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Chapter 10 Introduction

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CHAPTER 10

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TOPIC OVERVIEW

Depressants

Alcohol

Sedative-Hypnotic Drugs

Opioids

Stimulants

Cocaine

Amphetamines

Stimulant Use Disorder

Hallucinogens, Cannabis, and Combinations of Substances

Hallucinogens

Cannabis

Combinations of Substances

What Causes Substance Use Disorders?

Sociocultural Views

Psychodynamic Views

Cognitive-Behavioral Views

Biological Views

How Are Substance Use Disorders Treated?

Psychodynamic Therapies

Behavioral Therapies

Cognitive-Behavioral Therapies

Biological Treatments

Sociocultural Therapies

Other Addictive Disorders

Gambling Disorder

Internet Gaming Disorder: Awaiting Official Status

Putting It Together: New Wrinkles to a Familiar Story

Substance Use and Addictive Disorders

“I am Duncan. I am an alcoholic.” The audience settled deeper into their chairs at these familiar words. Another chronicle of death and rebirth would shortly begin [at] Alcoholics Anonymous….

“I must have been just past my 15th birthday when I had that first drink that everybody talks about. And like so many of them ….t was like a miracle. With a little beer in my gut, the world was transformed. I wasn’t a weakling anymore, I could lick almost anybody on the block. And girls? Well, you can imagine how a couple of beers made me feel like I could have any girl I wanted….

“Though it’s obvious to me now that my drinking even then, in high school, and after I got to college, was a problem, I didn’t think so at the time. After all, everybody was drinking and getting drunk and acting stupid, and I didn’t really think I was different…. I guess the fact that I hadn’t really had any blackouts and that I could go for days without having to drink reassured me that things hadn’t gotten out of control. And that’s the way it went, until I found myself drinking even more—and more often—and suffering more from my drinking, along about my third year of college….

“My roommate, a friend from high school, started bugging me about my drinking. It wasn’t even that I’d have to sleep it off the whole next day and miss class, it was that he had begun to hear other friends talking about me, about the fool I’d made of myself at parties. He saw how shaky I was the morning after, and he saw how different I was when I’d been drinking a lot—almost out of my head was the way he put it. And he could count the bottles that I’d leave around the room, and he knew what the drinking and carousing was doing to my grades…. [P]artly because I really cared about my roommate and didn’t want to lose him as a friend, I did cut down on my drinking by half or more. I only drank on weekends—and then only at night…. And that got me through the rest of college and, actually, through law school as well….

“Shortly after getting my law degree, I married my first wife, and ….or the first time since I started, my drinking was no problem at all. I would go for weeks at a time without touching a drop….

“My marriage started to go bad after our second son, our third child, was born. I was very much career- and success-oriented, and I had little time to spend at home with my family…. My traveling had increased a lot, there were stimulating people on those trips, and, let’s face it, there were some pretty exciting women available, too. So home got to be little else but a nagging, boring wife and children I wasn’t very interested in. My drinking had gotten bad again, too, with being on the road so much, having to do a lot of entertaining at lunch when I wasn’t away, and trying to soften the hassles at home. I guess I was putting down close to a gallon of very good scotch a week, with one thing or another.

“And as that went on, the drinking began to affect both my marriage and my career. With enough booze in me and under the pressures of guilt over my failure to carry out my responsibilities to my wife and children, I sometimes got kind of rough physically with them. I would break furniture, throw things around, then rush out and drive off in the car. I had a couple of wrecks, lost my license for two years because of one of them. Worst of all was when I tried to stop. By then I was totally hooked, so every time I tried to stop drinking, I’d experience withdrawal in all its horrors ….ith the vomiting and the ‘shakes’ and being unable to sit still or to lie down. And that would go on for days at a time….

“Then, about four years ago, with my life in ruins, my wife given up on me and the kids with her, out of a job, and way down on my luck, [Alcoholics Anonymous] and I found each other…. I’ve been dry now for a little over two years, and with luck and support, I may stay sober….”

(Spitzer et al., 1983, pp. 87–89)

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Human beings enjoy a remarkable variety of foods and drinks. Every substance on earth probably has been tried by someone, somewhere, at some time. We also have discovered substances that have interesting effects—both medical and pleasurable—on our brains and the rest of our bodies. We may swallow an aspirin to quiet a headache, an antibiotic to fight an infection, or a tranquilizer to calm us down. We may drink coffee to get going in the morning or wine to relax with friends. We may smoke cigarettes to soothe our nerves. However, many of the substances we consume can harm us or disrupt our behavior or mood. The misuse of such substances has become one of society’s biggest problems; it has been estimated that the cost of substance misuse is more than $600 billion each year in the United States alone (Johnston et al., 2014).

Not only are numerous substances available in our society, but new ones are also introduced almost every day. Some are harvested from nature, others derived from natural substances, and still others produced in the laboratory. Some, such as antianxiety drugs, require a physician’s prescription for legal use. Others, such as alcohol and nicotine, are legally available to adults. Still others, such as heroin, are illegal under all circumstances. In 1962, only 4 million people in the United States had ever used marijuana, cocaine, heroin, or another illegal substance; today the number has climbed to more than 100 million (SAMHSA, 2014). In fact, 24 million people have used illegal substances within the past month. Almost 24 percent of all high school seniors have used an illegal drug within the past month (Johnston et al., 2014).

A drug is defined as any substance other than food that affects our bodies or minds. It need not be a medicine or be illegal. The term “substance” is now frequently used in place of “drug,” in part because many people fail to see that such substances as alcohol, tobacco, and caffeine are drugs, too. When a person ingests a substance—whether it be alcohol, cocaine, marijuana, or some form of medication—trillions of powerful molecules surge through the bloodstream and into the brain. Once there, the molecules set off a series of biochemical events that disturb the normal operation of the brain and body. Not surprisingly, then, substance misuse may lead to various kinds of abnormal functioning.

substance intoxication A cluster of temporary undesirable behavioral or psychological changes that develop during or shortly after the ingestion of a substance.

Substances may cause temporary changes in behavior, emotion, or thought; this cluster of changes is called substance intoxication in DSM-5. As Duncan found out, for example, an excessive amount of alcohol may lead to alcohol intoxication, a temporary state of poor judgment, mood changes, irritability, slurred speech, and poor coordination. Similarly, drugs such as LSD may produce hallucinogen intoxication, sometimes called hallucinosis, which consists largely of perceptual distortions and hallucinations.

substance use disorder A pattern of long-term maladaptive behaviors and reactions brought about by repeated use of a substance.

tolerance The brain and body’s need for ever larger doses of a drug to produce earlier effects.

withdrawal Unpleasant, sometimes dangerous reactions that may occur when people who use a drug regularly stop taking or reduce their dosage of the drug.

Some substances can also lead to long-term problems. People who regularly ingest them may develop substance use disorders, patterns of maladaptive behaviors and reactions brought about by the repeated use of substances (Higgins et al., 2014; APA, 2013). People with a substance use disorder may come to crave a particular substance and rely on it excessively, resulting in damage to their family and social relationships, poor functioning at work, and/or danger to themselves or others (see Table 10.1). In many cases, people with such a disorder also become physically dependent on the substance, developing a tolerance for it and experiencing withdrawal reactions. When people develop tolerance, they need increasing doses of the substance to produce the desired effect. Withdrawal reactions consist of unpleasant and sometimes dangerous symptoms—cramps, anxiety attacks, sweating, nausea—that occur when the person suddenly stops taking or cuts back on the substance. Duncan, who described his problems to fellow members at an Alcoholics Anonymous meeting, was caught in a form of substance use disorder called alcohol use disorder. When he was a college student and later a lawyer, alcohol damaged his family, social, academic, and work life. He also built up a tolerance for alcohol over time and had withdrawal symptoms such as vomiting and shaking when he tried to stop using it.

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Figure 10.1: figure 10.1 How do races differ in substance use disorders? In the United States, American Indians are much more likely than members of other ethnic or cultural groups to have substance use disorders. (Information from: NSDUH, 2013.)

In any given year, 8.9 percent of all teens and adults in the United States, over 23 million people, have a substance use disorder (SAMHSA, 2014; NSDUH, 2013). American Indians have the highest rate of substance use disorders in the United States (21.8 percent), while Asian Americans have the lowest (3.2 percent). White Americans, Hispanic Americans, and African Americans have rates close to 9 percent (see Figure 10.1). Only 11 percent (around 2.5 million people) of all those with substance use disorders receive treatment from a mental health professional (Belendiuk & Riggs, 2014; NSDUH, 2013).

The substances people misuse fall into several categories: depressants, stimulants, hallucinogens, and cannabis. In this chapter you will read about some of the most problematic substances and the abnormal patterns they may produce. In addition, at the end of the chapter, you’ll read about gambling disorder, a problem that DSM-5 lists as an additional addictive disorder. By listing this behavioral pattern alongside the substance use disorders, DSM-5 is suggesting that this problem has addictive-like symptoms and causes that share more than a passing similarity to those at work in substance use disorders.