Drug Abuse and Dependence
Aside from alcohol, the psychoactive drugs most commonly associated with abuse and dependence in our society appear to be (1) narcotics such as opiates or opioids, including opium and heroin; (2) sedatives such as barbiturates; (3) stimulants such as cocaine and amphetamines; (4) antianxiety drugs such as benzodiazepines; (5) pain medications such as OxyContin (Whoriskey, 2013 ); (6) hallucinogens such as LSD (the effects of these and other drugs are summarized in Table 11.2 ); and (7) caffeine and nicotine, which are also drugs of dependence (disorders associated with tobacco withdrawal and caffeine intoxication are included in the DSM-5 diagnostic classification system).
An estimated 20.1 million Americans who are 12 years of age or older reported using an illicit drug during the month before a recent survey. This represents 8.0 percent of the population (Substance Abuse and Mental Health Services Administration, 2009 ). According to the Monitoring the Future Study, in 2008 the annual prevalence rate of using any illicit drug was 37 percent for 12th graders, 35 percent for college students, 34 percent for 19- to 28-year-olds, 27 percent for 10th graders, and 14 percent for 8th graders (Johnston et al., 2009 ). The extent of drug abuse in the population is likely to be underestimated because many abusers do not seek help (Compton et al., 2007 ). Although they may occur at any age, drug abuse and dependence are most common during adolescence and young adulthood (Campbell, 2010 ) and vary according to metropolitan area, race and ethnicity, labor force status, and other demographic characteristics (Hughes, 1992 ). Substance-abuse problems are relatively more prominent in economically depressed minority communities (Akins et al., 2003 ).
The extent to which drug abuse has become a problem for society is reflected in a study of drug involvement among applicants for employment at a large teaching hospital in Maryland (Lange et al., 1994 ). Beginning in 1989, and for a 2-year period, all applicants for employment were screened through a preemployment drug-screening program (individuals were not identified in the initial study). Of 593 applicants, 10.8 percent were found to have detectable amounts of illicit drugs in their systems. The most frequently detected drug was marijuana (55 percent of those who tested positively), followed by cocaine (36 percent) and opiates (28 percent).
The impact of drug use among employed people has also been reported to be significant. In an extensive survey of illegal drug use among 40,000 currently employed workers, researchers found the following rates of illicit drug use within the month prior to the survey: 19 percent for those age 18 or younger, 10.3 percent for those between 18 and 25, 7 percent for those between 26 and 34, 7 percent for those between 35 and 49, and 2.6 percent for those between 50 and 64 (Larson et al., 2007 ). The overall frequency of illegal drug use rate in this work sample was 8.2 percent. The high rate of drug use in this population (many reported actually using drugs on the job) is problematic. For example, among those workers who reported current illicit drug use, 12.3 percent reported that they had worked for three or more employers in the past year, compared with 5.1 percent for nonabusing workers.
Among people who abuse drugs, behavior patterns vary markedly depending on the type, amount, and duration of drug use; on the physiological and psychological makeup of the individual; and, in some instances, on the social setting in which the drug experience occurs. Thus it appears most useful to deal separately with some of the drugs that are more commonly associated with abuse and dependence in contemporary society.
Opium and Its Derivatives (Narcotics)
OPIUM People have used opium and its derivatives for centuries. Galen (a.d. 130–201) considered theriaca, whose principal ingredient was opium, to be a panacea:
· It resists poison and venomous bites, cures inveterate headache, vertigo, deafness, epilepsy, apoplexy, dimness of sight, loss of voice, asthma, coughs of all kinds, spitting of blood, tightness of breath, colic, the iliac poisons, jaundice, hardness of the spleen, stone, urinary complaints, fevers, dropsies, leprosies, the trouble to which women are subject, melancholy and all pestilences. (See Brock, 1979 , for a discussion of Galen.)
Even today, opiates are still used for some of the conditions Galen mentioned.
Opium is a mixture of about 18 chemical substances known as alkaloids. In 1805, the alkaloid present in the largest amount (10 to 15 percent) was found to be a bitter-tasting powder that could serve as a powerful sedative and pain reliever; it was named morphine after Morpheus, the god of sleep in Greek mythology. The hypodermic needle was introduced in America around 1856, allowing morphine to be widely administered to soldiers during the Civil War—not only to those wounded in battle but also to those suffering from dysentery. As a consequence, many Civil War veterans returned to civilian life addicted to the drug, a condition euphemistically referred to as “soldier’s illness.”
Scientists concerned with the addictive properties of morphine hypothesized that one part of the morphine molecule might be responsible for its analgesic properties (that is, its ability to eliminate pain without inducing unconsciousness) and another for its addictiveness. At about the turn of the century, it was discovered that if morphine was treated with an inexpensive and readily available chemical called acetic anhydride, it would be converted into another powerful analgesic called heroin . Heroin was hailed enthusiastically by its discoverer, Heinrich Dreser (Boehm, 1968 ). Leading scientists of his time agreed on the merits of heroin, and the drug came to be widely prescribed in place of morphine for pain relief and related medicinal purposes. However, heroin was a cruel disappointment, for it proved to be an even more dangerous drug than morphine, acting more rapidly and more intensely and being equally, if not more addictive. Eventually, heroin was removed from use in medical practice.
As it became apparent that opium and its derivatives—including codeine, which is used in some cough syrups—were perilously addictive, the U.S. Congress enacted the Harrison Act in 1914. Under this and later legislation, the unauthorized sale and distribution of certain drugs became a federal offense; physicians and pharmacists were held accountable for each dose they dispensed. Thus, overnight, the role of a chronic narcotic user changed from that of addict—whose addiction was considered a vice, but was tolerated—to that of criminal. Unable to obtain drugs through legal sources, many turned to illegal channels, and eventually to other criminal acts, as a means of maintaining their suddenly expensive drug supply.
BIOLOGICAL EFFECTS OF MORPHINE AND HEROIN
Morphine and heroin are commonly introduced into the body by smoking, snorting (inhaling the powder), eating, “skin popping,” or “mainlining,” the last two being methods of introducing the drug via hypodermic injection. Skin popping is injecting the liquefied drug just beneath the skin, while mainlining is injecting the drug directly into the bloodstream. In the United States, a young addict usually moves from snorting to mainlining.
Among the immediate effects of mainlined or snorted heroin is a euphoric spasm (the rush) lasting 60 seconds or so, which many addicts compare to a sexual orgasm. However, vomiting and nausea have also been known to be part of the immediate effects of heroin and morphine use. This rush is followed by a high, during which an addict typically is in a lethargic, withdrawn state in which bodily needs, including needs for food and sex, are markedly diminished; pleasant feelings of relaxation and euphoria tend to dominate. These effects last from 4 to 6 hours and are followed—in addicts—by a negative phase that produces a desire for more of the drug.
The use of opiates over a period of time generally results in a physiological craving for the drug. The time required to establish the drug habit varies, but it has been estimated that continual use over a period of 30 days is sufficient. Users then find that they have become physiologically dependent on the drug in the sense that they feel physically ill when they do not take it. In addition, users of opiates gradually build up a tolerance to the drug so increasingly larger amounts are needed to achieve the desired effects.
When people addicted to opiates do not get a dose of the drug within approximately 8 hours, they start to experience withdrawal symptoms. The character and severity of these reactions depend on many factors including the amount of the narcotic habitually used, the intervals between doses, the duration of the addiction, and especially the addict’s health and personality.
Withdrawal from heroin is not always dangerous or even very painful. Many addicted people withdraw without assistance. Withdrawal can, however, be an agonizing experience for some people, with symptoms including runny nose, tearing eyes, perspiration, restlessness, increased respiration rate, and an intensified desire for the drug. As time passes, the symptoms may become more severe. Typically, a feeling of chilliness alternates with flushing and excessive sweating, vomiting, diarrhea, abdominal cramps, pains in the back and extremities, severe headache, marked tremors, and varying degrees of insomnia. Beset by these discomforts, an individual refuses food and water, and this, coupled with the vomiting, sweating, and diarrhea, results in dehydration and weight loss. Occasionally, symptoms include delirium, hallucinations, and manic activity. Cardiovascular collapse may also occur and can result in death. If morphine is administered, the subjective distress experienced by an addict temporarily ends and physiological balance is quickly restored.
Withdrawal symptoms are usually on the decline by the third or fourth day and by the seventh or eighth day have disappeared. As the symptoms subside, the person resumes normal eating and drinking and rapidly regains lost weight. After withdrawal symptoms have ceased, the individual’s former tolerance for the drug is reduced; as a result, there is a risk that taking the former large dosage might result in overdose.
SOCIAL EFFECTS OF MORPHINE AND HEROIN
Typically, the life of a person addicted to opiates becomes increasingly centered on obtaining and using drugs, so the addiction usually leads to socially maladaptive behavior as the individual is eventually forced to lie, steal, and associate with undesirable contacts to maintain a supply of drugs. Many addicts resort to petty theft to support their habits, and some addicts turn to prostitution as a means of financing their addictions.
Along with the lowering of ethical and moral restraints, addiction has adverse physical effects on an individual’s well-being—for example, disruption of the immune system (Theodorou & Haber, 2005 ). Lifestyle factors can lead to further problems; an inadequate diet, for example, may lead to ill health and increased susceptibility to a variety of physical ailments. The use of unsterile equipment may also lead to various problems including liver damage from hepatitis (Lucey et al. 2009 ) and transmission of the AIDS virus. In addition, the use of such a potent drug without medical supervision and government controls to ensure its strength and purity can result in fatal overdose. Injection of too much heroin can cause coma and death. In fact, heroin-related deaths have shown an increase in cities where data are collected (DAWN Report, 2006 ) and among soldiers in Afganistan where eight deaths were recorded from opiates in 2011 (Martinez, 2011). The most common drug-related deaths in the United States involve combinations of heroin, cocaine, and alcohol. Women who use heroin during pregnancy subject their unborn children to the risk of dire consequences. One tragic outcome is premature babies who are themselves addicted to heroin and vulnerable to a number of diseases.
Addiction to opiates usually leads to a gradual deterioration of well-being (Brown & Lo, 2000 ). For example, some research has shown that opiates actively alter the immune system, rendering the person vulnerable to organ damage (McHugh & Kreek, 2004 ). The ill health and general personality degeneration often found in opiate addiction do not always result directly from the pharmacological effects of the drug, however; rather, they are often products of the sacrifices of money, proper diet, social position, and self-respect as an addict becomes more desperate to procure the required daily dosage.
CAUSAL FACTORS IN OPIATE ABUSE AND DEPENDENCE
No single causal pattern fits all addictions to opiate drugs. Kendler and Sundquist ( 2012 ) recently reported that drug abuse is etiologically complex involving both genetic and environmental influences. A study by Fulmer and Lapidus ( 1980 ) concludes that the three most frequently cited reasons for beginning to use heroin were pleasure, curiosity, and peer pressure. Pleasure was, by far, the single most widespread reason—given by 81 percent of addicts. Other reasons such as a desire to escape life stress, personal maladjustment, and sociocultural conditions also play a part. Zuckerman ( 2007 ) provided the view that substance abuse such as smoking, drinking, and the use of drugs are all related to a personality characteristic he refers to as “sensation seeking.” He considered this trait to be mediated through genetic and biological mechanisms as well as through peer influences.