
of hospital usage in the United States.
 Why Worry?

 Either directly or indirectly, substance

abuse is the most common “disease”
encountered by the modern physician,
but often not recognized.
 The abuse of illicit drugs is a major
cause of ischemic stroke in adults,
increasing the individuals risk of such
and event.
 The most common cause of psychotic
conditions in young adults is
 Why Worry?
 Suicide is 30 times as common among
alcoholics as among the general population.
In one study, 33% of completed suicides were
found to have alcohol in their bodies.
 Suicide is the cause of death in 35% of all
intravenous drug abusers.
 Fully 56% of all assaults are alcohol-related,
and 60% of men with a history of domestic
assault are intoxicated on alcohol when they
attack their partner.
 Why Worry?
 Substance abuse disorders are involved in
89% of substantiated cases of child abuse
involving a child under the age of 12 months.
 There is a known relationship between
substance abuse and homicide. Researchers
have found that there is 28-fold of a woman’s
chances of being murdered by a significant
other, even when she herself was not using
drugs. Alcohol alone is implicated in half of
all homicides committed in the United States.
 Why Worry..
 The role of alcohol/drugs in
victimization has been underscored in
many studies. Sexual abuse of both men
and woman have been documented.
 Who “Treats” Those Who Abuse or are
Addicted to Chemicals
 Physicians most often fail to attribute the causes
of illnesses in their patients to the use of
drugs/alcohol. Very few medical schools or
residency programs have an adequate required
course in addictions, and most physicians fail to
screen for alcohol or drug dependence during
routine exams.
 In spite of the known relationship between
alcohol use and traumatic injury, almost three-
quarters of the trauma centers reviewed do not
screen for alcohol abuse/addiction.
 Treatment..
 Many physicians continue to feel that illicit drug
use to untreatable. Only 40% of general practice
physicians are motivated to work with the alcoholic
patient.
 Nurses, psychologists and relationship counselors
have similar problems dealing with the chemically
dependent person and their family. Therapy
continues in a very haphazard fashion when a
substance abuse problem is not acknowledged or
uncovered. Vital clues to the very real illness within
the family are missed; treatment is ineffective.
 Scope of the Problem
 1. People tend to hide evidence that they abuse
recreational chemicals. Because the typical
abusers are not poor and have full time jobs it is
difficult for researchers or the general public to
comprehend the trends of abuse as it evolves.
 2. The news media often concentrates on
“breaking news”, and not long-term problems.
 3. Often scientists might reach different
conclusions regarding the problem, based on
the sample they are reviewing.
 Scope of the Problem
 Finally, the public has been increasingly
skeptical, convinced that many problems
outlined in the media are just “fake news” items.
 At least half of the world’s population has used
at least one psychoactive substance at least once
with alcohol being the most commonly used
psychoactive chemical. However, only about 200
million people, or about 5% of the entire
population of the world, has abused an illicit
substance.
 Scope
 Illicit drug use might be considered an
“American way of life”. Sixteen percent of the
entire population over the age of 12 is addicted
to nicotine, alcohol, or illegal drugs. This figure is
deceptive however since it is possible for a
person who is addicted to nicotine to be addicted
to another compound such as alcohol. With just
5% of the world’s total population the United
States consumes 60% of the illicit drugs
produced. Each day in the U.S. 8,000 people try
an illicit drug for the first time.
 Scope
 Many of these individual probably only experiment
with illicit drugs out of curiosity for less then 12
months and then discontinue or curtail further use. The
most commonly used illicit substance is marijuana
with 75.5% of illicit drug abusers using only marijuana.
This figure still means that 8.6 million people over the
age of 12 abused an illicit drug other than marijuana
proceeding the survey. Research studies reveal that
waste water from both rural and urban areas contained
measurable amounts of cocaine and methamphetamine
metabolites, underscoring the widespread abuse of
these compounds in this country.
 Substance Use Disorders
 The majority of those who use a psychoactive substance
do so on a short-term experimental basis and rarely
present problems to society seen in cases of substance
addiction. Addiction develops only in a minority of
persons who abuse a compound(s). However a thriving
“black market” has evolved to meet the demand for
illicit drugs created by the curious user, the infrequent
abuser, the heavy abuser, or the person who is addicted
to a chemical(s). The worldwide illicit drug trade is
estimated to be an $800 billion/year industry, making it
larger than the annual gross domestic product of 90%
of the world’s countries.
 Alcohol Use, Abuse and Addiction
 An estimated 119 million people in the U.S. ingest
alcohol at least once each year. Between 8 and 16
million persons will become physically dependent
and 5.6 million are believed to abuse it on a regular
basis. This underestimate the total number of persons
with an alcohol use disorder, since many are high
functioning, and are able to hide this fact from
friends, family, and coworkers for decades. Ten
percent of drinkers consume 60% of the alcohol
consumed in the United States, whereas the top 30%
of drinkers consume 90% of the alcohol consumed in
this country.
 Alcohol Use, Use and Addiction.
 If the persons drinking has resulted in their
suffering, social, physical, emotional, or
vocational consequences, then it is said that
they have a AUD (alcohol use disorder). The
majority of those who do develop an AUD
are men by a ratio of 2-3 to every woman.
This underscores the danger of alcohol use
and abuse in spite of its legal status as a
socially acceptable recreational compound
for adults.
 Opiate Abuse and Addiction
 Current estimates indicate that 3million people
have abused heroin at some point in their lives and
that there are between 810,000 and 1 million people
currently dependent on it. The states with the
largest number of opioid abusers are thought to be
California, New York, Massachusetts and New
Jersey; although heroin use disorders are found in
every state. In the U.S. is a growing number of
people who are addicted to prescription narcotic
analgesics either prescribed for the user or obtained
from illicit sources. An estimated 33 million person
have used a narcotic analgesic not prescribed to
them at some point in their lives.
 Estimates of the Problem of Stimulant
Abusers and Addiction
 Globally, the problem of central nervous system
(CNS) stimulant abuse has apparently reached a
plateau with approximately 25 million people
around the world abusing a CNS stimulant at least
once each year. In North America, the demand for
the most potent of the CNS stimulants, the
amphetamines (especially methamphetamine), has
been stable, with about 3.8 million people in North
America abusing these compounds at least once each
year. Much of the methamphetamine in the U.S.
enters the country from other countries, although
there are still “local” labs.
Estimates of the Problem of Cocaine Abuse
and Addiction
 The number of cocaine abusers/addicts has
remained relatively stable around the globe over
the past decade. 14 million people are cocaine
abusers or addicts, most living in living in north
America. In the U.S. there are perhaps 2.5 million
people who are addicted to cocaine; an unknown
number who have tried it, or abused it in their
life time. The true scope of the problem is
confused by the fact that researchers estimate
that only 2-3% of people who abuse will become
addicted.
 Marijuana Use, Abuse and Addiction
 Estimated 160 million people have used
marijuana in the last month. Just under
30 million in North America are current
users. 25% of the entire population in the
U.S. is thought to have abused marijuana
at least once with 3million people being
addicted.
 Hallucinogen Abuse
 Researchers question if one can be addicted to
hallucinogens, but it is thought that perhaps
10% of the population have abused at least
once in the U.S. It is estimated that 1.1 million
people in the U.S. have abused and
hallucinogenic compound in the last month.
 Tobacco
 Legal but destructive and addictive.
20.8% of the entire population of the U.S.
smoke cigarettes; 25% are former
smokers and 50% have never smoked.
 The Cost…
 Drug use disorders are the sixth leading cause of
disease in adults in the world. Illicit drug use costs the
global economy $800 billion/year, with AUDs costing
the world economy another $880 billion/year. In the
U.S., the alcohol and drug use disorders are thought
to drain at least 375 billion/year from the economy.
The annual toll from the various diseases associated
with illicit drug use in the United States, combined
with the number of drug related infant deaths,
suicides, homicides, and motor vehicle accidents, is
estimated at 12,000-17,000 people a year.
 Cost….

 440,000 persons are thought to die each year from

smoking related illnesses brought on by their own
tobacco use, and an additional 35,000 to 56,000
persons each year in the United States who die
from the effect of second hand or environmental
tobacco smoke. 100,000 people die each year in the
Untied States as a direct result of the individual
alcohol use. The alcohol use disorders contribute to
or exacerbate 60 disorders. If one was to include all
the “indirect” alcohol-related deaths, it becomes
clear that alcohol indirectly or directly causes as
many deaths in the U.S.as tobacco.
 Cost of Alcohol Use/Abuse/Addiction
 Globally, alcohol use is thought to be a direct factor in
10-11% of all deaths each year. In the U.S., alcohol
dependence ranks third as the most common cause of
preventable death.
 The annual economic impact of
alcohol/abuse/addiction in the U.S. is thought to be at
least $185 billion/year, of which $26 billion is for
direct health care costs, and 37 billion as a result of lost
productivity brought on by alcohol-related premature
deaths. The alcohol use disorders cost every man,
woman and child in the U.S. in the U.S. $638 per year.
 The Cost…
 It has been estimated that the complications brought on
by the use of alcohol can account for 15-25% of the
annual total expenditure for health care each year in
the U.S. Although only 5-10% of the population of this
country has an AUD, they consume a disproportionate
amount of the yearly health care cost; 15-30% of those
individuals in nursing homes are thought to be there
either as a direct or indirect result of their AUD.
Alcohol is thought to be involved in approximately
40% of all motor vehicle accidents and 40-60% of all
traumatic injury cases involve patient with an SUD.
Alcohol abuse and motor accidents cost $24/7 billion a
year.
 Costs….Tobacco
 Globally, more than 3 million
people/year die around the world as a
direct result of their use of tobacco
products;442,000 live in the U.S.
Economic cost in the U.S. alone is $157
billion. One of every five deaths can be
traced to smoking related illness in the
U.S., not counting exposure second-hand
smoke.
 Costs… Substance Use Disorders
 Cost of premature deaths and illness, lost
wages, financial losses by victims of
substance related crime, who were hurt
by others combined with the cost of law
enforcement activities directly aimed at
the problem of SUDs illicit substance use
costs at least $900 for every person over
18yrs old in the U.S.; total impact on the
economy is $428 billion each year.
 Concepts of Chemical Dependency
 Why Worry about Recreational Chemical Use In the
U.S.
The abuse of drugs and alcohol is intermixed with every
other problem society faces today. The challenge of finding
effective health care has been compounded by alcohol and
drugs
 Approximately 21% of patients admitted to a hospital

Intensive Care Unit are there because of alcohol use.

 The medical treatment of alcoholism and drug

addiction, in combination with the various psychiatric

consequences of these disorders, accounts for up to 60%
of hospital usage in the United States.
 Why Worry?

 Either directly or indirectly, substance

abuse is the most common “disease”
encountered by the modern physician,
but often not recognized.
 The abuse of illicit drugs is a major
cause of ischemic stroke in adults,
increasing the individual’s risk of such
and event.
 The most common cause of psychotic
conditions in young adults is
 Why Worry?
 Suicide is 30 times as common among
alcoholics as among the general population.
In one study, 33% of completed suicides were
found to have alcohol in their bodies.
 Suicide is the cause of death in 35% of all
intravenous drug abusers.
 Fully 56% of all assaults are alcohol-related,
and 60% of men with a history of domestic
assault are intoxicated on alcohol when they
attack their partner.
 Why Worry?
 Substance abuse disorders are involved in
89% of substantiated cases of child abuse
involving a child under the age of 12 months.
 There is a known relationship between
substance abuse and homicide. Researchers
have found that there is 28-fold of a woman’s
chances of being murdered by a significant
other, even when she herself was not using
drugs. Alcohol alone is implicated in half of
all homicides committed in the United States.
 Why Worry..
 The role of alcohol/drugs in
victimization has been underscored in
many studies. Sexual abuse of both men
and woman have been documented.
Who “Treats” Those Who Abuse or
are Addicted to Chemicals
 Physicians most often fail to attribute the causes
of illnesses in their patients to the use of
drugs/alcohol. Very few medical schools or
residency programs have an adequate required
course in addictions, and most physicians fail to
screen for alcohol or drug dependence during
routine exams.
 In spite of the known relationship between
alcohol use and traumatic injury, almost three-
quarters of the trauma centers reviewed do not
screen for alcohol abuse/addiction.
 Treatment..
 Many physicians continue to feel that illicit drug
use to untreatable. Only 40% of general practice
physicians are motivated to work with the alcoholic
patient.
 Nurses, psychologists and relationship counselors
have similar problems dealing with the chemically
dependent person and their family. Therapy
continues in a very haphazard fashion when a
substance abuse problem is not acknowledged or
uncovered. Vital clues to the very real illness within
the family are missed; treatment is ineffective.
 Scope of the Problem
 1. People tend to hide evidence that they abuse
recreational chemicals. Because the typical
abusers are not poor and have full time jobs it is
difficult for researchers or the general public to
comprehend the trends of abuse as it evolves.
 2. The news media often concentrates on
“breaking news”, and not long-term problems.
 3. Often scientists might reach different
conclusions regarding the problem, based on
the sample they are reviewing.
 Scope of the Problem
 Finally, the public has been increasingly
skeptical, convinced that many problems
outlined in the media are just “fake news” items.
 At least half of the world’s population has used
at least one psychoactive substance at least once
with alcohol being the most commonly used
psychoactive chemical. However, only about 200
million people, or about 5% of the entire
population of the world, has abused an illicit
substance.
 Scope
 Illicit drug use might be considered an
“American way of life”. Sixteen percent
of the entire population over the age of
12 is addicted to nicotine, alcohol, or
illegal drugs. This figure is deceptive
however since it is possible for a person
who is addicted to nicotine to be
addicted to another compound such as
alcohol. With just 5% of the world’s total
population the United States consumes
 Scope
 Many of these individual probably only experiment
with illicit drugs out of curiosity for less then 12
months and then discontinue or curtail further use. The
most commonly used illicit substance is marijuana
with 75.5% of illicit drug abusers using only marijuana.
This figure still means that 8.6 million people over the
age of 12 abused an illicit drug other than marijuana
proceeding the survey. Research studies reveal that
waste water from both rural and urban areas contained
measurable amounts of cocaine and methamphetamine
metabolites, underscoring the widespread abuse of
these compounds in this country.
 Substance Use Disorders
 The majority of those who use a psychoactive substance
do so on a short-term experimental basis and rarely
present problems to society seen in cases of substance
addiction. Addiction develops only in a minority of
persons who abuse a compound(s). However a thriving
“black market” has evolved to meet the demand for
illicit drugs created by the curious user, the infrequent
abuser, the heavy abuser, or the person who is addicted
to a chemical(s). The worldwide illicit drug trade is
estimated to be an $800 billion/year industry, making it
larger than the annual gross domestic product of 90%
of the world’s countries.
 Alcohol Use, Abuse and Addiction
 An estimated 119 million people in the U.S. ingest
alcohol at least once each year. Between 8 and 16
million persons will become physically dependent
and 5.6 million are believed to abuse it on a regular
basis. This underestimate the total number of persons
with an alcohol use disorder, since many are high
functioning, and are able to hide this fact from
friends, family, and coworkers for decades. Ten
percent of drinkers consume 60% of the alcohol
consumed in the United States, whereas the top 30%
of drinkers consume 90% of the alcohol consumed in
this country.
 Alcohol Use, Use and Addiction.
 If the persons drinking has resulted in their
suffering, social, physical, emotional, or
vocational consequences, then it is said that
they have a AUD (alcohol use disorder). The
majority of those who do develop an AUD
are men by a ratio of 2-3 to every woman.
This underscores the danger of alcohol use
and abuse in spite of its legal status as a
socially acceptable recreational compound
for adults.
 Opiate Abuse and Addiction
 Current estimates indicate that 3million people
have abused heroin at some point in their lives and
that there are between 810,000 and 1 million people
currently dependent on it. The states with the
largest number of opioid abusers are thought to be
California, New York, Massachusetts and New
Jersey; although heroin use disorders are found in
every state. In the U.S. is a growing number of
people who are addicted to prescription narcotic
analgesics either prescribed for the user or obtained
from illicit sources. An estimated 33 million person
have used a narcotic analgesic not prescribed to
them at some point in their lives.
 Estimates of the Problem of
Stimulant Abusers and Addiction
 Globally, the problem of central nervous system
(CNS) stimulant abuse has apparently reached a
plateau with approximately 25 million people
around the world abusing a CNS stimulant at least
once each year. In North America, the demand for
the most potent of the CNS stimulants, the
amphetamines (especially methamphetamine), has
been stable, with about 3.8 million people in North
America abusing these compounds at least once each
year. Much of the methamphetamine in the U.S.
enters the country from other countries, although
there are still “local” labs.
 Estimates of the Problem of
Cocaine Abuse and Addiction
 The number of cocaine abusers/addicts has
remained relatively stable around the globe over
the past decade. 14 million people are cocaine
abusers or addicts, most living in living in north
America. In the U.S. there are perhaps 2.5 million
people who are addicted to cocaine; an unknown
number who have tried it, or abused it in their
life time. The true scope of the problem is
confused by the fact that researchers estimate
that only 2-3% of people who abuse will become
addicted.
 Marijuana Use, Abuse and
Addiction
 Estimated 160 million people have used
marijuana in the last month. Just under
30 million in North America are current
users. 25% of the entire population in the
U.S. is thought to have abused marijuana
at least once with 3million people being
addicted.
 Hallucinogen Abuse
 Researchers question if one can be addicted to
hallucinogens, but it is thought that perhaps
10% of the population have abused at least
once in the U.S. It is estimated that 1.1 million
people in the U.S. have abused and
hallucinogenic compound in the last month.
 Tobacco
 Legal but destructive and addictive.
20.8% of the entire population of the U.S.
smoke cigarettes; 25% are former
smokers and 50% have never smoked.
 The Cost…
 Drug use disorders are the sixth leading cause of
disease in adults in the world. Illicit drug use costs the
global economy $800 billion/year, with AUDs costing
the world economy another $880 billion/year. In the
U.S., the alcohol and drug use disorders are thought
to drain at least 375 billion/year from the economy.
The annual toll from the various diseases associated
with illicit drug use in the United States, combined
with the number of drug related infant deaths,
suicides, homicides, and motor vehicle accidents, is
estimated at 12,000-17,000 people a year.
 Cost….

 440,000 persons are thought to die each year from

smoking related illnesses brought on by their own
tobacco use, and an additional 35,000 to 56,000
persons each year in the United States who die
from the effect of second hand or environmental
tobacco smoke. 100,000 people die each year in the
Untied States as a direct result of the individual
alcohol use. The alcohol use disorders contribute to
or exacerbate 60 disorders. If one was to include all
the “indirect” alcohol-related deaths, it becomes
clear that alcohol indirectly or directly causes as
many deaths in the U.S.as tobacco.
 Cost of Alcohol
Use/Abuse/Addiction
 Globally, alcohol use is thought to be a direct factor in
10-11% of all deaths each year. In the U.S., alcohol
dependence ranks third as the most common cause of
preventable death.
 The annual economic impact of
alcohol/abuse/addiction in the U.S. is thought to be at
least $185 billion/year, of which $26 billion is for
direct health care costs, and 37 billion as a result of lost
productivity brought on by alcohol-related premature
deaths. The alcohol use disorders cost every man,
woman and child in the U.S. in the U.S. $638 per year.
 The Cost…
 It has been estimated that the complications brought on
by the use of alcohol can account for 15-25% of the
annual total expenditure for health care each year in
the U.S. Although only 5-10% of the population of this
country has an AUD, they consume a disproportionate
amount of the yearly health care cost; 15-30% of those
individuals in nursing homes are thought to be there
either as a direct or indirect result of their AUD.
Alcohol is thought to be involved in approximately
40% of all motor vehicle accidents and 40-60% of all
traumatic injury cases involve patient with an SUD.
Alcohol abuse and motor accidents cost $24/7 billion a
year.
 Costs….Tobacco
 Globally, more than 3 million
people/year die around the world as a
direct result of their use of tobacco
products;442,000 live in the U.S.
Economic cost in the U.S. alone is $157
billion. One of every five deaths can be
traced to smoking related illness in the
U.S., not counting exposure second-hand
smoke.
 Costs… Substance Use Disorders
 Cost of premature death and illness, lost wages,
financial losses by victims of substance-related
crime, who were hurt by others combined with the
cost of law enforcement activities directly aimed at
the problem of SUDs, illicit substance use costs at
least $900 for every person over 18yrs old in the
U.S. each year. When the cost of disability,
accidental injuries, health care and absenteeism
from work are added together, the total economic
impact of SUDs on the U.S. economy each year is
estimated to be $428 billion dollars.
 Costs…
 Average cost of hospitalization of alcohol
abusers was 120% higher than non-
abusers. Opioid abusers 482% higher
than non-users.
 Who Treats
 Various government spend only 4cents of every
dollar on programs devoted to the treatment or
prevention for persons with SUD. Most health
care professionals are under trained and ill
prepared to work with substance abusers.
 Marriage therapists and psychologists have little
background in the area of substance abuse
treatment. Professional abuse substance
counselors make up a small percentage of the
number of health care workers generally who
will work with this population.
 CHAPTER 11
Opioid Use, Abuse, and Addiction

© 2015. Cengage Learning. All rights

reserved.
 Introduction
 Many physicians under prescribe narcotic
analgesics and then interrupt request of addition
analgesics as evidence of drug-seeking behavior
 An estimated 73% of persons in moderate to
sever pain receive less than adequate analgesics
due to physicians fear of inducing a SUD
 74.6% increase in number of prescription
analgesics between 2002and 2010
 Narcotics also involved in 40% of overdose
deaths in recent years
© 2015. Cengage Learning. All rights
reserved.
 A history of opioids
 Anthropologists believe opium has used as an
analgesic for at least 3,500 years
 There is evidence of it being cultivated as early
as 10,000 years ago suggesting an even earlier
knowledge of its analgesic effects
 In 1806, morphine was isolated as the main
active ingredient in opium
 In 1857, the hypodermic needle was invented
and by the Civil War both were available
without a prescription
© 2015. Cengage Learning. All rights
reserved.
 A history of opioids
 Was often a “hidden” ingredient in over the
counter “patent” medicines
 By 1900 more than 4% of the US population
was addicted to opium or other narcotics
 The Pure Food and Drug Act of 1906 required
ingredients be listed on patent medicines
 The Harrison Narcotics Act of 1914, ruled that
only a licensed physician or dentist prescribe a
narcotic analgesic

© 2015. Cengage Learning. All rights

reserved.
Medical applications of narcotics
 Classification of narcotic analgesics:
 Natural
 Semi-synthetic
 Synthetic
 The problem of pain
 General anesthetic agents
 Local anesthetic agents
 Narcotics which block pain in the CNS

© 2015. Cengage Learning. All rights

reserved.
 Where Opium is Produced
 Morphine is usually derived from opium
poppies
 The need to medicinal opium can be met by
opium fields in India
 However vast opium fields in other countries
meant for illicit trade
 Afghanistan produces 63% of the opium on the
planet

© 2015. Cengage Learning. All rights

reserved.
Current medical uses of narcotics
 For thousands of years, opium was one of the
few compounds available to treat pain
 Used for pain, cough suppression and severe
diarrhea
 Estimated that 5% of the US adult population
took an opioid in the past 12 months
 Vast majority of users take for short term pain
control, but nearly half use them for more than
2 years, and 1 in 5 more than 5 years

© 2015. Cengage Learning. All rights

reserved.
 Pharmacology of Narcotics
 Morphine is the gold standard against which
effects of narcotics are measured
 Pain suppression achieved through:
 Inhibiting pain signal from the spinal cord to the
brain
 Activates pain suppressing systems in brain and
spinal cord
 Alters perception and emotional response to pain

© 2015. Cengage Learning. All rights

reserved.
 Pharmacology of Narcotics
 Mimics the effects of endogenous opioid
peptides
 Each family of opioid peptides is found mainly
in a specific region of the brain, with some
overlap
 Narcotic analgesics function as opioid agonists,
stimulating or enhancing the their effects
 Subjective effects of narcotic analgesics differ in
those in pain vs. those not in significant pain
 Any sense of euphoria thought to be caused by
the effects of these compounds
© 2015. Cengage Learning. All rights in the ventral
reserved.
 Codeine
 Mild analgesic potential
 Can suppress the cough reflex
 1/5th the potency of morphine
 Usually administered orally
 Commonly mixed with OTC aspirin or
acetaminophen

© 2015. Cengage Learning. All rights

reserved.
 Fentanyl
 A synthetic opioid introduced in 1968
 Popular during and immediately after surgery
 Quite a potent compound
 A typical intravenous dose is one microgram
 Suppresses respiration longer than it induces
analgesia
 Patients may experience anxiety, hallucinations
or feelings of depression

© 2015. Cengage Learning. All rights

reserved.
 Heroin
 Heroin is just two morphine molecules joined
together by an oxygen molecule
 Twice as potent as morphine
 Not used medically in the US but is used in
other countries to treat severe pain

© 2015. Cengage Learning. All rights

reserved.
 Hydrocodone/hydromorphone
 Semisynthetic narcotic derived from codeine
 Used to control coughs and mild to moderate
levels of pain relief
 Orally administered doses of hydromorphone
are thought to be 5-7 times as potent as
morphine
 Side effects include dizziness, sedation, mental
confusion, anxiety, fear, nausea and or
vomiting, dysphoria and respiratory
depression
© 2015. Cengage Learning. All rights
reserved.
 Methadone
 Synthetic opioid developed in the 1930’s
 Used as a substitute for morphine during
WWII
 Used in Methadone Maintenance Programs
 About as potent as Morphine
 Tolerance to euphoria develops quickly
 Can induce cardiac arrhythmias both when
used at therapeutic doses and when it is
abused
 When used as prescribed has a very good
© 2015. Cengage Learning. All rights
safety profile reserved.
 Morphine
 First isolated more than 150 years ago
 Usually administered by intramuscular or
intravenous injections
 Analgesic affects last approximately 4 hours

© 2015. Cengage Learning. All rights

reserved.
 OxyContin
 Introduced in 1995
 A time released form of oxycodone, a synthetic
opioid
 A relatively stable blood level of OxyContin
could be reached after 2-3 doses, providing
better pain control than could be achieved
using short-acting narcotic analgesics
 OxyContin has become a major drug of abuse

© 2015. Cengage Learning. All rights

reserved.
 Tramadol
 A distant cousin to codeine
 Used to treat mild to moderate levels of pain
 Thought to be about as potent as morphine
 May be more toxic than originally thought

© 2015. Cengage Learning. All rights

reserved.
 Neuroadaptation to narcotics
 Analgesia influenced by host of factors:
 Genetic heritage
 Innate tolerance
 Disease progression
 Level of activity
 Medication compliance
 Medication interaction
 Neuroadaptation to the medications being used
 Acquired tolerance
 Pseudo-addiction

© 2015. Cengage Learning. All rights

reserved.
 Subject effects of narcotics in
medicinal setting
 Several factors influence the effects such as:
 Route of administration
 Interval between doses
 Actual dose
 Half life of the medication being used
 Individual’s anxiety level
 Individual’s expectations
 Individual’s biochemistry

© 2015. Cengage Learning. All rights

reserved.
 Complications caused by
narcotics
 Constriction of the pupils
 Respiratory depression
 Gastrointestinal side effects
 Blood pressure effects
 Urinary retention
 Sedation
 Irritability
 Physician-induced addiction
 Unless history of SUD, only 1 in 14,000 receiving
narcotics for short-term pain is thought to be at risk
© 2015. Cengage Learning. All rights
reserved.
 Opiates as drugs of abuse
 Popular because it makes people feel “good”
i.e., induce a sense of pleasure
 Depending on several factors, subjective
experience can range from mild to comparable
to sexual orgasm
 Globally, about 11.7 million users
 About 1.2 million in the US

© 2015. Cengage Learning. All rights

reserved.
 Heroin
 Short history of heroin
 Developed by Bayer pharmaceuticals
 Thought to be treatment of morphine addiction
 Pharmacology of heroin
 More potent than morphine
 Is metabolized into morphine
 Crosses blood-brain barrier 100 times more rapidly
than morphine

© 2015. Cengage Learning. All rights

reserved.
 Subjective effects when abused
 A number of factors influence the subjective
effects of heroin when it is abuse including:
 The individual’s expectations
 Dose
 Method of heroin abuse
 Intranasal user report a gentle euphoria while
IV report a minute long “rush” or “flash” that
is similar to sexual orgasm
 Users report warmth under skin, floating
sensation “nodding off”
© 2015. Cengage Learning. All rights
reserved.
 Other Opioids of Abuse
 Codeine has emerged as a drug of abuse
accounting for 10% of all drug related deaths
 OxyContin-was released in 1995 and became a
drug of abuse shortly afterwards. It has been
estimated that 13.7 million people in the US
have used OxyContin for non-medical
purposes in the year 2003
 Buprenorphine-administered sublingually is an
alternative to methadone as a treatment for
opioid addiction. Intravenously administered
has significant abuse potential
© 2015. Cengage Learning. All rights
reserved.
 Methods of opiate abuse
 Injected under the skin (skin popping)
 Injected directly into a vein (intravenously, IV)
 Smoked
 Used intranasally (insufflation)

© 2015. Cengage Learning. All rights

reserved.
 Sources of Illicit Narcotics
 Pharmaceuticals are obtained in a variety of
ways
 The diversion of prescription narcotics
 Internet pharmacies have become a source of
“prescribed” medications that are used for illicit
purposes
 Heroin is still illegal in the US so it must be
smuggled in
 Health care professionals may divert
pharmaceuticals for their own use

© 2015. Cengage Learning. All rights

reserved.
 Development of tolerance
 The mechanism through which tolerance to a
narcotic analgesic develops is poorly
understood
 While tolerant to many of the effects, abusers
still experience the narcotic-induced sense of
gentle euphoria that is by itself an incentive for
continued use
 It is not uncommon for an abuser to
miscalculate their tolerance level and overdose
 some users go through cycles of use until
tolerance develops and
© 2015. Cengage then
Learning. periods of
All rights
reserved.
Scope of the problem of narcotic
abuse and addiction
 Physical dependence can develop in a very
short time, possibly after just a few days of use
 In the US, abuse of prescription narcotics is
more common than heroin addiction
 Males predominate the opioid addiction
problem by a ration of about 3:1
 Is difficult to separate drug-seeking patients
from those with a legitimate need for pain
relief, especially in patients with a physical
illness © 2015. Cengage Learning. All rights
reserved.
 Scope of heroin abuse in the US
 The late 1990’s heroin use rose
 “Heroin chic”
 Average age of the individual’s first use of
heroin dropped from 27 in 1988 to 19 by the
mid 90s

© 2015. Cengage Learning. All rights

reserved.
 Complications caused by chronic opiate
abuse
 Narcotic withdrawal syndrome
 Acute withdrawal
 Extended withdrawal symptoms
 Organdamage
 Overdose
 Suicide attempt
 Use of substitute or contaminated illicit drugs
 Unusual sensitivity
 Error in calculating dosage

© 2015. Cengage Learning. All rights

reserved.
Opioid use or abuse and the DSM-V
 Opioid use disorder
 Opioid intoxication
 Opioid withdrawal
 Other opioid-induced disorders
 Unspecified opioid-related disorders

© 2015. Cengage Learning. All rights

reserved.
 CHAPTER 10
Marijuana Abuse and Addiction

© 2015. Cengage Learning. All rights

reserved.
 Marijuana abuse and addiction
 Marijuana is a plant, a member of cannabis
sativa family of plants
 Almost 3,000 years ago Chinese physicians
used cannabis as a treatment for malaria,
constipation, the pain of childbirth
 Introduced in the US by immigrants
 Widely used during prohibition in 1920s

© 2015. Cengage Learning. All rights

reserved.
 Marijuana abuse and addiction
 Most commonly abused illicit drug in the US
 More than 50% of the population have used it at
least once
 A medico-legal conundrum
 May be able to relieve some of the symptoms of
amyotrophic lateral sclerosis (ALS), multiple sclerosis,
rheumatoid arthritis, chronic pain
 A lot of scientific research have been blocked by various
government agencies
 Some states have legalized the medical use of marijuana,
the federal government still takes precedence.

© 2015. Cengage Learning. All rights

reserved.
 Question of Potency
 The marijuana being consumed today is much
more potent (20-32%) than the marijuana than
just over 20 years ago (3%) in the 1990s
 There is much variation today between
samples of marijuana so that it is impossible to
tell the potency of any specific plant unless one
is a chemist
 Leads to question previous research using
strains woth such lower potency

© 2015. Cengage Learning. All rights

reserved.
 Scope of the problem of
marijuana abuse
 125-203 million people worldwide have abused
marijuana at least once in the last year; 32.5
million in the north America
 Peak age of initiation around 18-19 years of age
 If not used by age 20, unlikely to do so

© 2015. Cengage Learning. All rights

reserved.
 Pharmacology of Marijuana
 In spite of its long history as a popular substance of
abuse, the pharmacokinetics of marijuana are still not
completely understood
 In the 1960’s researchers discovered that the majority
of marijuana’s effects are caused by a compound
known as ∆-9-tetrahydro-cannabinol (“THC”).
However other psychoactive compounds are also
thought to contribute to its effects
 Chronic marijuana abusers might test “positive” for
THC in their urine for up to 30 days, but this is
happens only with exceptionally heavy levels of
marijuana abuse
© 2015. Cengage Learning. All rights
reserved.
 Pharmacology of Marijuana
 No known effect on respiration center in brain
stem
 THC mimics endocannabinoids which has
receptor sites throughout the brain
 Affects the synthesis of acetylcholine
 The mechanism through which marijuana is
able to induce a sense of mild euphoria is not
understood.
 Even under the best of conditions, the body is
not able to biotransform THC quickly, and in
chronic abusers the half-life might vary from
© 2015. Cengage Learning. All rights
reserved.
Interactions between marijuana
and other chemicals
 There has been relatively little research into
potential interactions between marijuana and
other compounds
 Given its popularity, there is surprisingly little
information regarding the possible interactions
between /marijuana and substance of abuse
 Clinical evidence would suggest that marijuana
use by patients on lithium can cause the
lithium levels in the blood to increase, possibly
to toxic levels © 2015. Cengage Learning. All rights
reserved.
 Methods of Abuse
 Oral abusers will usually bake marijuana into
cookies or brownies, which are then ingested
 Orally administered marijuana is slowly
absorbed, with the results being that the abuser
does not feel the first effects of THC until 30-
120 minutes after ingestion
 Peak THC levels are usually seen 1-5 hours
after the marijuana-laced cookie or brownie
was ingested. The effects last for 5 to possibly
as long as 24 hours after ingestion
© 2015. Cengage Learning. All rights
reserved.
 Methods of Abuse
 Methods of administration
 Most popular is by smoking, a practice of more than
5,000 years old
 Smoking makes 60% of the available THC admitted
into the body
 “joints” a marijuana form of cigarettes typically
contains 500-750 mg of marijuana (equivalent to 2.5
to 20 mg of THC
 “blunt” are made from unwrapping a cigar and then
refilling it with high potency marijuana

© 2015. Cengage Learning. All rights

reserved.
 Methods of Abuse
 Technique of smoking marijuana is different
than cigarette smoking or cigars
 Inhale deeply into the lungs, holding the breath for
20-30 seconds to get as much THC into the blood as
possible
 The effects reach peak intensity within 20-30
minutes and began to decline within an hour

© 2015. Cengage Learning. All rights

reserved.
Subjective Effects of Marijuana
 Marijuana smokers achieve the strongest
effects, producing a mild sense of euphoria,
relaxation, some sensory distortions, and
altering the individual’s perception of ordinary
activities such as eating, watching television or
movies, and having sex
 In social settings, marijuana smokers are prone
to infectious laughter, excessive talkativeness,
and a feeling of relaxation.

© 2015. Cengage Learning. All rights

reserved.
Subjective Effects of Marijuana
 Individual’s expectations influence effects of
marijuana
 Users anticipate the drug will
 Impair cognitive functions and behavior
 Help to relax
 Help to interact socially and enhance sexual function
 Enhance creative abilities and alter perception
 Negative consequential effects
 A sense of craving

© 2015. Cengage Learning. All rights

reserved.
 Adverse effects of marijuana
abuse
 Marijuana is viewed by many as relativity
harms. A 160lb person would need to smoke
the equivalent of 900 marijuana cigarettes,
simultaneously to reach a potentially lethal
level
 Bloodshot eyes
 Anxiety
 Drug induced panic reactions
 Impaired motor skills
 Toxic or drug induced psychosis
 Reduce sexual desire
© 2015. Cengage Learning. All rights
 Erectile problems reserved.
 Chronic Marijuana Abuse
 Marijuana abusers are known to be at risk for
the development of a drug-induced psychosis.
 Permanent brain “shrinkage” in certain areas
 Suppresses REM Sleep
 marijuana smokers who had smoked just one
“joint” a day for 10 years had a 570% higher
risk of lung cancer as nonsmokers in spite of
whether they smoked tobacco cigarettes or not.

© 2015. Cengage Learning. All rights

reserved.
 Chronic Marijuana Abuse
 Animal research also confirms that heavy
marijuana abuse appears to suppress the
immune system’s effectiveness
 Reproductive system dysfunctions
 “Amotivational syndrome”
 Increase in heart rate

© 2015. Cengage Learning. All rights

reserved.
 Addiction to Marijuana
 Marijuana is indeed addictive
 8-20% of chronic abusers will become
dependent on it
 Marijuana does not induce the same dramatic
withdrawal symptoms seen in alcohol or
narcotic-dependent persons who discontinue
the abuse of their desired drug
 Tolerance rapidly develops
 May experience irritability, aggression, anxiety,
depression, insomnia, sweating, nausea and
tachycardia if suddenly stopped
© 2015. Cengage Learning. All rights
reserved.
 Marijuana use and DSM -IV
 Cannabis intoxication
 Cannabis use disorder
 Cannabis withdrawal
 Other cannabis-induced disorders
 Unspecified cannabis-related diorder

© 2015. Cengage Learning. All rights

reserved.