CHAPTER 1
DRUGS—USE, ABUSE, AND ADDICTION

Drugs are nonfood chemicals that alter the way a person thinks, feels, functions, or behaves. This includes everything from prescription medications, to illegal chemicals like heroin, to popular and widely available substances like alcohol, tobacco, and caffeine. A wide variety of laws, regulations, and government agencies exist to control the possession, sale, and use of drugs. Different drugs are held to different standards based on their perceived dangers and usefulness; a fact that some-times leads to disagreement and controversy.

Illegal drugs are drugs with no currently accepted medical use in the United States, such as heroin, LSD, and marijuana. It is illegal to buy, sell, possess, and use these drugs except for research purposes. They are supplied only to registered, qualified researchers. Legal drugs, by contrast, are drugs whose sale, possession, and use as intended are not forbidden by law. Their use may be restricted, however. For example, the United States Drug Enforcement Administration (DEA) controls the use of legal psychoactive (mood-or mind-altering) drugs that have potential for abuse. These drugs, which include narcotics, depressants, and stimulants (see "Five Categories of Substances" below), are available only with a prescription and are called "controlled substances."

The goal of the DEA is to ensure that controlled substances are readily available for medical use, while preventing their illegal sale and abuse. The agency works toward accomplishing its goal by requiring people and businesses that manufacture, distribute, prescribe, and dispense controlled substances to register with the DEA. Registrants must abide by a series of requirements relating to drug security, records accountability, and adherence to standards.

The U.S. Food and Drug Administration (FDA) also plays a role in drug control. This agency regulates the manufacture and marketing of prescription and nonprescription drugs, requiring the active ingredients in a product to be safe and effective before allowing the drug to be sold.

Alcohol and tobacco are monitored and specially taxed by the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) of the U.S. Department of Justice. The alcohol program of this governmental agency regulates the qualification and operations of distilleries, wineries, and breweries. Additionally, it tests alcoholic beverages to ensure that their regulated ingredients are within legal limits and monitors labels for misleading information. The ATF tobacco program screens applicants who wish to manufacture, import, or export tobacco products.

FIVE CATEGORIES OF SUBSTANCES

Drugs may be classified into five categories:

• Depressants, including alcohol and tranquilizers: These substances slow down the activity of the nervous system. They produce sedative (calming) and hypnotic (trancelike) effects as well as drowsiness. If taken in large doses, depressants can cause intoxication (drunkenness).
• Hallucinogens, including marijuana, PCP (phencyclidine), and LSD (lysergic acid diethylamide): Hallu-cinogens produce abnormal and unreal sensations such as seeing distorted and vividly colored images. Hallucinogens also can produce frightening psychological responses such as anxiety, depression, and the feeling of losing control of one's mind.
• Narcotics, including heroin and opium, from which morphine and codeine are derived: Narcotics are drugs that alter the perception of pain and induce sleep and euphoria (an intense feeling of well-being; a "high").
• Stimulants, including caffeine, nicotine, cocaine, amphetamines, and methamphetamines: These substances speed up the processing rate of the central nervous system. They can reduce fatigue, elevate mood, increase energy, and help people stay awake. In large doses, stimulants can cause irritability, anxiety,

  Substance: category and name	Examples of commercial and street names	DEA schedulea/how administeredb	Intoxication effects /potential health consequences
  Depressants
  Alcohol	Beer, wine, hard liquor	Not scheduled/swallowed	Reduced anxiety; feeling of well-being; lowered inhibitions; slowed pulse and breathing; lowered blood pressure; poor concentration/fatigue; confusion; impaired coordination, memory, judgment; addiction; respiratory depression and arrest, death
  Barbiturates	Amytal, Nembutal, Seconal, Phenobarbital; barbs, reds, red birds, phennies, tooies, yellows, yellow jackets	II, III, V/injected, swallowed	Also, for barbiturates—sedation, drowsiness/depression, unusual excitement, fever, irritability, poor judgment, slurred speech, dizziness, life-threatening withdrawal.
  Benzodiazepines (other than flunitrazepam)	Ativan, Halcion, Librium, Valium, Xanax; candy, downers, sleeping pills, tranks	IV/swallowed, injected	For benzodiazepines—sedation, drowsiness/dizziness
  Flunitrazepamc	Rohypnol; forget-me pill, Mexican Valium, R2, Roche, roofies, roofinol, rope, rophies	IV/swallowed, snorted	For flunitrazepam—visual and gastrointestinal disturbances, urinary retention, memory loss for the time under the drug's effects
  GHBc	gamma-hydroxybutyrate; G, Georgia home boy, grievous bodily harm, liquid ecstasy	I/swallowed	For GHB—drowsiness, nausea/vomiting, headache, loss of consciousness, loss of reflexes, seizures, coma, death
  Methaqualone	Quaalude, Sopor, Parest; ludes, mandex, quad, quay	I/injected, swallowed	For methaqualone—euphoria/depression, poor reflexes, slurred speech, coma
  Cannabinoids (hallucinogens)
  Hashish	Boom, chronic, gangster, hash, hash oil, hemp	I/swallowed, smoked	Euphoria, slowed thinking and reaction time, confusion, impaired balance and coordination/cough, frequent respiratory infections; impaired memory and learning; increased heart rate, anxiety; panic attacks; tolerance, addiction
  Marijuana	Blunt, dope, ganja, grass, herb, joints, Mary Jane, pot, reefer sinsemilla, skunk, weed	I/swallowed, smoked	Increased heart rate and blood pressure, impaired motor function/memory loss; numbness; nausea/vomiting
  Dissociative anesthetics (hallucinogens)
  Ketamine	Ketalar SV; cat Valiums, K, Special K, vitamin K	III/injected, snorted, smoked	Also, for ketamine—at high doses, delirium, depression, respiratory depression and arrest
  PCP and analogs	phencyclidine; angel dust, boat, hog, love boat, peace pill	I, II/injected, swallowed, smoked	For PCP and analogs—possible decrease in blood pressure and heart rate, panic, aggression, violence/loss of appetite, depression
  Hallucinogens			Altered states of perception and feeling; nausea; persisting perception disorder (flashbacks)
  LSD	Lysergic acid diethylamide; acid, blotter, boomers, cubes, microdot, yellow	I/swallowed, absorbed through mouth tissues	Also, for LSD and mescaline—increased body temperature, heart rate, blood pressure; loss of appetite, sleeplessness, numbness, weakness, tremors
  Mescaline	Buttons, cactus, mesc, peyote	I/swallowed, smoked	For LSD—persistent mental disorders
  Psilocybin	Magic mushroom, purple passion, shrooms	I/swallowed	For psilocybin—nervousness, paranoia
  Opioids and morphine derivatives (narcotics)
  Codeine	Empirin with Codeine, Fiorinal with Codeine, Robitussin A-C, Tylenol with Codeine; Captain Cody, Cody, schoolboy; (with glutethimide) doors & fours, loads, pancakes and syrup	II, III, IV/injected, swallowed	Pain relief, euphoria, drowsiness/nausea, constipation, confusion, sedation, respiratory depression and arrest, tolerance, addiction, unconsciousness, coma, death
  Fentanyl and fentanyl analogs	Actiq, Duragesic, Sublimaze; Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, Tango and Cash	I, II/injected smoked, snorted	Also, for codeine—less analgesia, sedation, and respiratory depression than morphine
  Heroin	Diacetylmorphine; brown sugar, dope, H, horse, junk, skag, skunk, smack, white horse	I/injected smoked, snorted	For heroin—staggering gait
  Morphine	Roxanol, Duramorph; M, Miss Emma, monkey, white stuff	II, III/injected, swallowed, smoked
  Opium	Laudanum, paregoric; big O, black stuff, block, gum, hop	II, III, V/swallowed, smoked
  Oxycodone HCL	Oxycontin; Oxy, O.C., killer	II/swallowed, snorted, injected
  Hydrocodone bitartrate, acetaminophen	Vicodin; vike, Watson-387	II/swallowed

  sleeplessness, and even psychotic behavior. Caffeine is the most commonly used stimulant in the world.
• Other compounds, including anabolic steroids and inhalants: Anabolic steroids are a group of synthetic substances that are chemically related to testoster-one and are promoted for their muscle-building properties. Inhalants are solvents and aerosol products that produce vapors having psychoactive effects. These substances dull pain and can produce euphoria.

Table 1.1 provides an overview of alcohol, nicotine, and selected other psychoactive substances.

It includes the DEA schedule for each drug listed. The DEA drug schedules are categories into which controlled substances are placed depending on their characteristics. The types of drugs categorized in each of the five schedules, with examples, are shown in Table 1.2.

DRUGS DISCUSSED IN THIS BOOK

This book focuses on three substances widely used throughout the world: alcohol, tobacco, and caffeine. Not only are alcohol, tobacco, and caffeine legal, relatively affordable, and more or less socially acceptable (depending on time, place, and circumstance), they are also important economic commodities. Industries exist to produce, distribute, and sell these products, creating jobs and income and contributing to economic well-being. The possible government regulation of alcohol and tobacco raises significant economic and political issues.

WHAT ARE ABUSE AND ADDICTION?

Scientists do not know why some people who use addictive substances become addicted and others do not. Results of numerous studies of identical and fraternal (nonidentical) twins, and families with histories of substance abuse and addiction, indicate that there is probably a genetic component to addiction. To date, however, researchers have not identified specific genes that would distinguish people who are at risk of becoming addicted. Results of a study published in 2004, however, show that a mutation in certain brain receptors lowers the threshold for nicotine dependence in mice with the mutation (Tapper et al., "Nicotine Activation of alpha4 Receptors: Sufficient for Reward,

Tolerance, and Sensitization," Science, vol. 306, November 5, 2004).

Research and treatment experts have identified three general levels of interaction with drugs: use, abuse, and dependence (or addiction). In general, abuse involves a compulsive use of a substance and impaired social or occupational functioning. Dependence (addiction) includes these traits, plus evidence of physical tolerance (a need to take increasingly higher doses to achieve the same effect) or withdrawal symptoms when use of the drug is stopped.

The progression from use to dependence is very complex, as are the abused substances themselves. Researchers have found no standard boundaries between using a substance, abusing a substance, and being addicted to a substance. They believe these lines vary widely from substance to substance and from individual to individual.

Physiological, Psychological, and Sociocultural Factors

Some researchers maintain that the principal causes of substance use are external social influences, such as peer pressure, while substance abuse and/or dependence result primarily from internal psychological and physiological needs and pressures, including inherited tendencies. Additionally, psychoactive drug use at an early age may be a risk factor (a characteristic that increases likelihood) for subsequent dependence.

Physically, mood-altering substances affect brain processes. Most drugs that are abused stimulate the reward or pleasure centers of the brain by causing the release of dopamine, which is a neurotransmitter—a chemical in the brain that relays messages from one nerve cell to another.

Psychologically, a person may become dependent on a substance because it relieves pain, offers escape from real or perceived problems, or makes the user feel more relaxed or confident in certain social settings. A successful first use of a substance may reduce the user's fear of the drug and thus lead to continued use and even dependence.

Socially, substance use may be widespread in some groups or environments. The desire to belong to a special group is a very strong human characteristic, and those who use one or more substances may become part of a subculture that encourages and promotes use. An individual may be influenced by one of these groups to start using a substance, or he or she may be drawn to such a group after starting use some-where else. In addition, a person—especially a young person—may not have access to alternative rewarding or pleasurable groups or activities that do not include substance use.

Figure 1.1 illustrates some relationships between physiological, psychological, and cultural factors that influence drinking and drinking patterns. Constraints (inhibitory factors) and motivations influence drinking patterns. In turn, drinking patterns influence the relationship between routine activities related to drinking and acute (immediate) consequences of drinking.

Definitions of Abuse and Dependence

Two texts provide the most commonly used medical definitions of substance abuse and dependence. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association. The International Classification of Diseases (ICD) is published by the World Health Organization (WHO). While the definitions of dependence in the two manuals are almost identical, the definitions of abuse are not.

THE DSM DEFINITION OF ABUSE.

The text revision of the fourth edition of the DSM (DSM-IV-TR), published in 2000, defines abuse as an abnormal pattern of recurring use that leads to "significant impairment or distress," marked by one or more of the following in a twelve-month period:

• Failure to fulfill major obligations at home, school, or work (for example, repeated absences, poor performance, or neglect).
• Use in hazardous or potentially hazardous situations, such as driving a car or operating a machine while impaired.
• Legal problems, such as arrest for disorderly conduct while under the influence of the substance.
• Continued use in spite of social or interpersonal problems caused by the use of the substance, such as fights or family arguments.

THE ICD DEFINITION OF "HARMFUL USE."

The tenth (and most recent) revision of the ICD (ICD-10), endorsed by the Forty-third World Health Assembly in May 1990 and used in WHO Member States since 1994, uses the term "harmful use" rather than abuse. It defines harmful use as "a pattern of psychoactive substance use that is causing damage to health," either physical or mental.

Because the ICD manual is targeted toward international use, its definition must be broader than the DSM definition intended for use by Americans. Cultural customs of substance use vary widely, sometimes even within the same country.

DEFINITIONS OF DEPENDENCE.

In general, the DSM-
IV-TR and the ICD-10 manuals agree that dependence is present if three or more of the following occur in a twelve-month period:

• Increasing need for more of the substance to achieve the same effect (occurs as the user builds up a tolerance to the substance), or a reduction in effect when using the same amount as used previously.
• Withdrawal symptoms if use of the substance is stopped or reduced.
• Progressive neglect of other pleasures and duties.
• A strong desire to take the substance or a persistent but unsuccessful desire to control or reduce the use of the substance.
• Continued use in spite of physical or mental health problems caused by the substance.
• Use of the substance in larger amounts or over longer periods of time than originally intended, or difficulties in controlling the amount of the substance used or when to stop taking it.
• Considerable time spent in obtaining the substance, using it, or recovering from its effects.

Progression from Use to Dependence

The rate at which individuals progress from drug use to drug abuse to drug dependence (or addiction) depends on many of the aforementioned factors. In general, each level is more dangerous, more invasive in the user's life, and more likely to cause social interventions, such as family pressure to enter treatment programs or prison sentences for drug offenses, than the previous level.

Figure 1.2 is a diagram of the progression to addiction. Notice that the intensification of use leads to abuse, and that abuse leads to addiction and dependence. The right side of the diagram shows social interventions appropriate at various stages of drug use, abuse, and dependence. The dotted lines to the left show that relapse after recovery may lead to renewed drug use, abuse, or dependence.