Substance Addiction & Consequences

Prevalence of Specific Drug Abuse

and Vulnerability to Develop
Addictions
National Household Survey and Related Surveys 1996 2002

Alcohol Use ever ~ 177 million

Alcoholism ~ 15 million

Cocaine Use ever ~ 26 million

Cocaine Addiction ~ 2 to 3 million

Heroin Use ever ~ 2.5 to 3 million

Heroin Addiction ~ 0.5 to 1 million

Illicit Use of Opiate Medication ever ~ 4.4 million

Resultant Opiate Medication Addiction ?

Development of Addiction After Self Exposure

Alcoholism ~ 1 in 8 to 1 in 15
Cocaine Addiction ~ 1 in 8 to 1 in 15
Heroin Addiction ~ 1 in 3 to 1 in 5
NIDA, SAMHSA Reports, 1998-2005
Global Scope of the
Problem
World Health Organization (2007)
76.3 million - alcohol use disorders
15.3 million - drug abuse disorders
People in 136 countries inject drugs
60 disease and injuries causally related to
alcohol consumptions = 1.8 million deaths
annually
Heroin production tripled since 1985
13.5 million people take opiates/9.2 heroin
European heroin injectors have 20 to 30 times
the likelihood of death compared to nonusers.
Trends in Substance Use

Prescription drug abuse

Heroin
Methamphetamine
Addiction as a disease

Psychoactive substances typically act in the

pleasure centers by:
Mimicking neurotransmitters
Stimulating the release of neurotransmitters
Blocking the re-uptake of neurotransmitters
Changing the action potential (speed at which
messages are transmitted)
Drugs and
Neurotransmitters
Dopamine amphetamines, cocaine, ETOH
Serotonin LSD, ETOH
GAGA benzos and ETOH
Endorphins opiods, ETOH
Glutamate ETOH
AcH nicotine, ETOH
ENCB marijuana, ETOH
Prescription Drug Abuse

Non medical use of prescription drugs has

increased from 5.4% in 2002 to 6.4% in 2006
Prescription pain medication (Vicodin and
Oxycontin) account for greatest abuse
According to epidemiological studies, 50 million
Americans are experiencing chronic pain at any
given time
Heroin

Increase in percentage of people who inhale

heroin
Proportion of inhalers who are Hispanic grew from
26%-69% (1996-2007)
Average age of inhalers has decreased from 30
to 27
Time between first use and seeking treatment is 7
years compared to 15 years for injectors
Cheese Heroin

Mixture of Tylenol PM and heroin in Texas, Dallas

area reports highest problem
Users are younger Dallas reports range from 12-
19 with average age of 16
High use reported among Hispanic males
Methamphetamine

Meth half-life is 8-12 hours (compared to 1-2 hr for

cocaine)
Paranoia lasts 7-14 days (compared to cocaine 4-
8 hr following drug cessation)
Higher incidence of psychosis than with any other
stimulant and neurotoxicity is greater
Methamphetamine

WHO estimates that meth is most widely used illicit

drug in the world (except for marijuana) with 26
million regular users (heroin at 16 million; 14 million
cocaine)
Research suggests that relapse rates are higher
and treatment needs to be longer than for other
substances
Health Effects of
Substance Abuse
ADDICTION:
One Disease-Many Problems

Health
Family
Social
Economic
Legal
 Prevalence of Drug abuse
66% OF SCHOOL GOING CHILDREN ARE ABUSING
GUTKA

7 OUT OF 10 COLLEGE STUDENTS HAVE ABUSED ONE

OR OTHER DRUG

3 OUT OF 10 GIRLS HAVE ABUSED ONE OR OTHER

DRUGS

20 LAKH PEOPLE ARE REGULAR DRUG USERS IN

PUNJAB ONLY

HOSTLERS MORE PRONE TO ADDICTION

Prevalence of Drug abuse...
PER HEAD CONSUMPTION OF
ALCOHOL IS HIGHEST IN PUNJAB
PRELIMINARY STUDY BY HEALTH
DEPT. PUNJAB SAYS MORE THAN 40%
YOUTH IN 15-25 AGE GROUP ARE
ADDICTS
ABOUT 48% FARMERS & LABOURERS
ARE DRUG ADDICTS
70% households are affected by drug
abuse in Punjab
 Alcohol
Is a depressant drug that affects the central
nervous system.
When consumed, it goes to the stomach
and small intestine where it directly enters
the blood stream without being digested.
Alcohol in the bloodstream circulates to the
brain in about 30 seconds.
 Health
Consequences of
Alcohol Use
Increased risk of
cardiovascular diseases
(Coronary Heart Disease,
Stroke, Hypertension)
Increased risk of cancer:
(liver, stomach, colon,
pancreas, breast, mouth,
throat)
Impaired immune system
Malnutrition
Reproductive problems
 DISEASES CAUSED BY
ALCOHOL
Gastritis
Stomach
Peptic Ulcer
Cancer
Fatty degeneration of the liver
Liver
Alcoholic hepatitis
Cirrhosis

Pancreas Acute pancreatitis

Chronic pancreatitis

Blood Folic Acid deficiency anaemia

Decreased WBC Production
.
 Behavioral Consequences
of Alcohol Use
Contributes to unsafe sex
and increased risk of AIDS
Contributes to risky behavior
and accidental death
Contributes to 50% of all
motor vehicle fatalities
 Alcohol Content in Drinks

All three have the

same alcohol content
despite different volumes

Beer: 4% alcohol X 12 oz = 0.48 oz alcohol

Wine: 12% alcohol X 4 oz = 0.48 oz alcohol
Whiskey: 40% alcohol X 1.25 oz = 0.50 oz alcohol
 Social Consequences of
Alcohol Use on Campus
80% of campus vandalism
involved alcohol
70% of violent behavior on
campus involved alcohol
75% of men involved in acquaintance
rape were under the influence of
alcohol
 ALCOHOL-Health effects

LIVER OF
Alcoholic
Heart of Alcoholic
Tobacco Causes Cancer
 Paan Masala & Gutkha
SUB-MUCOUS FIBROSIS -MOUTH OPENING IS
RESTRICTED
CANCER OF MOUTH
CANCER OF TONGUE
CANCER OF JAWS
CANCER OF GUMS
CANCER OF NASOPHARYNX
SWALLOW SALIVA EXTRACT CAUSING
CANCER OF OTHER PARTS OF BODY
Cancer Of Lips
GUM ULCER
CANCER OF MOUTH
 Effect on the Family
Alcohol and drug use have
genetic influences
Domestic violence
Child abuse
Impaired family relationships
Dysfunctional family
responses
Marital conflict - abuse,
separation, divorce
Drawing the Science Together:
10 Broad Principles of Drug Use and Problems
Drug use is a chosen behavior
Drug problems emerge gradually and occur along a
continuum of severity
Once well-established, drug problems tend to become self-
perpetuating
Motivation is central to prevention and intervention
Drug use responds to reinforcement
Drug problems do not occur in isolation, but as part of behavior
clusters
There are identifiable and modifiable risk and protective
factors for problem drug use
Drug problems occur within a family context
Drug problems are affected by a larger social context
Relationship matters
Drug Use is a Chosen Behavior
Drug use is chosen from among behavioral options.
Most people who recover from drug problems do so on
their own, without formal treatment.
Effective interventions facilitate and perhaps support
natural change processes.
Evidence suggests that change frequently involves a
decision, commitment, or turnabout.
Personal commitment appears to be a final common
pathway toward change in drug use.
There is every reason to treat the individual drug user as
an active participant, responsible choosing agent, and
a collaborator in prevention and treatment
interventions.
Drug Problems Emerge Gradually and
Occur Along a Continuum of Severity
Drug addiction happens gradually, with initial
experimentation, moving to more frequent use.
There is no clear moment when a person the
commons dependent or addicted.
Dependence emerges over time as the persons life
becomes increasingly centered on drug use.
It is easier to back out of drug use at earlier and less
severe stages of problem development.
Once Well-Established, Drug Problems
Tend to Become Self-Perpetuating
Addictive behaviors take on a life of their own, becoming self
organizing and robust.
Addressing just one component of the system is often ineffective.
It is important to understand for each individual what is maintaining
the pattern of drug use, and, more importantly, which components
need to be addressed in order to produce stable change.
The pharmacological effects can lead to stable preference for
drug use and displacement of natural sources of reinforcement.
An initial period of drug abstinence can be helpful in destabilizing
dependent drug use.
Hospitalization, incarceration, antagonist medications and
differential reinforcement of nonuse can produce initial periods of
abstinence.
Drug Problems Do Not Occur in Isolation,
but As Part of Behavior Clusters
For adolescents, drug use occurs in conjunction with poor school
performance, precocious sexuality, mood problems (anxiety,
depression), and antisocial behavior.
For adults, drug use occurs in conjunction with elevated rates of
family discord, violence, health problems, unemployment,
poverty and financial problems, homelessness, crime, injury, child
behavior problems, child abuse and neglect, disability, and a
host of psychological and mood problem.
Drug use occurs in a context of life problems, and abstinence is
often well down on a clients list of priorities.
Interventions that target a broader range of life functioning are
more successful in resolving drug problems.
 There Are Identifiable and
Modifiable Risk and Protective
Factors for Problem Drug Use
Heredity contributes to risk for alcohol problems, and evidence is
mounting for genetic predispositions for or against other drug use.
Some Asian groups inherit a metabolic abnormality (that)
decreases risk for problem drinking.
People who are relatively insensitive to the intoxicating an
adverse effects of alcohol are greater risk of alcohol
dependence.
Escapist reasons for drug use and avoided styles of coping are
both associated with increased risk for drug involvement.
Protective factors include
Nondrug positive reinforcement, stimulating environments,
stress-buffering resources, close, high-quality positive
relationships with nondrug involved people.
Drug Problems Occur Within a Family
Context
Parental drug use is the risk factor for childrens drug use, and is
linked to a host family problems and more general risk factors.
Children of drug impaired parents are, less likely to develop self-
regulation skills particularly if parenting is disrupted before the
child is age 6, the critical period for learning self-control.
Domestic violence and child abuse are greatly increased with
parental alcohol and other drug problems.
Protective family factors include
Parental disapproval of drug use, consistent, supportive and
authoritative parenting style, parental monitoring of child
whereabouts, family involvement in religion and other
conventional activities.
Effective family interventions include (1) strengthening family skills
for constant communication and monitoring, and (2) building
family reciprocity in exchanging in sharing positive reinforcement.
Drug Problems Are Affected by a Larger
Social Context
There are large regional differences in the problems of drug use
and problems.
Social modeling can promote or deter use.
Criminal sanctions for use are relatively ineffective in suppressing
drug use, particularly once it is an established pattern.
Clear norms and modeling of moderation influence drinking rates.
Adding one heavy drinker can increase the consumption rate at
a table, whereas adding one moderate drinker has little effect.
Having a meaningful role in society is a protective factor, while
the loss of significant role increases the risk of drug problems.
Social isolation is both a promoter and a consequence of the
progression of drug dependence, and social bonding with non-
users can be the antidote.
Relationship Matters
There is something therapeutic about certain
relationships.
Counselors who are higher in warmth and
accurate empathy have clients who showed
greater improvements in drug use and
problems.
As early as the second session, clients ratings
of their working relationship with the counselor
are predictive of treatment outcome.
A confrontational style that puts clients on the
defensive appears to be counterproductive
producing significantly worse outcomes.
Addiction is a Developmental Disease:
It Starts Early
100 67%
26%

10 5.5%

1.5%

1
Child Teen Young Adult Adult
<12 12-17 18-25 >25
Basic Science Tells Us that Adolescents
Brains Are Still Developing
 MRI Scans of Healthy Children and Teens Over Time

Copyright 2004 by the National Academy of Sciences Gogtay, Giedd, et al. (2004) Proc. Natl. Acad. Sci. USA 101, 8174-8179
 When Reading Emotion
Adults Rely More on the Frontal Cortex
While Teens Rely More on the Amygdala

Source: Deborah Yurgelon-Todd 2000.

Do Adolescents
React Differently
than Adults to
Substances of
Abuse?
Rats Exposed to Nicotine in
Adolescence
Self-Administer More Nicotine Than
Rats First Exposed as Adults

Sources: Collins et al, 2004, Levin et al, 2003, NIDA Notes

v19.2
 Do We Need Fundamentally
Different Strategies At
Different Stages of Adolescence?
 Vulnerability

Why do some people

become addicted while
others do not?
 We Know Theres A
Big Genetic Contribution To
Drug Abuse and Addiction
And the Nature of this Contribution
Is Extremely Complex
Dopamine (DA) Receptors and the Response to
Methylphenidate (MP)
High DA high
receptor

Dopamine receptor level

low
Low DA
receptor

As a group, subjects with low receptor levels found MP pleasant

while those with high levels found MP unpleasant
Adapted from Volkow et al., Am. J. Psychiatry, 1999.
 Effects of a Social Stressor on Brain DA D2
Receptors and Propensity to Administer Drugs
Individually Group Dominant
Housed Housed
50 Subordinate

Becomes Dominant
No longer stressed 40

30
* *
20

10
Becomes Subordinate
Stress remains
0
S.003 .01 .03 .1
Cocaine (mg/kg/injection)
Morgan, D. et al. Nature Neuroscience, 5: 169-174, 2002.
Factors Contribute
to Addiction?

Co-morbid mental illness

Early physical or sexual abuse
Witnessing violence
Stress
Peers who use drugs
Drug availability
 COMORBIDITY
Drug Users have a Higher Risk of
Developing Mental Disorders

Psychosis
Depression
Anxiety
Panic attacks

Example: SMOKING EPIDEMIOLOGY

normal population: 23%
alcoholism: 90%+
other addictions: 90%+
schizophrenia: 85%
depression: 80%
Why do Mental Illnesses and
Substance Abuse Co-occur?
Self-medication hypothesis
substance abuse begins as a
means to alleviate symptoms of
mental illness
Causal effects of substance
abuse
Substance abuse may increase
vulnerability to mental illness
Common or correlated
causes
the life processes and risk factors
that give rise to mental illness
and substance abuse may be
related or overlap
 Changes in Attitudes Lead to
Changes in Use
60
50
40
30
20
10
0
'75 '77 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03

Past Year Use of Marijuana

Perceived Risk of Occasional Marijuana Use

Source: Monitoring the Future Study, 2003.

 Why Cant Addicts Just Quit?
Non-Addicted Brain Addicted Brain

Control
Control

Saliency Drive NO Saliency Drive GO

GO

Memory Memory

Because Addiction Changes Brain Circuits

Source: Adapted from Volkow et al., Neuropharmacology, 2004.
This is why addicts cant just quit
This is why treatment is essential
Treating a Biobehavioral Disorder Must Go Beyond Just
Fixing the Chemistry
We Need to Treat the
Whole Person!

Pharmacological
Behavioral Therapies
(medications)

Medical and Social Services

In Social Context
Treatment Can Work
 We Are Using Science to
Develop Even Better Treatments

Genetics Mechanisms Treatments

Basic Research Medication
Opiate agonists stabilize brain Agonist Therapy
function in heroin addicts Methadone
Buprenorphine

CB1 KO mice have decreased

responses to multiple drugs of CB1 Antagonists
abuse

Smokers who are poor nicotine Inhibitors of

metabolizing
metabolizers smoke less enzymes

Stress triggers relapse in animal

models of addiction and CRF
antagonists interfere with the CRF Antagonists
response to stress
 But, drug addiction is a chronic
illness with relapse rates similar to
those of hypertension, diabetes, and
asthma

McLellan et al., JAMA, 2000.

Relapse Rates Are Similar for Drug
Addiction & Other Chronic Illnesses

100
90
Percent of Patients Who Relapse

80
70
60
50
40

50 to 70%

50 to 70%
40 to 60%

30 to 50%
30
20
10
0
Drug Type I Hypertension Asthma
Addiction Diabetes
McLellan et al., JAMA, 2000.
 Addiction is Similar to Other
Chronic Illnesses Because:
Recovery from it--protracted abstinence and restored functioning--
is often a long-term process requiring repeated treatments

Relapses to drug abuse can occur during or after successful

treatment episodes

Participation in self-help support programs during and following

treatment can be helpful in sustaining long-term recovery

Therefore
Full recovery is a challenge
but it is possible
 [C-11]d-threo-methylphenidate

DAT Recovery Normal Control

high
with prolonged
abstinence from
methamphetamine
Methamphetamine Abuser
(1 month detoxification) low

Methamphetamine Abuser
(24 month abstinent)
Volkow et al., J. Neuroscience, 2001.
Treatment Reduces Drug Use and Recidivism
Delaware Work Release Therapeutic Community (CREST) + Aftercare
3 Years After Release (N=448)

p < 0.05,
compared to No Treatment group
Percentage of Participants

Drug-Free Arrest-Free
In Treating Addiction
We Need to Keep Our Eye on
the Real Target