Table of Contents
Disorders related to alcohol use
Disorders related to sedative, hypnotic or anxiolytic substances
Disorders related to amphetamine use
Disorders related to cocaine use
Disorders related to nicotine use
Disorders related to caffeine use
Other hallucinogens including LSD.
Other abused drugs
Causes of substance-related disorders
Substance related disorders treatment
Intermittent Explosive Disorder
The drugs mentioned in this paper each have their own specific effects on the user but they are similar in the manner in which they are used and the treatment used when working with the abuser.
A ‘substance’ is a chemical compound that alters behaviour or mood when ingested. This group includes alcohol, nicotine, caffeine, heroin and cocaine along with chocolate and soft drinks. The vast majority of users of the ‘safe’ drugs are not perceived as addicts, they can be equally as addictive and harmful to one’s health.
There is a clear distinction between a user and an abuser of drugs. ‘Substance use’ suggests that the individual ingests the drug in moderate amounts that have no significant effect on their social, educational or occupational functionality. The drug has the ability, based on the quantity ingested to create impaired judgement, mood changes and lowered motor ability; this result is referred to as intoxication. ‘Substance abuse’ as an extension of ‘use’ is really defined on how the use of the drug affects the individual’s relationships, his work or education and whether it causes him to place himself or others in physically dangerous situations (Barlow & Durand: 2005).
‘Drug dependence’ is often described as addiction. There is however some disagreement in how we best define substance dependence (Woody & Cacciola: 1997). One definition would explain how the individual requires systematically greater quantities of the drug to experience the same level of intoxication (tolerance), and will behave negatively if the drug is not ingested (withdrawal) (Franklin & Frances: 1999). An alternate view on substance dependence pertains to the behaviour that focuses on finding the required drug as a dependence indicator. A different view of substance dependence focuses on the drug seeking behaviour itself as an indication of dependence. The repetitive ingestion of the drug, an increased need for more of the drug and the likelihood that re-use of the drug will occur after a period of abstinence; are all behaviours that help to define the extent of the drug dependence. These behaviours have a psychological component and these in conjunction with physiological components of tolerance and withdrawal make for a better understanding of substance dependence.
Many people are able to ‘enjoy’ a glass of wine or beer on a regular basis without becoming intoxicated or drinking to excess. In addition, some people are able to use heroin, cocaine or ‘crack’ occasionally without abusing them (M.S. Goldman & Rather: 1993). It would be remiss not to mention that substance dependence may be present in an individual even though substance abuse is absent.
The DSM-IV-TR has specific criteria for diagnosis of substance abuse and substance dependence; please refer to the Appendix for these criteria.
Substance related disorders are divided into five general categories for ease of classification; depressants, stimulants, opiates, hallucinogens and other drugs of abuse.
- Depressants are behavioural sedatives that induce relaxation. This group includes alcohol, anxiolytic drugs, hypnotic and sedatives in the family of benzodiazepines and barbiturates.
- Stimulants cause increased activity and alertness and usually elevate the mood. Amphetamines, cocaine, nicotine and caffeine are included in this group.
- Opiates produce temporary analgesia and euphoria. This group includes heroin, opium, codeine and morphine.
- Hallucinogens produce delusions, hallucinations and paranoia. Included in this group is marijuana and LSD.
- Other drugs include the group of drugs that are abused but do not fall into one of the other categories, such as anabolic steroids, inhalants, over-the-counter and prescription medications.
Each of these categories will be discussed in turn.
The function of depressants is to decrease activity in the central nervous system. This essentially lowers physiological arousal and hence allows the user to relax. This category is the most like to create physical dependence in the user, tolerance and withdrawal. Probably the most commonly used substance in this category is alcohol.
Disorders related to alcohol use
The fermentation of fruits and vegetables using yeast in the presence of sugar and water produces ethyl alcohol. We have managed to ferment a wide variety of fruits and vegetables over the course of time (Lazare: 1989). Alcohol is often perceived to be a stimulant because of its initial apparent stimulant affect. However, alcohol is a depressant of a number of centres in the brain; initially the inhibitory centre is depressed and we experience feelings of well-being, reduced inhibition and we become for sociable. As consumption of alcohol continues more areas in the brain are depressed and this affects the ability to function properly; confusion ensues, reaction time increases and motor coordination is impaired, our judgement is impaired and our senses of vision and hearing can also become impaired.
Alcohol affects a number of areas of the body. The alcohol passes through the oesophagus into the stomach where small amount are absorbed. The vast majority of the consumed alcohol passes into the small intestine where its absorption into the bloodstream is optimum. The circulatory system distributes the alcohol throughout the body where it reaches every major organ of the body including the heart. Alcohol also reaches the lungs where it is vaporised and exhaled, as alcohol passes through the liver it is metabolised into carbon dioxide and water by enzymes. An average individual is able to metabolise seven to ten grams of alcohol per hour; this is comparable to one beer or one glass of wine (Moak & Anton: 1999).
Alcohol interacts with numerous neuroreceptors in the brain. The gamma-aminobutyric acid (GABA) system is particularly receptive to alcohol; GABA is an inhibitory neurotransmitter that interferes with the firing of neurons it connects to. When GABA attaches to the receptor chloride ions enter the cell and make it less sensitive to the effects of other neurotransmitters. Alcohol has the ability to enhance the movement of these chloride ions into the cells and thus inhibit their firing – as such the neurons have difficulty ‘communicating’ with each other (Oscar-Berman, Shagrin, Evert & Epstein: 1997). Alcohol’s antianxiety properties may be a result of its interaction with the GABA system which acts on our feelings.
The glutamate system has an excitatory function as it facilitates the firing of neurons; it is believed to be involved in the learning process and memory and as such it may be the reason that alcohol abuse has an adverse effect on our cognitive abilities. Characteristic ‘black-outs’ and memory loss while intoxicated, may be a result of the interaction of alcohol with the glutamate system.
The serotonin system also seems to be sensitive to alcohol (Oscar-Berman et al: 1997). Alcohol cravings are thought to stem from the serotonin system which controls mood, sleep patterns and eating behaviour.
The withdrawal symptoms from chronic alcohol use includes tremors of the hand, nausea and vomiting, anxiety, transient hallucinations, agitation, insomnia and withdrawal delirium which may produce hallucinations and whole body tremors. The effects of alcohol on the individual depends on the genetic vulnerability of the individual, the frequency of use, the duration of the drinking binge, blood alcohol levels during use and the recovery period between periods of abuse (Mack, Franklin & Frances: 2003). Prolonged alcohol abuse may result in liver disease, pancreatitis, cardiovascular disorders and brain damage. Dementia and Wernicke’s disease can result from prolonged alcohol abuse as a result of neurotoxicity. Wernicke’s disease, less well known than dementia, is characterised by a deficiency of thiamine, causing unintelligible speech, confusion and loss of muscle coordination.
Fetal alcohol syndrome (FAS) is a result of alcohol consumption by the mother during pregnancy. FAS is characterised by growth retardation, cognitive deficits, behaviour problems and learning difficulties; these children have characteristic facial features such as skin folds at the corner of the eyes, low nasal bridge, short nose, groove between the nose and upper lip, small head circumference, small eye opening, small midface and thin upper lip.
Not everyone who drinks alcohol becomes dependent on alcohol or abuses it. It is estimated that up to 15 million adults are alcohol dependent (Substance Abuse and Mental Health Services Administration: 2003). Alcoholism does not manifest out-of-the-blue, it has a progressive nature and if the disease is left unchecked it will gradually become worse. Individuals who develop alcoholism graduate through a series of stages, with alcohol dependence being quite progressive in nature; yet alcohol abuse is less distinct in its progression. It has been suggested that the following stages in alcoholism exist although as yet they have not been confirmed scientifically:
- Prealcoholic stage – drinking occasionally with few consequences
- Prodromal stage – drinking heavily with few outward signs of a problem
- Crucial stage – loss of control with occasional binges
- Chronic stage – the primary daily activities involve getting and drinking alcohol
In a study of over 6000 lifetime drinkers, it was found that drinking at an early age (<14years old) was predictive of later alcohol use disorders (DeWitt, Adlaf, Offord & Ogborne: 2000).
Disorders related to sedative, hypnotic or anxiolytic substances
Depressants also include sedatives, hypnotics and anxiolytic drugs. The sedatives have a calming effect, the hypnotics induce sleep and the anxiolytic drugs are anxiety-reducing in nature. This category of drugs also includes the barbiturates and benzodiazepines.
Barbiturates are sedative drugs that were first synthesized in 1882 and prescribed for insomnia. They were widely prescribed by physicians in the 1930s and 1940s and by the 1950s they were one of the most abused categories of drugs (Franklin & Frances: 1999).
Benzodiazepines replaced the barbiturates in the 1960s; their primary function is anxiety reduction. While the benzodiazepines are deemed ‘safer’ than the barbiturates, both groups can be abused. Rohypnol is the current drug of choice in date rape cases (Smith & Wesson: 1999).
In low doses barbiturates will relax the muscles, yet higher doses will cause ‘drunken’ effects and extreme doses (overdose) can cause death by suffocation. The benzodiazepines are used to induce sleep, as muscle relaxants and anticonvulsants. With continued use, tolerance and dependence can develop. In similar manner to alcohol, these drugs affect the GABA neurotransmitter system. The consumption of alcohol and barbiturates or benzodiazepines can have serious life-threatening consequences.