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Chapter 11: Substance- Related Disorders

Terms in this set (23)

Substance abuse has become a prominent public health concern in our society as a maladaptive pattern of adjustment to life's demands. Individual lifestyle and personality do play an important role in the development of a problem and are central themes in certain treatment.

Substance abuse disorder can be seen all around us: In extremely high rates of alcohol abuse and dependence and drug abuse of mass media. Addictive behaviour based on the pathological need for a substance - may involve the abuse of substances such a nicotine, ecstasy, or cocaine.

Addictive behaviour is one of the most prevalent and difficult to treat mental health problems today. The most commonly used problem substances are those that affect mental functioning in the central nervous system - *Psychoactive Substances: alcohol, nicotine, barbiturates, tranquilizers, amphetamines, heroin, ecstasy, and marijuana. Some of these can be purchased legally, some can be used legally under medical supervision, and others are illegal.

For diagnostic purposes, addictive substance - related disorders are divided into two major categories.

1. The first includes those conditions that involve organic impairment resulting from the prolonged and excessive ingestion of psychoactive substances. For example, an alcohol-abuse dementia disorder involving amnesia, formerly known as Korsakoff syndrome.

2. The other category includes substance-induced organic mental disorders and syndromes. These conditions stem from toxicity which can lead to different intoxications or deliriums, or physiological changes int eh brain due to vitamin deficiencies.

The majority of substance abuse problems fall into the second category, which focuses on the maladaptive behaviours resulting from regular and consistent use of a substance and includes substance abuse disorders and substance dependence disorders, the two categories outlined by the DSM and ICD-10 for classification.
The term alcoholism and alcoholic have been subject to some controversy and have been used differently in the past. Alchohol dependence syndrome, is a state, psychic and usually also pcysical, resulting from taking alcohol, characterized by behavioural and other responses that always include a compulsion to take alcohol on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence, tolerance may or may not be present. This has been coined by the World health organization, but terms of alcoholism an alcoholic are still widely used.

Many ancient cultures made wide use of alcohol. Beer was first invented in Egypt and early wine making recipes are dated back to the years of christ. The process of distilation was also invented in anchent times to increase the potency of alcohol. Problems with excessive use were observed almost form the beginning.

Alcoholism is a major problem in the USA and effects indivduals and also their families and friends. Heavy drinking as associated with vulnerability to injury, marital discord, and interpartner violence. Life span of the average alchoholic is about 12 years shorter than avergae. Is significantly lowers cognitive performance on tasks and problem solving, even more severly on complex tasks. Organic impairment, including brain shrinkage, ocurs in a high proportion of peope with dependance, espcially in binge drinkers. Significant emergency room visits are alchohol related in people under 21 years of age. Those who were heavy drinkers or alchohol depenent were significantly more likley to report multiple prior emergnvy room visits.

Over 40% of deaths by automobile are related to alchohol abuse each year and about 40-50% of all murders. Arrests and violent encournters are also related with a majority of violent crimes being assoicated opposed to with drugs.

Alchoholism cuts through all age, education, occupational and socioeconomic bounadries. Alchohol abuse is also known to have a strong place in the work force, which many showing problemsed behaviorus or even drinkign ont he job or before they go to work.
A great deal of research has been conducted on the physiological effects of alcohol on the brain. The first tendency it towards sexual inhibition, but lowered sexual performance. An appreciable number of abusers also experience blackouts that occur at high blood alcohol levels - this is where the individual will be able to carry out regular and rational activities, but have no recollection of them the next day. For heavier drinkers, even moderate drinking can lead to memory lapses. Another phenomenon associated with alcoholic intoxication is the hangover, and no one has come up with a satisfactory explanation of or remedy for the symptoms.

Effect on the brain

Alcohol has a complex and contradictory impact on the brain. In lower levels, it can stimulate the brain to have opium-like effect operating pleasurably. At higher levels it has a depressive function in the brain, inhibiting one of the brain's excitatory neurotransmitters which slow down the activity sensors of the brain. Inhibition of this glutamate neurotransmitter impairs the organisms ability to learn and affects higher brain functioning, impairing judgement and lowering self-control. This can cause an individual to react on impulses usually held in check. Some degree of motor coordination and perception of cold, pain and other discomforts may also be dulled. Typically the drinker experiences a sense of warmth, expansiveness, and well-being. In such a mood, unpleasant realities are screened out, and the drinkers self-esteem rises. Worries are temporarily left behind.

Intoxication in the USA is defined when the blood alcohol level goes over 0.08 and should not be operating a vehicle. Muscle coordination, speech, and vision are impaired and thought processes are confused. Before this level is reached, judgement is so impaired they are unaware of their condition. When the blood alcohol level surpasses 0.5, the individual will pass out. Blood alcohol level over 0.55 is considered lethal. It is usually the amount of alcohol concentrated in the bodily fluids, not the amount consumed, that determined intoxication. The effect of alcohol on an individual can vary depending on their physical condition, the amount of food they have consumed, and the duration of their drinking. Also, a tolerance we usually built up with those who drink regularly, so more alcohol is required to gain the same desired effects. Women metabolize alcohol less effectively than men and therefore become intoxicated on less.

Development of dependence

Excessive drinking can be viewed as progressing insidiously from early to middle to late stage alcohol related disorder, although some do not follow this pattern. No safe amount has been recognised for pregnant women.

Physical Effects of chronic alcohol use

Alcohol taken in must be assimilated by the body through the liver. In excess, the liver works overtime and can develop significant damage. Cirrhosis of the liver - the stiffening of the blood vessels - is common. Alcohol is also high in calories. Thus consumption of alcohol reduces appetite for food. Also, alcohol has no vitamins so that an excessive drinker can suffer from malnutrition. Additionally, alcohol impairs the bodies ability to utilize nutrients, so the nutritional deficiency cannot be made up by popping vitamins. Increased gastrointestinal symptoms are also common.

Psychosocial Effects of Alcohol Abuse

Chronic fatigue, oversensitivity, and depression is also common. Initially, it may appear to act as a crutch for dealing with stressful life events, however, over time it becomes counterproductive, resulting in impaired reasoning, poor judgement, and personality deterioration. Behaviour typically becomes course and inappropriate, and the drinker assumes less responsibility, loses pride in personal appearance, and neglects their spouse and family. They become touchy, irritable and unwilling to discuss their problems. An excessive drinker may not be able to hold down a job due to their impaired judgement and become unable to cope with the demands that arise. Personality Disorganization deterioration may be reflected in a loss of employment or marital breakup. Some research also suggests drinking to have an effect on organic brain damage later in life, but this can be reversible if the individual with stains.
Excessive use of alcohol can result in severe mental health problems. Severe Acute psychotic reactions for the diagnostic criteria for substance abuse disorders. These reactions may develop in people who have been drinking excessively over long periods of time or who have a reduced tolerance for alcohol for the reasons. Such acute reaction usually does not last a long period and consist of confusion, excitement, and delirium.

1) These distortions are called Alcoholic psychoses because they are marked by temporary loss of contact with reality. Among those who drink excessively for a long period a reaction called alcohol withdrawal delirium formerly known as delirium tremens may occur. This usually happens after a prolonged drinking spree when the person enters a state of withdrawal. Slight noises or sudden moving objects may cause considerable excitement and agitation. Full-blown symptoms may include 1) distortion for time and place - where a persona may mistake a hospital for a church, no longer recognise a friend, or identify strangers as acquaintances. 2) Vivid hallucinations particularly of small, fast moving animals, 3) acute fear, I which these animals change forms, 4) extreme suggestibility where the person will view the animals as anything by mere suggestion, 5) marked tremors of the hands, tongue, and lips and 6) perspiration fever, and rapid and weakening heartbeat, a coated tongue and foul breath.

This delirium typically lasts about 3-6 days and is usually followed by a deep sleep. When they awake few symptoms remain. Typically it scared the victim into never wanting to drink again or not for a long period. However, drinking usually resumes after a period, renewing the cycle. The death rate from withdrawal delirium as a result of convulsions, heart failure, and another complication is about 10%. Certain drugs, however, can help reduce this rate.

2) the second alcohol-related psychosis is resisting alcohol disorder or alcohol amnestic disorder This condition was first described by Russian Psychiatrist Korsakoff and is one of the most severe alcohol-related disorders. The outstanding symptom is memory defect to recent events which sometimes accompanies falsification of events. People with this disorder may not recognise pictures, faces, rooms or other objects they have just seen, although they may see them as fimilar. Often these individual fills in the gaps with fantasies that lead to unconnected and distorted associations. Tey may appear to be religious or delusional, but these behaviours are usually an attempt to fill memory gaps. These memory disturbances seem related to an inability to form new associations in a manner that renders then readily retrievable. These reactions usually occur in long-term alcohol abusers after many years of excessive drinking. These patients also have cognitive impairments such as planning defects, judgement deficits, and cortical lesions.

The symptoms of alcohol amnestic disorder are now thought o be due to a vitamin B deficient and other dietary inadequacies. A diet rich in vitamins has been thought o restore general health, but this is inconclusive. Some long-term abstinence has also been noted to help this disorder but some deterioration of memory blunted intellectual capacity and lowered moral and ethical standard usually remain.
Biological Causes

Genetic and biochemical factors have been stressed. Psychosocial factors and sociocultural factors have also been implicated. Some combination of all these seems to influence the risk of alcohol dependency.

All addictive substances have powerful effects because 1) most, if not al,l have the ability to activate the areas of the brain that produce intrinsic pleasure and sometimes powerful immediate reward. AND 2) personas biological makeup, or constitution, including his or her genetic inheritance and the environmental influences that enter into their need to seek mind altering substances to increasing degree as use continues. The development of alcohol addiction is a complex process involving constitutional vulnerability and environmental encouragement, as well as the unique biochemical properties of certain psychoactive substances.

Neurobiology of Addiction - When addictive substances enter the brain central neurochemical processes underlying addiction activate the pleasure pathways. Drug ingestion or behaviours that lead to activation of the brain reward system re reinforced by the brain's normal functioning to activate the pleasure pathway. As a result, further use is promoted. The exposure of the brain to an addictive drug alters its neurochemical structure nd results in some behavioural effects. With continued use, neuroadaptation and tolerance, as well as dependence on the substance, can develop.

Genetic vulnerability - The possibility of genetic predisposition to developing alcohol abuse problems has been widely researched. Heredity probably plays an important role in sensitivity to addiction. Alcohol abuse problems tend to run in families due to inherent sensitivity to the drug or inherent motivation.

The heritability of personality characteristics inclined to alcoholism has also been studied. An alcohol risk personality is usually described as impulsive, risk taker and emotionally unstable. Additionally, pre-alcoholic men ( those genetically predisposed but who have not yet developed the problem) show different psychological patterns. They experience the greater lessening of stress when consuming alcohol, they also show different alpha wave patterns in their EEGs and have a larger conditioned physiological response to alcohol cues. This may further suggest that pre-alcoholic men may be more prone to developing a tolerance for alcohol than low-risk men.

Some research suggests that different ethnic groups, particularly Asians and Native Americans have abnormal physiological reactions to alcohol. "Alchohol flush reaction". Asian and Eskimo subjects showed hyper sensitivity including the flush of their skin, a drop in blood pressure, and heat palpitations and nausea doing the ingestion of alcohol. This results from a mutant enzyme that has difficulty breaking down alcohol in most Asian genetic systems. The relatively lower rate of alcoholism in Asian populations may be linked to this.

Genetics

Although genetic inclination os one-factor contributing to heredity. It is not his whole story as it does not follow the same pattern of strickly hereditary disorders of other kinds. Some argue that genetic play a larger role in men than women.Negative results have been found in twin and adoptive studies as well as positive. Additionally, a great majority of children who have parents with alcohol-related problems do not themselves develop these same problems.The children of those who make successful life adjustments have not been sufficient studies. Although much genetic research implicated heresy in alcoholism, we do not know the precise role they play. At present, genetics are an attractive hypothesis. However, additonal research is needed. Social circumstances are still considered powerful forces in providing both the availability and the option of drug abuse and use. Genetic influence should be viewed as compatible, rather than competitive, with psychological and social determinants.

Genetics and leanringlearnign factors appear to play an important role in the development of constitutional or predetermined tendencies to behave in particular ways. Having a genetic predisposition or biological vulnerability to substance abuse, of course, is not a sufficient cause for a disorder. The individual must be exposed to the substance in significant degree for the addictive behaviour to appear. The development of a problem in linked to the environment that promotes the initial as well as the continuing use of the substance. People then become conditioned to the stimuli and tend to respond in a particular way as a result of learning. Learning has a key role in substance abuse. There are numerous reinforcements for using alcohol in today culture, but additional research shows that alcohol also contains an intrinsic reward property - apart from the social context of the drugs operation to diminish worry or frustration. The drug stimulates the pleasure centers in the brain and develops a reward system of our own.
Failures in parental guidance - family structure and stable relationships along with parental guidance are extremely important molding influences on a child. This stability if often lacking in families who have parents that abuse substance. Children are thus at risk themselves for substance abuse problems. Children exposed to negative role models and dysfunction in families that lack guidance at an early age and result in young people developing maladaptive behaviours such as alcohol and drug abuse. Parenting skills and parenting behaviour is associated with substance use in adolescence. Specifically, alcohol abusing parents are less likely to keep track of their children, and this lack of monitoring often leads to the adolescent's affiliation with drug-using peers. Additionally, stress and negative affect are also associated with alcoholism in adolescence. Parental alcoholism was associated with instability and uncontrolled negative life events which, in turn, were linked to negative affect and associations with drug use and drug-using peers. Physical child abuse and sexual abuse is also linked to a vulnerability of later alcoholism and other psychological problems.

Psychological vulnerability

Research suggests that personality factors related to having a family history of alcoholism are associated with the developments of alcohol use disorders. Many potential alcohol abusers tend to be emotionally immature, expect a great deal from the world, and require a great deal fo praise and appreciation, react to failure with marked feelings of hurt and inferiority, have low frustration tolerance, and feel inadequate and unsure of their abilities to fulfill expected male-female roles. They have also been found to more impulsive and aggressive. About half of the persons with schizophrenia have either drug abuse or alcohol abuse dependence. Antisocial personality shows the highest comorbidity rates with alcoholism as well as with aggression. Additionally there are relationships between depressive disorder and alcohol use, and there may be stronger gender differences in females in an association between these disorders.

Stress, Tension reduction and reinforcement

Research shows that individuals with substance abuse problems how high levels of trauma in their prior histories. High rates of those with PTSD also show correlation with substance abuse. Trauma would result from a threat of personal injury, witnessing an injury, sexual abuse, witnessing a major catastrophic disaster, and exposure to threatening situations and atrocities such as war. Typical alcohol abusers are discontent with their lives and are unable to tolerate tension or stress. High degrees are reported between alcohol consumption and negative affectivity such as anxiety and somatic complaints. Alcoholics thus tend to drink to relax.As a result, anyone who finds alcohol to be a tension reducing substance is at risk to abuse alcohol, even without especially threatening or stressful situations. However, this causal model is not a sole explanatory hypotheses. If it were the case, we would expect substance abuse disorder to be way more common as alcohol tends to reduce tension fo most people who use it. This also does not explain why some excessive drinkers are still able to maintain control over their drinking and continue to function in society when others cannot.

Expectations of social success Some have studied the idea that cognitive expectation may play a role in the initiation of drinking and the maintenance of drinking behaviour once the person has begun the use of alcohol. Many people, especially young adolescence, expect that alcohol will lower tension and anxiety and increase sexual desire and pleasure in life. Many begin the use with the expectation that it will increase their popularity and acceptance among their peers. This gives professionals a powerful motivation to want to catch adolescence at an earlier time, to help provide them better skills to alleviate social tensions so that they do not resort to alcohol. Prevention efforts should target children before they are even at an age that they can drink so that positive feedback and a reciprocal cycle of reinforcement between expectancy and drinking will never be established. Tim and experience do have moderating influences on these alcohol expectancies. There is a significant decrease in outcome expectancy over time, meaning that older students show less expectation of the benefits of alcohol than beginning students.

marital and other intimate relationships
Adults with less intimate and supportive relationship tend to show greater drinking following sadness or hostility than those with close peers and with more positive relationships. Excessive drinking usually begins during a crisis period in marital or other intimate relationship, a particularly crisis that leads to hurt and devastating. The marital relationship may serve to maintain a pattern of excessive drinking as the partners may behave in a way together that promotes the excessive drinking. For example, a husband who lives with a wife who abuses alcohol may be unaware fo the fac that, gradually, many of the decision she makes every day are based on the expectation that his wife will be drinking. These expectations, in turn, may make the drinking behaviour more likely. Eventually, an entire marriage may centre on the drinking of substance abusing spouse. In some instances, the husband and wife may also begin drinking together excessively. This one important concern fo many treatments today identify the personality or lifestyle factors in a relationship that tends to foster the drinking in the alcohol abusing person.These relationships can also occur in those in love in love affairs and friendships.

Excessive use of alcohol is one of the most frequent causes of divorce and is often a hidden factor in the two most common causes - financial and sexual problems. The deterioration of interpersonal relationships of the alcohol abuse or dependant further augments the stress and disorganization in her or her life. The breakdown of marital relationships can be highly stressful for most people. The stress of divorce can then also increase substance abuse.
Family relationship problems have also been found to be central to the development of alchoholis. Important family variables that were considered to predispose an individual to substance abuse problems involved the presence of an alcoholic father, acute marital conflict, lax maternal supervision and inconsistent discipline, many moves during the families early years, lack of attachment to the father and lack of family cohesiveness.
Alcohol use is a pervasive component of social life in Western culture. Social events often revolve around alcohol use, and alcohol use before and during meals is common. It is often seen as a social lubricant or tension reducer to enhances social events The effect of cultural attitudes towards drinking is well illustrated by Muslims and Mormons, whose religious values prohibit the use of alcohol, and by orthodox Jews, who have traditionally limited this to only religious rituals. The incidence of alcoholism among these groups is this limited. In comparison, the incidence of alcoholism is high among Europeans. The highest users among young people are reported in Denmark and Malta. Europe and six countaries that have been influenced by European culture - Argentina, Chile, Canada, Japan, new Zealand and the USA make up less than 20% of the world's population but consume around 80% of the worlds alcohol. The French appear to have the highest rates in the wodl and have one of the highest death rates from cirrhosis of the liver. Additionally, France is said to have the highest prevalence ratesSweden is another country high on the ratar. The behaviour that is manifested when under the influence is also seemed to be determined by cultural factors. For example, studies have found that most people expressed the view that aggressive behaviour frequently followed their drinking after many drinks. However, the expectation that alcohol leads to aggression is related the early cultural traditions and early exposure to violent or aggressive behaviour, not due to the alcohol itself.

In sum, we can identify any reason why people drink, and many conditions that predispose people to do so, but the exact combination of factors that results in persons becoming an alcoholic is still unknown.
Medications that block the desire to drink:

Disulfiram, a drug that causes violent vomiting when followed by ingestion of alcohol may be administered to prevent an immediate return to drinking., However, such deterrent therapy is seldom advocated as the sole approach because the pharmacological methods alone have not proved effective in treating the many severe alcohol abuse problems. For example, because ethe drug is self-administers; the patient may just choose not to take it after they have been released from the hospital or treatment facility and then the cycle starts again. The primary value of drugs such as this is to temporarily stop the cycle of abuse long enough for therapy to begin. The cost of this treatment is quite high comparatively, and other side effects can occur.

Another medication prominently used Naltrexone an opiate antagonist that helps rescue cravings for alcohol by blocking the pleasure producing effects of alcohol. This is particularly effective for individuals with a high level of craving. However, some studies have also found this drug to not reduce cravings, so confidence in its use must await more research.

Medications to reduce the side effects of acute withdrawal

The initial focus in cases of acute intoxication is detoxification, treatment of the withdrawal symptoms described earlier, and on a medical regime for physical rehabilitation. One of the primary goals in the treatment of withdrawal symptoms is to reduce the physical symptoms characteristic of withdrawal such as insomnia, headache, gastrointestinal distress, and tremulousness. Central to the medical treatment approaches is the prevention of heart arrhythmias, seizures, delirium, and death. These are usually best handled in a hospital or clinic, where drugs such as Valium have largely revolutionized the treatment of withdrawal symptoms. Such drugs overcome the motor excitement, nausea, and vomiting; prevent withdrawal delirium and convulsions; nd help alleviates the tension and anxiety associated with withdrawal. Treatments with long lasting benzodiazepines have also shown to reduce the severity of withdrawal symptoms.

The concern is growing over the use of tranquilizers - drugs that suppress the central nervous system, resulting in calmness, relaxation, reduction fo anxiety, and sleeping - stating that they do not promote long-term recovery and may simply transfer addiction to another substance. Other clinics are exploring alternative approaches including the gradual weaning off from alcohol instead of a sudden detox. The maintenance dose of mild tranquilizers is sometimes given to patients withdrawing from alcohol to reduce anxiety and help them sleep. However, this can be worse than no treatment at all as many patients must learn to abstain from alcohol as well as tranquilizers as they have come to abuse both. Further, under the influence of medication, individuals may even turn back to alcohol use.
One the patient has their drinking under control; detoxification is usually followed by psychological treatment, including family counseling and the use of community resources related to employment the other aspects of a person's social readjustment. Although some psychotherapy can be effective, most treatments rely on group therapy, environmental interventions, behaviour therapy, in the approach used by alcoholics anonymous and family groups such as AlAnon.

Group Therapy

Group therapy has shown to be very effective for many clinical probes, especially substance-related disorders. In the confrontational give and take of group therapy, alcohol abusers are often forces, to face their problems and their tendencies to deny or minimize them. These group situations can be tough for those who have been in denial, but such treatment helps them see new possibilities of coping with the circumstances that thave led to their difficulty. This allows them to learn more effective ways of coping and dealing with their stress. In some instances, the spouses of alcohol abusers and event their children may be invited to join the group therapy meetings. In other situations, family treatment is itself the central focus of therapeutic effects. In this case, the alcohol abuser is seen as a member of a disturbed family in which all members have a responsibility for cooperating in treat Because family members are frequently the people that are most victimized by the alcohol abusers addiction, they often tend to be judgmental and punuative, and the individual in treatment may take this further devaluation poorly. In other instances, the family may be unwilling to enforce an alcohol abuser to remain addicted - for example, a man with a need to dominate his wife may find that a continualy drunken and reorsful spouse may best meet his needs.

Environmental Intervention

Treatment that requires the measure to alleviate a patient's aversive life situation. Environmental support plays a significant role in alcoholics recovery. People often become estranged from family n friends because of their drinking and jeopardize their jobs. As a result, they are typically lonely and in impoverished neighbourhoods. Simply helping an abuser with better coping skill may not be enough if their environment remains hostile and threatening. For those who have been hospitalized, halfway houses are often important adjuncts to the total treatment program.

Behavioral cognitive therapy

Adverse conditioning therapy - involves the presentation of a wide range of noxious stimuli with alcohol consumption to suppress addictive behaiour. For example, alcohol consumption may be paired with an electric shock or a drug that promotes nausea.

Intramuscular injections are another similar deterrent measure where emetine hydrochloride, an emetic, is injected into the patient after they are given alchhol, so the sight, smell, and taste of the beverage become associated with severe vomiting. A conditioned aversion results. With repetition, the classical condition procedure acts as a strong deterrent for drinking.

One of the most effective contemporary procedures for treating alcohol abusers has been cognitive behavioural approach recommended by Alan Marlatt. This combines the cognitive behavioural strategy of intervention with social learning theory and modeling behaviour. The approach often referred to as skills training procedure, is usually aimed at younger problem drinkers whoa reconsidered to be at risk for developing more severe drinking problems because of an alcohol abuse history in their family or their current heavy consumption. This approach involves imparting specific information about alcohol, associated developing coping skills in associated with increased risk of drinking, modifying conditions and expectancies, acquiring stress management skills, and providing training in life skills.This is highly effective.
Self-control training techniques such as brief motivational intervention in which the goal of therapy is to get alcoholics to reduce alcohol intake without necessarily obtaining all together have a great deal of appeal for some drinkers. Although some studies shave shown promising results, it is still difficult for individual with extreme dependency​ to abstain completely from drinking, and thus they fail to complete for these programs.
Outcomes of treatment vary considerably depending on the population studied and on the treatment facilities. Those who are hardcore abusers or who have personality disorders also linked to their substance abuse tend to have lower rates of recovery. Treatment is most effective when the individual realizes that they need help, adequate treatment facilities are available and the individual attends treatment frequently. One important treatment strategy is aimed at reinforcing treatment motivation and abstinence early in the treatment process by providing chek up following ups on drinking behaviour. Some researchers have highlighted the importance of taking into account other patient characteristics when treating patients, matching the individuals to specific treatments based on their unique characteristics. This "project MATCH" patient treatment matching view, however, has shown inconclusive, and data reveals that patients from competently run treatment programs would do as well in any of the treatments studies.

One of the greatest problems with treatment for addictive substances includes maintaining self-control after treatment and over various periods of follow-up. Many treatments do not pay enough attention to maintain effective behaviour and preventing relapse. In cognitive behavioural treatment, relapse behaviour is a key factor in treatment. Relapse prevention treatment worked most effectively when a family was involved in the treatment.Behaviours behind relapses are seen as indulgent behaviours based on the patients learning history. Over time, when an individual contained, they gain more and more power over their indulgent behaviour and affirm a sense of personal control over their history. The longer they can maintain this control, the greater the sense of achievement they have - self-confidence - and the greater the chance he or she will cope with the addiction and maintain control over time.

However, though the behaviour abstains from, the cognitive behavioural view would state that the individual may still make a series of mini-decisions, through a gradual unconscious unraveling process, that establishes a chain of behaviours that render relapse inevitable for some abusers.

Additionally, the abstinence violation effect is another type of relapse behaviour where even minor transgression is seen by the abstainer as having drastic significance. For example, if that individual take a small drink at a friends wedding, they see this as a major offense, and then rationalizes that they have "blown it, and become a drunk again, so why not go all the way."

In relapse prevention treatment, clients are taught to recognize the apparently irrelevant decisions that serve as early warming signals of all the possibilities of relapse. High-risk situations such as parties are targeted, and the individuals learn to assess their vulnerability to relapse. Clients are also treated not to become so discouraged that if they do relapse, they lose their confidence. Some cognitive behavioural therapists even have incorporated planned relapses into phases in treatment. Those who have relapse prevention strategies are shown to be more effective in providing a continual improvement over time. If patients are taught to expect a relapse, they have things better over time.
Opium is a mixture of about 18 chemical substances called alkaloids. In 1805 the alkaloid present in the largest amount was found to be a bitter tasting poweder that served as a powerful sedative and pain reliever named Morphine. This was administered by a needle to help civil war soldiers. As a result, many returned from the war addicted to the drug.

At the turn of the century, it was discovered that morphine was mixed with acetic anhydride ( cheap and available chemical) is was converted into a powerful analgesic called Heroin. Originally this was widely administered and renowned for its pain relief a medical purpose in place of morphine. However, heroin was a cruel disappointment, as is functioned more rapidly, intensely, and addictive than morphine. Eventually, I was removed from medical practice.

Is soon became apparent that opium and all its derivatives including codeine were seriously addictive. It was soon designated as a federal offense to administer certain drugs, and physicians and pharmacists were held highly accountable for each dose they dispensed. It soon turned from tolerated vice to criminal offense. Many turned to criminal acts to obtain these drugs.

Biological Effects: Introduced to the body through smoking, snorting, eating, skin popping or mainlining through injection. Immediate effects include euphoric spasm lasting 60 seconds or so, which is compared to an organism. This is followed by a lethargic withdrawn in which bodily needs are diminished ( a high). Pleasant feelings of relaxation and euphoria are dominant. Effects last 4-6 hours followed by a negative effect that produces a desire for more of the drug.

The use of opiates over time usually results in a physiological craving for the drug. With Heroin, dependence usually comes after 30 days of use. They feel ill when not using. Additionally, tolerance is built up, so an increasingly larger amount of the drug are needed. After 8 hours between, addicts experience withdrawal symptoms and severity depend on one the degree of narcotics usually used., the intervals between doses, and duration of the addiction.
Withdraw is not always dangerous or painful, and many can do so without assistance. For others, it can be agonising with symptoms such as a runny nose, tearing eyes, perspiration, restlessness, increased desperation and desire for the drug. After more time passes symptoms become more severe typically exhibiting cold sweats, vomiting, diarrhea, abdominal cramps, pain in the back, headaches, tremors, and insomnia. Food is unappealing nd dehydration occurs, causing the individual to lose weight. Occasional symptoms of delirium, hallucinations nd manic activity can result. Cardiovascular collapse can also occur resulting in death. If morphine is administered, the subjective distress experienced by the addict temporarily end, and physiological balance is quickly restored. Withdrawal symptoms usually decline by the 3rd or 4th day and have disappeared by the 7th or 8th. As symptoms subside the patients behind to eat and drink again regain g their weiht and former tolerance for the drug is reduced. As a result, taking the former large dosage may result in overdose.

Causal Factors in Opiate abuse
No single causal factor fits all addictions to opiate drugs. The three most frequently cited reasons were a pleasure, curiosity, and peer pressure - with pleasure being the widest spread reason. Other reasons include a desire to escape from life, personal maladjustment, and sociocultural conditions. Some substance abuse can be related to a sensation seeking personality charactersitc that could be mediated through genetic and biological mechanisms as well as peer influences.

Neural basis for physiological addiction
Certain isolated receptor sites int he brains act sites where certain drugs work as a skeleton key for the release of certain neurotransmitters. This interaction results in sin the drugs interaction in the brain and can result in addiction. The repeated use of the opiates results in changes in the neurotransmitter systems that regulate the incentive and motivation and stress management centers of the brain. Central nervous system dysfunction such as slower response times, impaired lraning, and impaired cognitive processing and impulse control problems can result. Th human body produces its opium like substances called endorphines int he brain. These ar believed to play a role in the human's reaction to pain. Some researchers believed that endorphins play a significant role in drug addiciton, speculating that chronic underproduction of endorphins can lead to drug addiction - but this is inconclusive.

Addiction associated with Psychopathology
High incidence of antisocial personality has been found in heroin addicts. Additionally, opiate addicts are found to be highly impulsive and unable to delay gratification. A high rate of heroin addicts is also diagnosed with personality disorders. These may result from, rather than precede, the long-term effects of addiction.

Sociocultural factors of drug use
Drug use can become a way of life when individuals join the narcotics subculture. This is a culture that protects addicts and perpetuates their addiction. The majority of illicit drug users were undereducated, and unemployed individuals from minority groups. With time, most young individuals who join drug culture become withdrawn from friends and social groups and indifferent and apathetic about sexual activity. They are likely to abandon scholarly and athletic endeavours and show a marked reduction in competitive and achievement striving. Most of these appear to lack clear sex role identification and experience feelings of inadequacy when confronted with the demands of adulthood. The feel progressively isolated but their feelings of belonging are bolstered by their continued association with their drug culture. They see drugs as a means to revolt against society and authority as a device to relieve anxiety and tensions.

Treatments

Treatments are usually similar to that of alcoholism in that it involves building up an addict both physically and psychologically and providing help through the withdrawal period. In a hospital setting, this also can include the help of drugs to ease the distress of withdrawal. After physical withdrawal is completed, treatment focuses on helping the former addict make adjustments to his or her community and obtain from further use. Many clients drop out fo treatment. Withdrawal does not remove the craving for heroin. As a result, a key focus of treatment must be helping to alleviate the craving. The drug methadone ( a synthetic hydrochloride related to heroin that satisfies cravings without the serious psychological impairment) and the drug *Buprenorphine* ( a substitute for heroin with fewer side effects) in conjunction with a rehabilitation program directed towards the total resocialization fo addicts can aid in recovery. *Methadone* can be as addictive as heroin however and should only be administered in the controlled setting of a clinic. BuprenorphineMethadoneare usually similar to that of alcoholism in that it involves building up an addict both physically and psychologically and providing help through the withdrawal period. In a hospital setting, this also can include the help of drugs to ease the distress of withdrawal. After physical withdrawal is completed, treatment focuses on helping the former addict make adjustments to his or her community and obtain from further use. Many clients drop out fo treatment. Withdrawal does not remove the craving for heroin. As a result, a key focus of treatment must be helping to alleviate the craving. The drug *methadone* ( a synthetic hydrochloride related to heroin that satisfies cravings without the serious psychological impairment) and the drug *Buprenorphine* ( a substitute for heroin with fewer side effects) in conjunction with a rehabilitation program directed towards the total resocialization fo addicts can aid in recovery. *Methadone* can be as addictive as heroin however and should only be administered in the controlled setting of a clinic. Buprenorphine does not create the same physical dependence as heroin and can be discontinued without severe withdrawal symptoms.
In contrast to narcotics ( which depresses or slows down the central nervous system, cocaine and amphetamines stimulate.

Cocaine is a plant product discovered in ancient times. Because of its cost, it was once seen as a "high" for the affluent. "Crack* is the street name given to the drug when mixed with hydrochloride so it can be smoked. It has gradually become less expensive and more available. It may be ingested by snorted, swallowed or injected. It precipitates a euphoric state from 4-6 hours in duration, during which user feels confident and content. However, after the state is preceded by headaches, dizziness, and restlessness. When it is chronically abused, it can result in acute toxic psychotic symptoms including frightening visual and auditory and tactile circination similar to that in acute schizophrenia. Stimulates excitement, sexual arousal, and sleeplessness. Acute tolerance has been demonstrated and some chronic tolerance as well. Cognitive impairment may also be a long-term consideration. The view that people did not develop a dependence on this drug has changed. Chronic abusers who become abstinent develop uniform, depression-like symptoms, but the symptoms are transient. Cocaine withdrawal - as identified in the DSM - involves symptoms of depression, fatigue, disturbed sleep, and increased dreaming. Employment, family, psychological, and legal problems are more likely to occur among cocaine and crack users than nonusers. A large part of this comes from the considerable amount of money it takes to support this habit. Increased sexual activity, often trading sex for drugs has also become common. However, problems with sexual functioning have also be associated with cocaine use. Althugh there is no fetal crack syndrom such as seen in alcohol users, women who use cocaine while pregnant place their babies at increased risk to lose their mothers at infancy, or be mistreated by their mothers.

Treatment and outcomes

Treatment for dependence of cocaine does not differ much compared to other drugs that involve psychological dependence. Drugs such as naltrexone are administered to help relieve symptoms during abstinence and withdrawal times. The feelings of tension and depression are dealt with immediately during the withdrawal period. Those who continued te drug use to help with their symptoms, and continued other structures treatment were at higher risk to complete, lower risk of relapse or overdose, and many do well with their treatment goals. Poor outcomes are associated with the severity of the abuse, proper psychiatric functioning, and the presence of alcoholism. People unable to sustain abstinence during treatment have a less likely chance of recovery after treatment. A few issues seen by clinicians include high dropout rate of cocaine abusers in treatment, a strong correlation between antisocial personality disorder and cocaine abusers - which results in resistance to treatment, or are psychosis-prone personalities. Additionally, men tended to have more problems transitioning to abstinence.

Amphetamines

Benzedrine was one of the earliest amphetamines an was initially available in drug stores as an inhalant for runny nose. However, some individual started chewing the wicks of the inhalers for a kick. Later on Dexedrine and then the more potent Methedrinewere introduced. The abuse of methedrine can be lethal. Initially these were prescribed as wonder pills o help keep people awake. They were used t ward off fatigue in war and help student cram for exams. It was also used as an appetite suppressant or to counter strong sleeping pills. Today they are sometimes used to medically curb appetite when weight reduction is needed or for individuals suffering from narcolepsy. Surprisingly, amphetamines have a calming rather than stimulating effect on many young people and are sometimes prescribed to help with mild depression, and fatigue. However, by far the most common use is for recreational purpose for young people to get high. These drugs are labeled to have a high abuse potential and must be prescribed for purchase. They are more difficult to obtain legally, and their use has been reduced even medically. They are, however, one of the most model abused drugs in the illegal market.

Effects
These amphetamines push users towards greater expenditures of their resources, often tot he point of hazardous fatigue. They are psychologically and physically addictive, and the body quickly builds up a tolerance for them. In some cases users inject the drug so it will absorb faster. For someone who exceeds to prescription dose, the consumption can result in high blood pressure, enlarged pupils, unclear or rapid speech, sweating, tremors, excitability, loss of appetite, confusion, and sleeplessness. Injected in large quantities, methedrine can raise blood pressure enough to cause immediate death. Chronic abuse can result in brain damage and a wide range of psychopathology including Amphetamine psychosis which is similar to paranoid schizophrenia. Suicide, homicide, and assult are also associated with this abuse.

Treatment

Research is scarce on this topic. Although withdrawl is usually safe from amphetamines, psychological dependence is a factor to consider in treatment. In some instanes, abrupt withdrawal from chronic use can result in cramping, nausea, diarrhea and even convulsions. Additionally feelings of weakness or depression also often result. Depression peeks at around 48 hours and can last two days, then lesson over several days. Mild depression may persist over a few weeks. If brain damage has occurred, impaired ability to concentrate, learn and remember with resulting social, economic and personality deterioration may result.
Are available as an aid in falling sleep. Although they have a legitimate medical use, they are also associated with both physiological and psychological dependence and lethal overdose. Origionally they were used to help induce sleep. They act as a depressant - somewhat like alcohol - to slow down the action of the central nervous system and significantly reduce performance on cognitive tasks. Shortly after taking it, the individual will feel relaxed and tension will disappear, followed by drowsiness. Intensity depends on the amount taken. Excessive doses are lethal because they result in paralysis of the brain's respiratory centres. Impaired decision making and problem solving, sluggishness, slow speech, and sudden mood shifts are also common. Excessive use can also lead to tolerance nd well as dependence. It can also lead to brain damage and psychological deterioration. Unlike other tolerances, tolerance for barbiturates does not increase the amount needed to cause death. This means that users can easily ingest fatal amounts intentionally or accidentally.

Causal factors

Although many young people have experience with the drug, many do not become dependent. It tends to be middle-aged and older people who rely on their use as sleeping pills and who do not use other classes of drugs commonly. These have been labeled as silent abusers because they take the drugs in the privacy of their homes and ordinarily do not become a public nuisance. Often these are used in conjunction ith alcohol because they can create an intense high when taken together along with amphetamines. However death a result of mixing alcohol with barbiturates due to the increased potency that can result.

Treatment

It is often essential in treatment to distinguish between barbiturate intoxication, which results from the toxic effects of overdose, and the symptoms associated with the drug withdrawal because different procedures are required. With barbiturates,w withdrawal symptoms are more dangerous, severe, and long-lasting than opiate withdrawal. They become anxious, apprehensive and manifest coarse tremors of the hands and face; additional symptoms include insomnia, weakness, nausea, vomiting, abdominal cramps, rapid heart rate, elevated blood pressure, barbituates and loss of weight. An acute delirious psychosis may also develop. For an individual used to taking large amounts, withdrawal symptoms may last for as long as a month, but usually, they end by the first week Fortunately, the withdrawal symptoms can be minimized by administering smaller dose barbiturate itself or another drug that produces similar effects. The withdrawal process is still a dangerous one, especially when combined with alcoholism or other drug dependencies.
______ Are drugs that induce hallucinations that distort sensory images so that an individual sees or hears things in a different way than usual. These are often referred to as psychedelic drugs. Major drugs of this category are LSD or Acid, mescaline, and psilocybin.

LSD is the most popular of hallucinogens. Is is odorless, colorless and tasteless and can produce intoxication ith a smaller amount than a grain of salt.Despite research and study, LSD has never been proven to have therapeutic use or benefit in studying other hallucinogenic tendencies. After taking LSD, a person typically goes through about 8 hours of changes in sensory preception, mood swings, and feelings of depersonalization and detachment. The LSD experience is not always pleasant. It can even be traumatic as the sensory images and sounds can be terrifying. In some instances, the drug has cause people to commit suicide by jumping off buildings or taking other lethal combinations of drugs with LSD. An unusual phenomenon that may occur is the flashback, an involuntary recurrence of perceptual distortions weeks or even months after the individual has taken the drug. This appears to be very rare among those who have taken LSD only once, and visual effects were found to occur even two years after LSD use.Although is has reduced in popularity since the 60's and 70's it is still used in rave culture or club scenes today.

Mescaline and Psilocybin are two other hallucinogenics that are derived from Mexican mushrooms These have been used for centuries by native people living in Mexico as ceremonial rituals. There is no evidence that this explains consciousness, nor does LSD, or create new ideas - rather they just distort and alter experiences.
Usually smoked can be considered a mild hallucinogen, there is a significant difference in its longevity of effects and severity than with LSD. It is the most commonly use illicit drug today all over the world in all different socioeconomic groups of people.

Effects

Effects vary depending on the quality and dosage, personality of the user and the user's experience wth the drug, and social setting and expectation of the user. A state of slight intoxication occurs. This is a situation of mild euphoria with increased feeling of well-being, heightened perceptual acuity, pleasant relaxation, and a feeling of drifting away. Senses are amplified and sense of time is stretched or distorted so that an even over a few second feels much longer. Short term memory may also be affected. For most users, pleasurable experiences such as sex are enhanced. Effects start within seconds and don't last more than 2-3 hours. It may also lead to unpleasant experiences if taken when a person is annoyed, angry, suspicious or frightened as emotions can be magnified. Overdosage can result in extreme talkativeness, hilarity, euphoria or intense anxiety. Physiological effects include moderately increased heart rate, slow reaction time, contraction in pupil size, bloodshot eyes, dry mouth, and increased appetite. It also includes memory dysfunction and slowing of information processing. Long-term effects are still under investigation but is associated with high lethargy and reduced life success. It also tends to diminish self-control and is related to murder and homicide.

treatment some research shows that those who obtain report withdrawal like symptoms of nervousness, tension, sleep problems, and appetite changes. Some users are more ambivalent and less confident about stopping than other drug users. Psychological treatment methods have been found useful in treating marijuana users, but no particular treatment approach has been found to be more effective than others. Other researchers show that there are poor result to treatment and that no pharmacotherapy treatment for cannabis dependency has shown useful. There also ay be other severe antisocial or psychosis-prone individuals associated with marijuana use. Treatment is hampered by the fact that there may be an underlying personality disorder
The two most widely used and available substances. These do not include extensive and self-destructive problems, but can create important physical and mental health problems because they are easy to abuse, readily available, and are addictive, it is difficult to quit them as they are integrated in culture, withdrawal symptoms are difficult to break through, and there are many health problems associate ( nicotine).

Negative effects of caffeine involve intoxication rather than withdrawl. Withdrawal from caffeine does not produce severe symptoms except headaches, which are usually mild. Intoxication can result in restlessness, nervousness, insomnia, excitement, muscle spasm and gastrointestinal issues.

Nicotine is a poisonous alkaloid and is a chief ingredient in tobacco.It is a long life habit that is difficult to break. It is highly prevalent among those with anxiety disorder. Withdrawal symptoms include, cravings, irritability, frusteration, anxiety, anger, difficulty concentrating, increased appetite or weight, decreased metabolism, headaches, insomnia, tremors, increased coughing, and attention impairment. These symptoms can continue for several weeks depending on the extent of the habit.

treatment includes social support, pharmacological agents to replace cigarets such as gum, patches, etc. giving guidance to the patient to help change behaviours. Professional cognitive behavioural treatments are also used showing photograph and ultrasounds to avert smokers. It is successfully treated although there are release rates.

Not all addictive disorders involve chemical properties that induce dependence. Pathological gambling, for example, is in many ways very similar to drug abuse. The maladaptive behaviours involved and the treatment approaches shown to be effective suggest that addictive disorders are quite similar.