Human beings have used mood-altering drugs—or drugs of potential abuse—for hundreds of thousands of years. Their use is due to the fact that all these drugs directly or indirectly produce quick surges of a neurotransmitter or brain chemical called dopamine. Dopamine is a substance which when released in the brain results in a feeling of pleasure or euphoria, in other words a “high.” Each drug of use, abuse, and addiction that has been carefully studied has been shown to result in this increase in dopamine and pleasurable euphoria.
CLASSES OF MOOD-ALTERING DRUGS
Although this effect of dopamine is the characteristic that results in the use of these drugs, they also have many other brain effects. It is these other brain effects that dictate the type or class of the drug. There are four main classes of mood-altering drugs: stimulants, opi-oids, sedative hypnotics, and hallucinogens. Table 1 lists the drugs that fall into each of these classes.
|Table 1. Four main classes of mood-altering drugs|
Stimulants are drugs that result in the release of varying amounts of norepinephrine or adrenaline in addition to dopamine. This release of adrenaline results in dilated or widening of the pupils, increased attention, increased reflexes, increased blood pressure and heart rate, increased alertness, decrease need for sleep, and decreased appetite. Therefore, stimulants produce euphoria from the release of dopamine, and stimulation from the release of adrenaline.
opioids are drugs, natural or synthetic compounds related to opium, that affect the mu or morphine receptor in the brain. As a consequence they produce constriction of the pupils, dry eyes, dry mouth, constipation, sedation or sleepiness, slowing of the heart rate and breathing rate, decrease in blood pressure, and pronounced pain relief.
The sedative hypnotic class of drugs is made up of substances that work on the gamma-aminobutyrate (GABA) receptor system of the brain. Gamma-aminobutyrate neurons are cells that excite and activate the brain, leading to wakefulness and at times even anxiety. Sedative hypnotic substances tend to depress or quiet down GABA nerve cells, causing a relief of anxiety, sleepiness, and when used at too high a dose result in coma or even death. Sedative hypnotic substances, like the more potent amphetamines and cocaine, tend to produce a high degree of judgment impairment as a consequence of overuse and intoxication. Thus, bizarre behavior contrary to the patient’s upbringing is commonplace with intoxication. These sedative hypnotics range from relatively weak substances like alcohol to very potent ones like the “date rape” drug Rohypnol. An additional danger of sedative hypnotics is that they clearly increase in potency of effect when used in combination, markedly increasing the chances of serious overdose.
Hallucinogens are a diverse group of substances that alter perception as part of their central nervous system or brain effect. This group includes LSD, phen-cyclidine (PCP), marijuana, and many naturally occurring hallucinogens from a variety of plants. Hallucinogens as a group, like the opioids, tend to produce a low degree of judgment impairment as a consequence of overuse and intoxication. The altering of perception seems to include many different effects such as visual distortions, spatial distortions, and loss of time perception.
Mood-altering drugs are primarily used for their ability to trigger a quick rise in dopamine, and thus an elevation in mood or euphoria. These same drugs have additional actions and effects that can generally be categorized into one of the above four classes. Virtually all of the drugs listed in Table 1 can be used, or abused, or trigger the development of an addiction.
THE CONTINUUM OF MOOD-ALTERING DRUG USE
Alcohol use, and to some extent other drug use, has been characterized as existing in our society as a gradual continuum. The levels of use are abstinence, low-risk or casual use, risky use or “substance abuse,” and chemical dependence or addiction. Definitions of each of these use levels follow.
These people are nonusers of mood-altering drugs, do not use even in low-risk amounts, and are more often older women or members of a relatively more fundamentalist sect of the major religions. Another smaller yet critically important group of abstainers are those people with a history of chemical dependence or addiction who are currently abstinent in an effort to deal with the addiction.
Abstinence is prevalent among three groups in society, those with a strong, relatively conservative or fundamentalist religious belief, those with a strong family history of addiction who do not want to take the risk of activating the disease in themselves, and those individuals with the disease of addiction who are in recovery and thus not using.
The most important issue in abstinence, for those who are in recovery from addiction, is to maintain complete abstinence from mood-altering drugs. Although there are very rare instances when medications that are mood-altering drugs must be prescribed, the long-term intake of these medications is generally very dangerous for persons in recovery and should be avoided. Common reasons for relapsing back to addiction are (a) trying to go back and control one’s use of the previously addicting drug, (b) trying to use mood-altering drugs other than the one that was the previous addicting drug, and (c) being prescribed mood-altering drugs on a long-term basis by a physician and reactivating addiction.
These people are low-level intermittent users of mood-altering drugs who do not binge, use only in socially acceptable situations, and have little if any evidence of health risk from their use. The federal government has published “Sensible Drinking Guidelines” for adult men and women that provide clear information about what drinking levels are associated with no detectable health risks. Interestingly, these guidelines stipulate at least a 30% lower level of alcohol use for women than for their male counterparts.
This is generally a very stable pattern of use, only in social situations, and always keeping to within the “sensible use guidelines” referenced above. True social users never have to try to limit their use, consciously construct rules around their use, cut back on their use because of an embarrassing situation, and the like. Persons with addiction problems constantly try to become low-risk “social” users, by cutting back and trying to control their use. In reality, low-risk users never have to think about controlling their use, it just happens unconsciously.
It is difficult to discuss low-risk use of drugs other than alcohol in American society where possession of other drugs is illegal and thus carries serious potential consequences. The limited data that are available from other countries seem to indicate that some nonalcohol mood-altering drugs might be available to a community for low-risk or “social” use purposes. However, for the foreseeable future, possession will remain illegal in this country, and thus low-risk use is not a term that can be applied to nonalcohol mood-altering drug use.
Substance abusers are individuals who use more alcohol than is considered “healthy,” or who use any amounts of nonalcohol mood-altering drugs. Although the use patterns tend to fall within their general peer group norm, and there are rare adverse consequences from the use, they tend to binge at levels that have clearly been shown to be a risk to health, and use to levels of intoxication that significantly impair their judgment and moral values. They are also individuals who do not meet the criteria for chemical dependence or addiction. It is generally thought that substance abuse is a behavior that many people participate in during late adolescence and early adulthood, which evolves either into low-risk use or addiction, and that is under a good deal of voluntary control.
Although not a disease or illness, substance abuse is responsible for a tremendous amount of pain and suffering in our society, including the majority of “date rapes,” and much young adult nonsexual interpersonal violence as well as destruction of property. In effect, although substance abuse is a behavior and not an illness, and it rarely involves problems for any person who might be an abuser, it is very common with an estimated 70-85% of the population in their teens and 20s passing through some period of substance abuse. As a result, there is a large amount of societal morbidity (pain and suffering) that occurs as a result of substance abuse.
Substance abusers tend to be intermittent binge users, using to risky levels of intoxication. This use tends to be self-limited in time with a gradual decrease over time and “maturity.” Some individuals labeled as “abusers” are probably addicted, and over time their use escalated (while that of many of their general peer group abates). This accounts for the phenomena of some substance abusers seeming to progress to addiction. The most appropriate intervention or treatment of substance abuse is to counsel the individual (a) against use of illegal and illicit drugs, (b) against the underage use of legal drugs, (c) away from binging behavior, and (d) toward staying within the “sensible drinking guidelines.”
Chemical Dependence or Addiction
Chemical dependence or addiction is clearly a chronic disease of the brain that bears no relationship with morality, education, social class, or ethnicity. It is a primarily genetic illness that clusters fairly heavily in families. Addiction is characterized by the repetitive, intermittent, loss of control over the use of a mood-altering drug that causes problems in a person’s life. As a consequence, addiction is not defined in terms of quantity and frequency of use, but rather in terms of patterns (loss of control) and consequences (repeated problems) of use.
The essential problem in addiction is this loss of control, and the resulting bizarre/uncharacteristic/ erratic/irresponsible behaviors. Thus, the domains in a person’s life where problems from addiction arise tend to be the following: self-respect/close love relationships/social relationships/financial problems/legal problems/work problems/and finally medical or psychiatric problems. Individuals with addiction or chemical dependence have developed one or more alcohol-related or drug-related problems such as a Driving Under the Influence of Alcohol (DUI), medical complications, family problems, or other behavioral consequences. The types of problems range from minimal—such as one or two blackouts in young adulthood, followed by family concern about the person’s drinking—to severe, including loss of work, or loss of family.
The societal costs of addictions are overwhelming. Tobacco dependence is the leading preventable cause of death in America, with 470,000 premature deaths per year. Fetal alcohol syndrome is the leading cause of preventable birth defects in our country. Over 70% of domestic violence is addiction related, 70% of child abuse and 90% of childhood sexual abuse are thought to be addiction related. The economic costs of addiction are estimated at 80-110 billion dollars per year, and addictions are considered the nation’s number one health problem!
SCREENING, INTERVENTION, AND TREATMENT
It can be difficult to figure out if a person’s use of mood-altering drugs is low risk, abuse, or dependence. Most of our societal belief systems regarding these issues are flawed, and therefore many of our “community screening criteria” are relatively weak. In general, the community misses the presence of substance abuse and dependence far more often than they are identified. Up to 90% of people with drinking problems are not noticed by their family, friends, faith communities, educational institutions, or health care providers. Clearly we as a society need better screening tools. One useful questionnaire is the f-CAGE or “family CAGE.” This stands for the first letter in key words from four screening questions: Cut down, Annoyed, Guilty and Eye-opener as shown in Table 2. Each positive response to a question on the f-CAGE, especially when it represents a repetition of behavior, has a 40% chance of addictive disease. The reason for this is the fact that the f-CAGE assesses for abnormal patterns and consequences of substance use and identifies repetitive loss of control and adverse consequences.
|Table 2. The f-CAGE questionnaire|
|C||Does anyone in your family ever periodically feel a need to cut down on their use of alcohol or other drugs?|
|A||Does anyone in your family ever get annoyed by comments made by friends or family about his/her use of alcohol or other drugs?|
|G||Does anyone in your family ever feel guilty, embarrassed, or even bashful about things they say or do while using alcohol or other drugs?|
|E||Does anyone in your family ever need eye-openers or to drink or drug in the morning to “get started” or “settle their nerves”?|
Intervention with persons who have substance abuse or dependence problems is a difficult but potentially very useful task. The most important part of intervening by one’s self with a friend who has a substance use problem is to be sure to actually do it. The most basic approach is to share one’s concern with the affected person about the substance use. It is helpful not to be judgmental, to focus on the use and the consequences and not on the person. The strategy is to separate the person from the addictive disease and behaviors associated with the disease when sharing concerns. This minimizes arguments and helps keep communication open. Phrases such as “I know it is not you, it is the drinking…” are very helpful. Other more specific suggestions are available through the references.
The Crisis Family Intervention is worth mentioning for several reasons, even though it is beyond the expertise of family member or loved one. First, over the past decade or two it has become the most successful approach to involve patients in treatment for chemical dependence. Second, family members are periodically asked to participate in the interventions. The crisis intervention is basically a group confrontation with the chemically dependent person, carefully organized, rehearsed, and choreographed by a trained “intervention counselor.” Each member of the group is a “significant other” of the patient, and is prepared to state several experiences where the drinking/drugging of the patient adversely affected that group member. With the weight of all of this objective evidence, presented by friends and family members, the “wall of denial” for most patients breaks down enough to help get that patient into a treatment program. Phrases and techniques that are coached by the intervention counselor include the following: “It’s not you, it is the drinking.” “It hurts me too much to see you continue in this painful disease.” “You did not develop this on purpose, but you’ve got it.” “We care about you, but hate your drinking.” “I will not argue; this is what you did, this is when you did it, and this is how it made me feel.” Obviously, there are a few common threads in these phrases:
- Exhibiting positive regard toward the individual and negative regard toward the drinking at all times.
- Obtaining specific data about specific events in order to adequately confront such patients.
- Validating the disease via statements about the obvious pain of this progressive illness—which ruins family, job, financial, legal, spiritual, and physical health—gives the patient permission to become less defensive.
- Acknowledging that patients with chemical dependence do not try to catch it, but need treatment anyway, can relieve some degree of guilt, and make patients even less defensive. When organized and supervised by a well-trained intervention counselor, a crisis intervention can motivate up to 80% of patients who are resisting treatment to change their minds and enter a treatment program.
Treatment of substance abuse primarily entails education about dangers of overuse and binging, efforts to eliminate illegal drug use altogether, and support in limiting use of alcohol to within the sensible drinking guidelines. Treatment for substance abuse is primarily education and advice, coupled with the reprimand of and intolerance for future intoxicated and disinhibited behavior.
Treatment of addiction requires a focus on eliminating mood-altering drug use. Therefore, abstinence is the treatment goal and most treatment efforts are aimed at achieving abstinence and maintaining abstinence long term. There are several levels of addiction treatment available, and each will be briefly described:
This is a short, 1- to 7-day inpatient or outpatient stay during which patients are detoxified from one or more mood-altering substances. A “detox” is indicated if a patient gives a history of not being able to “get sober or straight” at all on her/his own.
Inpatient Treatment (Rehabilitation)
This refers to an inpatient stay on a residential unit for a variable period of time ranging from 7 days to 6 weeks. Admission criteria as well as programs tend to vary, but generally accept insured patients who have finished the worst of their withdrawal. Some programs accept uninsured patients. While enrolled, patients spend their time being educated about addiction, recovery, and Alcoholics Anonymous (AA) in group therapy, individual counseling, family counseling sessions, and doing reading and writing homework assignments.
Advantages of these programs include protected environments, intensive education and therapy, and new friends and associates who are drug- and alcohol-free. Disadvantages include cost and thus limited access to this treatment as well as separation from the realities of life during treatment. For some patients, separation from their environment via residential treatment will be essential for establishing a period of drug-free time to allow treatment and recovery to begin.
Outpatient Treatment (Rehabilitation)
With limited insurance resources but a commitment to treat the illness of chemical dependence, more and more emphasis is being placed on flexible outpatient programs. These programs offer most of what the inpa-tient programs do, except that it is “day treatment” or “evening treatment” and, thus, less expensive.
Advantages are a longer period of treatment for the same or less cost, a chance for patients to continue to work or care for their home while participating, and the opportunity to interact with the environment (home, work, etc.) while exploring, through treatment, the strategies to use in that environment to stay sober and develop a recovery plan. Disadvantages include the cost not being covered by insurance, large co-pay percentages, limited number of programs available, and a less structured environment and greater tendency for relapse during treatment.
Self-Help Programs (AA, NA, CA, etc.)
The self-help programs, notably AA, were developed in the 1930s and 1940s, and were the first successful approaches to recovery from chemical dependence. Though difficult to describe and nearly impossible to explain, AA works as a fellowship of individuals, all of whom have alcoholism or drug dependence and all of whom meet regularly to act as support for each other’s efforts to live without drinking or drugging. Daily meetings, which take place in all communities, are free and are open to all people in need. They follow a general outline of opening with a recitation of the Twelve Steps and Twelve Traditions of AA, followed by a member telling his/her story of life with and without alcohol, and closing with a discussion and then the Lord’s Prayer. Though clearly spiritual in orientation, AA is not religious and mainly concentrates on how to live sober. Advantages include cost (free), accessibility, convenience, and success. Disadvantages include preconceived notions/prejudices on the part of patients so they refuse to attend, and the fact that what is good treatment for many is not sufficient for everyone.
When using 12-step meetings, it is important for women in early recovery to try to attend at least some “women-only closed” meetings. A women-only meeting should be the person’s “home group” and utilizing a person from the home group for a “sponsor” is very important. These recommendations are made to counteract the strong tendency toward male-female socializing at times in formal and self-help treatment programs. It is clearly not in the best interests of a woman’s recovery to develop a relationship in treatment. In fact, unstable romantic relationships are such a strong predictor for relapsing back to addiction that it is recommended not to begin any new relationships for the first 12-18 months of sobriety.
Family Treatment Resources
There are several resources available to help family and friends educate themselves about chemical dependence in the references. After family members have read these materials, they will be more likely to agree to referral for individual counseling or family therapy. There are self-help organizations also available for family members of people with chemical dependence problems, including AlAnon, Alateen, Tough Love, and Families Anonymous. In addition, family members can benefit from individual counseling or family therapy when dealing with a loved one who has addiction problems.
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- Alcoholics Anonymous. (1976). Third edition. New York: Alcoholics Anonymous World Services.
- Barker, L. R., & Whitfield, C. L. (2002). Alcoholism. In L. Barker, J. R. Burton, & P. D. Zieve (Eds.), Principles of ambulatory medicine (pp. 258-259). Baltimore: Williams & Wilkins.
- Institute of Medicine, Division of Mental Health and Behavioral Medicine. (1990). Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press.
- Mooney, A. (1992). The recovery book. New York: Workman.
- National Institute on Alcohol Abuse and Alcoholism. (1995). NIAAA sensible guide to drinking The physicians guide to helping patients with alcohol problems (NIH Publication No. 95-3769). Washington, DC: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health.
- Principles of Addiction Medicine. (2003). Vol. 3. Washington, DC: American Society of Addiction Medicine.
- Rogers, R. L., & McMillin, C. S. (1992). Freeing someone you love from alcohol and other drugs. New York: The Body Press.
- Valliant, G. E. (1983). The natural history of alcoholism: Causes, patterns, and paths to recovery. Cambridge, MA: Harvard University Press.