Addiction DisordersALCOHOL ABUSE AND DEPENDENCEThe Prevalence, Comorbidity, and Demographics

of Alcohol Abuse and DependenceThe Clinical Picture of Alcohol Abuse and

DependenceBiological Factors in the Abuse of and

Dependence on Alcohol and Other SubstancesPsychosocial Causal Factors in Alcohol Abuse

and DependenceSociocultural FactorsTreatment of Alcohol Abuse Disorders

DRUG ABUSE AND DEPENDENCEOpium and Its Derivatives (Narcotics)Cocaine and Amphetamines (Stimulants)Barbiturates (Sedatives)LSD and Related Drugs (Hallucinogens)EcstasyMarijuana

UNRESOLVED ISSUES:Exchanging Addictions:

Is This an Effective Approach?

he increasing problem of substance abuse and dependence in our society has drawn both publicand scientific attention. Although our present knowledge is far from complete, investigating theseproblems as maladaptive patterns of adjustment to life's demands, with no social stigmainvolved, has led to clear progress in understanding and treatment. Such an approach, of course,does not mean that an individual bears no personal responsibility in the development of a prob-lem. Individual lifestyles and personality features are thought by many to play important roles inthe development of addictive disorders and are central themes in some types of treatment.

Addictive behavior-behavior based on the pathological need for a substance or activity-may involve the abuse of substances such as nicotine, alcohol, or cocaine. Addictive behavior isone of the most pervasive and intransigent mental health problems facing our society today.Addictive disorders can be seen all around us: in extremely high rates of alcohol abuse anddependence, in tragic exposes of cocaine abuse among star athletes and entertainers, and inreports of pathological gambling, which has increased with the widening opportunity for legal-ized gambling today.

The most commonly used problem substances are those drugs that affect mental function-ing, or psychoactive drugs: alcohol, nicotine, barbiturates, tranquilizers, amphetamines, heroin,ecstasy, and marijuana. Some of these drugs, such as alcohol and nicotine, can be purchasedlegally by adults; others, such as the barbiturates or pain killers, can be used legally under med-ical supervision; still others, such as heroin, ecstasy, and methamphetamine, are illegal.

For diagnostic purposes, addictive or substance-related disorders are divided into two majorcategories. The first category includes those conditions that involve organic impairment result-ing from the prolonged and excessive ingestion of psychoactive substances-for example, analcohol-abuse dementia disorder involving amnesia, formerly known as "Korsakoff's syndrome."The other category comprises substance-induced organic mental disorders and syndromes (thelatter of which are included within the organic mental disorders). These conditions stem fromtoxicity. the poisonous nature of the substance (leading to, for example, amphetamine delu-sional disorder, alcoholic intoxication, or cannabis delirium), or physiological changes in thebrain due to vitamin deficiency.

The majority of addictive disorders fall into the second category, which focuses on the mal-adaptive behaviors resulting from regular and consistent use of a substance and includes sub-stance-abuse disorders and substance-dependence disorders. The system of classification forsubstance-abuse disorders that is followed by both DSM-IV-TR and ICD-10 (International Classi-fication of Disease System, published by the World Health Organization) provides two majorcategories: substance-dependence disorders and substance-abuse disorders. Although someresearchers and clinicians disagree with the dichotomous grouping, others consider this classi-fication approach to have both research and clinical utility (Epstein, 2001).

Substance abuse generally involves a pathological use of a substance resulting in (1) poten-tially hazardous behavior such as driving while intoxicated, or (2) continued use despite a per-sistent social, psychological, occupational, or health problem. Substance dependence includesmore severe forms of substance-use disorders and usually involves a marked physiological needfor increasing amounts of a substance to achieve the desired effects. Dependence in these disor-ders means that an individual will show a tolerance for a drug and/or experience withdrawalsymptoms when the drug is unavailable. Tolerance-the need for increased amounts of a sub-stance to achieve the desired effects-results from biochemical changes in the body that affectthe rate of metabolism and elimination of the substance from the body. Withdrawal symptomsare physical symptoms such as sweating, tremors, and tension that accompany abstinence fromthe drug.

ALCOHOL ABUSE ANDDEPENDENCEThe terms alcoholic and alcoholism have been subject tosome controversy and have been used differently by vari-ous groups in the past. The World Health Organization nolonger recommends the term alcoholism but prefers theterm alcohol dependence syndrome-"a state, psychic andusually also physical, resulting from taking alcohol, char-acterized by behavioral and other responses that alwaysinclude a compulsion to take alcohol on a continuous orperiodic basis in order to experience its psychic effects,and sometimes to avoid the discomfort of its absence; tol-erance mayor may not be present" (1992, p. 4). However,because the terms "alcoholic" and "alcoholism" are stillwidely used in practice, in scientific journals, and in gov-ernment agencies and publications, we will sometimes usethem in this book.

People of many ancient cultures, including the Egypt-ian, Greek, and Roman, made extensive and often excessiveuse of alcohol. Beer was first made in Egypt around 3000B.C. The oldest surviving wine-making formulas wererecorded by Marcus Cato in Italy almost a century and ahalf before the birth of Christ. About A.D. 800, the processof distillation was developed by an Arabian alchemist, thusmaking possible an increase in both the range and thepotency of alcoholic beverages. Problems with excessiveuse of alcohol were observed almost as early as its usebegan. Cambyses, King of Persia in the sixth century B.C.,

has the dubious distinction of being one of the first alco-holic abusers on record.

The Prevalence, Comorbidity, andDemographics of Alcohol Abuse andDependenceAlcohol abuse and dependence are major problems in theUnited States and are among the most destructive of thepsychiatric disorders (Volpicelli, 2001). In 2003, 22.6 per-cent of Americans 12 or older reported binge drinking, and6.8 percent were found to be heavy drinkers (SubstanceAbuse and Mental Health Services Administration, 2004).In the recent National Comorbidity Survey-Replicationstudy, the lifetime prevalence for alcohol abuse in theUnited States is 13.4 percent (Kessler, Chiu, et al., 2005).

The potentially detrimental effects of excessive alco-hol use-for an individual, his or her loved ones, andsociety-are legion. Heavy drinking is associated with vul-nerability to injury (Shepherd & Brickley, 1996) andbecoming involved in intimate partner violence (O'Leary& Schumacher, 2003). The life span of the average personwith alcohol dependence is about 12 years shorter than

that of the average person without this disorder. Alcoholsignificantly lowers performance on cognitive tasks such asproblem solving-and the more complex the task, themore the impairment (Pickworth, Rohrer, & Fant, 1997).Organic impairment, including brain shrinkage, occurs ina high proportion of people with alcohol dependence(Gazdzinski, Durazzo, & Meyerhoff, 2005; Harper, Dixon,et al., 2003), especially among binge drinkers-people whoabuse alcohol following periods of sobriety (Hunt, 1993).

Over 37 percent of alcohol abusers suffer from at leastone coexisting mental disorder (Lapham, Smith, et al.,2001). Not surprisingly, given that alcohol is a depressant,depression ranks high among the mental disorders oftencomorbid with alcoholism. It is no surprise that manyalcoholics commit suicide (Hufford, 2001; McCloud,Barnaby, et al., 2004). In addition to the serious problemsthat excessive drinkers create for themselves, they also poseserious difficulties for others (Gortner et al., 1997). Alco-hol abuse also co-occurs with high frequency with person-ality disorder. Grant, Stinson, et al. (2004) reported thatamong individuals with a current alcohol-use disorder,28.6 percent had at least one personality disorder.

Alcohol abuse is associated with over half the deathsand major injuries suffered in automobile accidents eachyear (Brewer, Morris, et al., 1994) and with about 40 to 50percent of all murders (Bennett & Lehman, 1996),40 per-cent of all assaults, and over 50 percent of all rapes (Abbey,Zawacki, et al., 2001). About one of every three arrests inthe United States is related to alcohol abuse, and over 43percent of violent encounters with the police involve alco-hol (McClelland & Teplin, 2001). In a study of substanceabuse and violent crime, Dawkins (1997) found that alco-hol is more frequently associated with both violent andnonviolent crime than other drugs such as marijuana andthat people with violence-related injuries are more likely tohave a positive Breathalyzer test (Cherpitel, 1997). An esti-mated 13.6 percent of people 12 or older drove under theinfluence of alcohol in the past year (Substance Abuse andMental Health Services Administration, 2004).

Alcohol abuse and dependence in the United Statescuts across all age, educational, occupational, and socioe-conomic boundaries. One recent study reported that in2001, there were an estimated 244,331 alcohol-relatedvisits to an emergency room among people ages 13 to 25.Of these, an estimated 119,503 involved people below thelegal drinking age of 21 (Elder, Shults, et al., 2004). How-ever, alcohol abuse is considered a serious problem inindustry, in the professions, and in the military as well;alcohol abuse is found among such seemingly unlikelycandidates as priests, politicians, surgeons, law enforce-ment officers, and teenagers. The image of the alcohol-dependent person as an unkempt resident of skid row isclearly inaccurate. Further myths about alcoholism arenoted in Table 12.1 on page 415.

Alcohol is associated with over half of the deaths and serious injuries suffered in automobileaccidents in the United States each year.

Most problem drinkers-people experiencing lifeproblems as a result of alcohol abuse-are men; menbecome problem drinkers at about five times the frequencyof women (Helzer et aI., 1990). This ratio, however, maychange in time, because women's drinking patterns appearto be changing (Zilberman, Tavares, & el-Guebaly, 2003).There do not seem to be important differences in rates ofalcohol abuse between black and white Americans. Itappears that problem drinking may develop during any lifeperiod from early childhood through old age. (See Chapter18 for further discussion on this topic.) Marriage, higherlevels of education, and being older are associated with alower incidence of alcoholism (Helzer et aI., 1990). About10 percent of men over age 65 were found to be heavydrinkers (Breslow, Faden, & Smothers, 2003). Surveys ofalcoholism rates across different cultural groups aroundthe world have found varying rates of the disorder acrossdiverse cultural samples (Caetano et aI., 1998; Hibell,Anderson, et aI., 2000).

The course of alcohol-related problems can be botherratic and fluctuating. A recent survey found that somealcohol-dependent persons go through long periods ofabstinence only to start drinking again later. Of 600respondents in the study (most of whom were alcohol-dependent), over half (56 percent) had periods of absti-nence lasting 3 months, and 16 percent reported a periodof 5 years of abstinence (Schuckit, Tipp, Smith, & Buck-holz, 1997). It is therefore important to keep in mind thatthe course of alcohol abuse and dependence can vary andmay even include periods of remission.

The Clinical Picture ofAlcohol Abuse andDependenceExactly how alcohol works on the brain isonly beginning to be understood, but severalphysiological effects are common. The first isa tendency toward decreased sexual inhibi-tion but, simultaneously, lowered sexual per-formance. An appreciable number of alcoholabusers also experience blackouts-lapses ofmemory. At first these occur at high bloodalcohol levels, and a drinker may carryon arational conversation or engage in other rela-tively complex activities but have no trace ofrecall the next day. For heavy drinkers, evenmoderate drinking can elicit memory lapses.Another phenomenon associated with alco-holic intoxication is the hangover, whichmany drinkers experience at one time oranother. As yet, no one has come up with asatisfactory explanation of or remedy for thesymptoms of headache, nausea, and fatiguethat are characteristic of the hangover.

ALCOHOL'S EFFECTS ON THE BRAIN Alcohol has com-plex and seemingly contradictory effects on the brain. Atlower levels, alcohol stimulates certain brain cells and acti-vates the brain's "pleasure areas," which release opium-likeendogenous opioids that are stored in the body (Braun,1996; Van Ree, 1996). At higher levels, alcohol depressesbrain functioning, inhibiting one of the brain's excitatoryneurotransmitters, glutamate, which in turn slows downactivity in parts of the brain (Koob, Mason, et aI., 2002).Inhibition of glutamate in the brain impairs the organism'sability to learn and affects the higher brain centers, impair-ing judgment and other rational processes and loweringself-control. As behavioral restraints decline, a drinker mayindulge in the satisfaction of impulses ordinarily held incheck. Some degree of motor uncoordination soonbecomes apparent, and the drinker's discrimination andperception of cold, pain, and other discomforts are dulled.Typically the drinker experiences a sense of warmth,expansiveness, and well-being. In such a mood, unpleasantrealities are screened out and the drinker's feelings of self-esteem and adequacy rise. Casual acquaintances becomethe best and most understanding of friends, and thedrinker enters a generally pleasant world of unreality inwhich worries are temporarily left behind.

In most states, when the alcohol content of the blood-stream reaches 0.08 percent, the individual is consideredintoxicated, at least with respect to driving a vehicle. Mus-cular coordination, speech, and vision are impaired, andthought processes are confused (NIAAA, 200l). Evenbefore this level of intoxication is reached, however, judg-

FictionAlcohol is a stimulant.

You can always detect alcohol on the breath of aperson who has been drinking.

One ounce of 86-proof liquor contains morealcohol than two 12-ounce cans of beer.Alcohol can help a person sleep more soundly.Impaired judgment does not occur before thereare obvious signs of intoxication.An individual will get more intoxicated by mixingliquors than by taking comparable amounts of onekind-e.g., bourbon, Scotch, or vodka.Drinking several cups of coffee can counteract theeffects of alcohol and enable a drinker to "soberup."

Exercise or a cold shower helps speed up themetabolism of alcohol.People with "strong wills" need not be concernedabout becoming alcoholics.Alcohol cannot produce a true addiction in thesame sense that heroin can.One cannot become an alcoholic by drinking justbeer.

In a heavy drinker, damage to the liver shows uplong before brain damage appears.The physiological withdrawal reaction fromheroin is considered more dangerous than iswithdrawal from alcohol.

ment becomes impaired to such an extent that the personmisjudges his or her condition. For example, drinkers tendto express confidence in their ability to drive safely longafter such actions are in fact quite unsafe. When the bloodalcohol level reaches approximately 0.5 percent (the leveldiffers somewhat among individuals), the entire neuralbalance is upset and the individual passes out. Uncon-sciousness apparently acts as a safety device, because con-centrations above 0.55 percent are usually lethal.

FactAlcohol is actually both a nervous system stimulant anda depressant.It is not always possible to detect the presence ofalcohol. Some individuals successfully cover up theiralcohol use for years.Two 12-ounce cans of beer contain more than an ounceof alcohol.

Alcohol may interfere with sound sleep.Impaired judgment can occur long before motor signsof intoxication are apparent.It is the actual amount of alcohol in the bloodstreamrather than the mix that determines intoxication.

Exercise and cold showers are futile attempts to increasealcohol metabolism.Alcohol is seductive and can lower the resistance of eventhe "strongest will."Alcohol has strong addictive properties.

One can consume a considerable amount of alcohol bydrinking beer. It is, of course, the amount of alcoholthat determines whether one becomes an alcoholic.There are considerably more individuals in treatmentprograms for alcohol problems than for marijuana abuse.Heavy alcohol use can be manifested in organic braindamage before liver damage is detected.The physiological symptoms accompanying withdrawalfrom heroin are no more frightening or traumatic to anindividual than alcohol withdrawal. Actually, alcoholwithdrawal is potentially more lethal than opiatewithdrawal.Actually, 28 percent of men and 50 percent of women inthe United States are abstainers.

In general, it is the amount of alcohol actually concen-trated in the bodily fluids, not the amount consumed, thatdetermines intoxication. The effects of alcohol, however,vary for different drinkers, depending on their physicalcondition, the amount of food in their stomach, and theduration of their drinking. In addition, alcohol users maygradually build up a tolerance for the drug so that ever-increasing amounts may be needed to produce the desiredeffects. Women metabolize alcohol less effectively than

Criteria for Substance-Dependence andSubstance-Abuse Disorders

Substance-Dependence DisorderA maladaptive pattern of substance use leading to clinicallysignificant distress or impairment, as manifested by at leastthree of the following occurring at any time in the same 12-

month period:

A. Tolerance as defined by either a need for increasedamounts of the substance to achieve intoxication ordesired effect, or diminished effect with continued use ofthe same amount of substance.

B. Withdrawal as manifested by either the characteristicwithdrawal syndrome for the substance, or same or closelyrelated substance is taken to relieve or avoid withdrawalsymptoms.

C. Substance is often taken in larger amounts or over alonger period than was intended.

D. Persistent desire or unsuccessful effort to cut down orcontrol substance use.

E. The person spends a great deal of time engaging inactivities necessary to obtain the substance, use thesubstance, or recover from its effects.

F. The person has given up or reduced the amount ofimportant social, occupational, or recreational activitiesbecause of substance use.

G. Continued substance use despite persistent or recurrentphysical or psychological problem caused or exacerbatedby the substance.

Substance-Abuse DisorderA. A maladaptive pattern of substance use leading to

clinically significant impairment or distress, as manifestedby at least one of the following occurring within a 12-

month period:

(1) Recurrent substance use that results in a failure tofulfill some major role obligations at work, school, orhome.

(2) Recurrent substance use in situations in which it isphysically hazardous (e.g., driving).

(3) Recurrent substance-related legal problems (e.g.,arrest for disorderly conduct).

(4) Continued substance use despite persistent orrecurrent social or interpersonal problems caused orexacerbated by the effects of the substance.

B. Person has never had symptoms or problems that havemet the criteria for Substance Dependence for this class ofsubstance.

Source: Adapted from American Psychiatric Association, DSM·IV-TR(2000).

Excessive use of alcohol can produce unexpected and oftendromatic changes in behavior. The men shown here illustrate thebehavioral disinhibition that can occur following alcohol abuse.

men and thus become intoxicated on lesser amounts ofalcohol (Gordis et aI., 1995).

DEVELOPMENT OF ALCOHOL DEPENDENCE Excessivedrinking can be viewed as progressing insidiously fromearly- to middle- to late-stage alcohol-abuse disorder,although some abusers do not follow this pattern. Manyinvestigators have maintained that alcohol is a dangeroussystemic poison even in small amounts, but others believethat in moderate amounts it is not harmful to most people.For pregnant women, however, even moderate amountsare believed to be dangerous; in fact, no safe level has beenestablished, as is discussed in Developments in Research12.1. The photo on page 417 shows the differences betweenthe brain of a normal teenager and those born with fetalalcohol syndrome (FAS), a condition that is caused byexcessive alcohol consumption during pregnancy andresults in birth defects such as mental retardation.

THE PHYSICAL EFFECTS OF CHRONIC ALCOHOL USEFor individuals who drink to excess, the clinical picture ishighly unfavorable (White, Altmann, & Nanchahal, 2002).Alcohol that is taken in must be assimilated by the body,except for about 5 to 10 percent that is eliminated throughbreath, urine, and perspiration. The work of assimilation isdone by the liver, but when large amounts of alcohol areingested, the liver may be seriously overworked and even-tually suffer irreversible damage (Martin, Singleton, &Hiller-SturmhOfel, 2003; Ramstedt, 2003). In fact, from 15to 30 percent of heavy drinkers develop cirrhosis of theliver, a disorder that involves extensive stiffening of theblood vessels. About 40 to 90 percent of the 26,000 annualcirrhosis deaths every year are alcohol-related (DuFour,Stinson, & Cases, 1993).

2.1 Fetal Alcohol Syndrome:How Much Drinking IsToo Much?

esearch indicates that heavy drinking byexpectant mothers can affect the health ofunborn babies, particularly binge drinkingand heavy drinking during the early days ofpregnancy (Maler & West, 2001). Newborn

infants whose mothers drank heavily dur-ing pregnancy have been found to have frequent physicaland behavioral abnormalities (Alison, 1994), includingaggressiveness and destructiveness (Gardner, 2000), andmay experience symptoms of withdrawal (Thomas & Riley,1998). For example, such infants have shown growth defi-ciencies, facial and limb irregularities, damage to the cen-tral nervous system (Goodlett & Horn, 2001; Mattson &Riley, 1998), and impairment in cognitive functioning(Kodituwakku, Kalberg, & May, 2001). As noted in TheThird Report on Alcohol and Health (HEW 1978), alcoholabuse in pregnant women is the third-leading cause ofbirth defects (the first two being Down syndrome andspina bifida, the incomplete formation and fusion of thespinal canal). Fetal alcohol syndrome is also associatedwith the development of mental disorder in adults (Famy,Streissguth & Unis, 1998). Although data on fetal alcoholsyndrome are often difficult to obtain the prevalence hasbeen estimated at between 0.5 and 2 cases per 1,000births (May & Gossage, 2001).

Research in laboratory animals has confirmed thedevastating neurological effects of alcohol exposure inutero (Hannigan, 1996). Interestingly, research shows fetalalcohol syndrome has largely been reported in the UnitedStates and not in other countries, some of which havehigher rates of alcohol use than the United States. Thephenomenon offetal alcohol syndrome has been referredto as an "American Paradox" (Abel, 1998) by researchersnoting that fetal alcohol syndrome is strongly related tolower SES.

How much drinking endangers a newborn health? TheHEW report warns against drinking more than 1 ounce of

The effects of fetal alcohol syndrome can be both dramaticand long-lasting. This child shows some of the permanentphysical abnormalities characteristic of the syndrome:widely spaced eyes, short broad nose, underdevelopedupper lip, and receding chin.

alcohol per day (one 12-ounce can of beer or one 5-ounceglass of wine, for example). The actual amount of alcoholthat can safely be ingested during pregnancy is not known,but existing evidence for fetal alcohol syndrome isstrongest when applied to binge drinkers or heavy alcoholusers rather than to light or moderate users (Kolata, 1981).Nonetheless the surgeon general and many medicalexperts have concurred that pregnant women shouldabstain from using alcohol as the "safest course" until safeamount of alcohol consumption can be determined(Raskin, 1993).

MRls of three children: (left) Normal control, l]-year-old female; (center) FAS, l]-year-old male with focal thinning of the corpus callosum;(right) FAS, 14-year-old male with complete agenesis (nondevelopment) of the corpus callosum.

Alcohol is also a high -calorie drug. A pint of whiskey-enough to make about eight to ten ordinary cocktails-provides about 1,200 calories, which is approximately halfthe ordinary caloric requirement for a day (Flier, Under-hill, & Lieber, 1995). Thus consumption of alcohol reducesa drinker's appetite for other food. Because alcohol has nonutritional value, the excessive drinker can suffer frommalnutrition (Derr & Gutmann, 1994). Furthermore,heavy drinking impairs the body's ability to utilize nutri-ents, so the nutritional deficiency cannot be made up bypopping vitamins. Many alcohol abusers also experienceincreased gastrointestinal symptoms such as stomachpains (Fields et al., 1994).

PSYCHOSOCIAL EFFECTS OF ALCOHOL ABUSE ANDDEPENDENCE In addition to various physical problems,an excessive drinker usually suffers from chronic fatigue,oversensitivity, and depression. Initially, alcohol may seemto provide a useful crutch for dealing with the stresses oflife, especially during periods of acute stress, by helpingscreen out intolerable realities and enhancing the drinker'sfeelings of adequacy and worth. The excessive use of alco-hol eventually becomes counterproductive and can resultin impaired reasoning, poor judgment, and gradual per-sonality deterioration. Behavior typically becomes coarseand inappropriate, and the drinker assumes increasinglyless responsibility, loses pride in personal appearance,neglects spouse and family, and becomes generally touchy,irritable, and unwilling to discuss the problem.

As judgment becomes impaired, an excessive drinkermay be unable to hold a job and generally becomesunqualified to cope with new demands that arise (Frone,2003). General personality disorganization and deteriora-tion may be reflected in loss of employment and maritalbreakup. By this time, the drinker's general health is likelyto have deteriorated, and brain and liver damage may haveoccurred. For example, there is some evidence that an alco-holic's brain is accumulating diffuse organic damage evenwhen no extreme organic symptoms are present (Sullivan,Deshmukh, et al., 2000), and even mild to moderate drink-ing can adversely affect memory and problem solving(Gordis, 2001). Other researchers have found extensivealcohol consumption to be associated with an increasedamount of organic damage in later life (Lyvers, 2000).

PSYCHOSES ASSOCIATED WITH SEVERE ALCOHOLABUSE Several acute psychotic reactions fit the diagnos-tic classification of substance-induced disorders. Thesereactions may develop in people who have been drinkingexcessively over long periods of time or who have areduced tolerance for alcohol for other reasons-forexample, because of brain lesions from excessive long-termuse. Such acute reactions usually last only a short time andgenerally consist of confusion, excitement, and delirium.There is some evidence that delirium may be associatedwith lower levels of thiamine in alcoholics (Holzbeck,

1996). These disorders are often called "alcoholic psy-choses" because they are marked by a temporary loss ofcontact with reality.

Among those who drink excessively for a long time, areaction called "alcohol withdrawal delirium" (formerlyknown as "delirium tremens") may occur (Palmstierno,2001). This reaction usually happens following a pro-longed drinking spree when the person is in a state ofwithdrawal. Slight noises or suddenly moving objects maycause considerable excitement and agitation. The full-blown symptoms include (1) disorientation for time andplace in which, for example, a person may mistake thehospital for a church or jail, no longer recognize friends,or identify hospital attendants as old acquaintances;(2) vivid hallucinations, particularly of small, fast-movinganimals like snakes, rats, and roaches; (3) acute fear, inwhich these animals may change in form, size, or color interrifying ways; (4) extreme suggestibility, in which a per-son can be made to see almost any animal if its presence ismerely suggested; (5) marked tremors of the hands,tongue, and lips; and (6) other symptoms including per-spiration, fever, a rapid and weak heartbeat, a coatedtongue, and foul breath.

The delirium typically lasts from 3 to 6 days and isgenerally followed by a deep sleep. When a person awak-ens, few symptoms-aside from possible slight remorse-remain, but frequently the individual is badly scared andmay not resume drinking for several weeks or months.Usually, however, drinking is eventually resumed, followedby a return to the hospital with a new attack. The death ratefrom withdrawal delirium as a result of convulsions, heartfailure, and other complications once approximated 10percent (Tavel, 1962). With drugs such as chlordiazepox-ide, however, the current death rate during withdrawaldelirium and acute alcoholic withdrawal has beenmarkedly reduced.

A second alcohol-related psychosis is the disorderreferred to as "alcohol amnestic disorder" (formerly knownas "Korsakoff's syndrome"). This condition was firstdescribed by the Russian psychiatrist Korsakoff in 1887and is one of the most severe alcohol-related disorders(Oscar-Berman, Shagrin, Evert, & Epstein, 1997). The out-standing symptom is a memory defect (particularly withregard to recent events), which is sometimes accompaniedby falsification of events (confabulation). Persons with thisdisorder may not recognize pictures, faces, rooms, andother objects that they have just seen, although they mayfeel that these people or objects are familiar. Such peopleincreasingly tend to fill in their memory gaps with remi-niscences and fanciful tales that lead to unconnected anddistorted associations. These individuals may appear to bedelirious, delusional, and disoriented for time and place,but ordinarily their confusion and disordered actions areclosely related to their attempts to fill in memory gaps. Thememory disturbance itself seems related to an inability toform new associations in a manner that renders them

readily retrievable. Such a reaction usually occurs in olderalcoholics, after many years of excessive drinking. Thesepatients have also been observed to show other cognitiveimpairments such as planning deficits (Brokate, Hilde-brandt, et aI., 2003), intellectual decline, and emotionaldeficits (Snitz, Hellinger, & Daum, 2002) and judgment(Brand, Fujiwara, et aI., 2003). Research with sophisticatedbrain-imaging techniques has found that patients withalcohol amnestic disorders show cortical lesions (Estruch,Bono, et aI., 1998).

The symptoms of alcohol amnestic disorder are nowthought to be due to vitamin B (thiamine) deficiency andother dietary inadequacies. Although it had been believedthat a diet rich in vitamins and minerals generallyrestores such a patient to more normal physical and men-tal health, some research evidence suggests otherwise.Lishman (1990) reported that alcohol amnestic disorderdid not respond well to thiamine replacement. Somememory functioning appears to be restored with pro-longed abstinence. However, some personality deteriora-tion usually remains in the form of memory impairment,blunted intellectual capacity, and lowered moral and eth-ical standards.

Averill B. was brought into the detoxification unit ofa local county hospital by the police after an incident at acrowded city park. He was arrested because of hisassaultive behavior toward others (he was walkingthrough the crowded groups of sunbathers muttering tohimself, kicking at people). At admission to the hospital,Averill was disoriented (did not know where he was).incoherent. and confused. When asked his name, hepaused a moment. scratched his head, and said. "GeorgeWashington." When asked about what he was doing atthe park he indicated that he was "marching in a paradein his honor."

Biological Factors in the Abuse ofand Dependence on Alcohol andOther SubstancesIn trying to identify the causes of problem drinking, someresearchers have stressed the role of genetic and biochemi-cal factors; others have pointed to psychosocial factors,viewing problem drinking as a maladaptive pattern ofadjustment to the stress of life; and still others haveemphasized sociocultural factors such as the availability ofalcohol and social approval of excessive drinking. As wewill see, some combination of all of these factors seems to

influence risk for developing alcohol abuse or alcoholdependence. As with most other forms of maladaptivebehavior, there may be several types of alcohol depen-dence, each with somewhat different patterns of biological,psychosocial, and sociocultural causal factors.

How do substances such as alcohol, cocaine, andopium (discussed below) come to have such powerfuleffects-an overpowering hold that occurs in some peopleafter only a few uses of the drug? Although the exact mech-anisms are not fully agreed on by experts in the field, twoimportant factors are apparently involved. The first is theability of most, if not all, addictive drugs to activate areasof the brain that produce intrinsic pleasure and sometimesimmediate, powerful reward. The second factor involvesthe person's biological makeup, or constitution, includinghis or her genetic inheritance and the environmental influ-ences (learning factors) that enter into the need to seekmind-altering substances to an increasing degree as usecontinues. The development of an alcohol addiction is acomplex process involving many elements-constitutionalvulnerability and environmental encouragement, as wellas the unique biochemical properties of certain psychoac-tive substances. Let's examine each of these elements inmore detail.

THE NEUROBIOLOGY OF ADDICTION Let's first exam-ine the role that drugs like alcohol play in the process ofaddiction. Drugs differ in their biochemical properties aswell as in how rapidly they enter the brain. There are sev-eral routes of administration-oral, nasal, and intra-venous. Alcohol is usually drunk, the slowest route,whereas cocaine is often self-administered by injection ortaken nasally. Central to the neurochemical processunderlying addiction is the role the drug plays in activat-ing the "pleasure pathway." The mesocorticolimbicdopamine pathway (MCLP) is the center of psychoactivedrug activation in the brain. The MCLP is made up ofaxons or neuronal cells in the middle portion of the brainknown as the "ventral tegmental area" (see Figure 12.1)and connects to other brain centers such as the nucleusaccumbens and then to the frontal cortex. This neuronalsystem is involved in such functions as control of emo-tions, memory, and gratification. Alcohol produceseuphoria by stimulating this area in the brain. Researchhas shown that direct electrical stimulation of the MCLPproduces great pleasure and has strong reinforcing prop-erties (Liebman & Cooper, 1989; Littrell, 2001). Otherpsychoactive drugs also operate to change the brain's nor-mal functioning and to activate the pleasure pathway.Drug ingestion or behaviors that lead to activation of thebrain reward system are reinforced, so further use is pro-moted. The exposure of the brain to an addictive drugalters its neurochemical structure and results in a numberof behavioral effects. With continued use of the drug, neu-roadaptation or tolerance and dependence to the sub-stance develop.

Ventraltegmentalarea

GENETIC VULNERABILITY The possibility of a geneticpredisposition to developing alcohol-abuse problems hasbeen widely researched. Many experts today agree thatgenetics probably plays an important role in developingsensitivity to the addictive power of drugs like alcohol(Mustanski, Viken, et al., 2003; Plomin & DeFries, 2003).Several lines of research point to the importance of geneticfactors in substance-abuse disorders.

A review of 39 studies of the families of 6,251 alco-holics and of 4,083 nonalcoholics who had been followedover 40 years reported that almost one-third of alcoholicshad at least one parent with an alcohol problem (Cotton,1979). Likewise, a study of children of alcoholics byCloninger and colleagues (1986) reported strong evidencefor the inheritance of alcoholism. They found that formales, having one alcoholic parent increased the rate ofalcoholism from 12.4 percent to 29.5 percent, and havingtwo alcoholic parents increased the rate to 41.2 percent.For females with no alcoholic parents, the rate was 5.0 per-cent; for those with one alcoholic parent, the rate was 9.5percent; and for those with two alcoholic parents, it was25.0 percent.

Alcoholism clearly tends to run in families (Wall,Shea, et al., 2001). Research has shown that some people,such as the sons of alcoholics, have a high risk for devel-oping problems with alcohol because of an inherent moti-vation to drink or sensitivity to the drug (Conrod, Pihl, &Vassileva, 1998). Research on the children of alcoholicswho were adopted by other (nonalcoholic) families hasalso provided useful information. Studies have been con-ducted of alcoholics' children who were placed for adop-tion early in life and so did not come under theenvironmental influences of their biological parents. Forexample, Goodwin and colleagues (1973) found that chil-dren of alcoholic parents who had been adopted by nonal-

FIGURE 12.1The Mesocorticolimbic PathwayThe mesocortico/imbic pathway (MCLP),running from theventral tegmental area to the nucleus accumbens to thefrontal cortex, is central to the release of theneurotransmitter dopamine and in mediating the rewardingproperties of drugs.Source: Office of Technology Assessment, 1993.

coholic foster parents were nearly twice as likely to havealcohol problems by their late-twenties as a control groupof adopted children whose real parents were not alco-holics. In another study, Goodwin and colleagues (1974)compared alcoholic parents' sons who were adopted ininfancy by nonalcoholic parents with sons raised by theiralcoholic parents. Both adopted and non adopted sonslater evidenced high rates of alcoholism-25 percent and17 percent, respectively. These investigators concludedthat being born to an alcoholic parent, rather than beingraised by one, increases the risk of a son's becoming analcoholic.

Another approach to understanding the precursors toalcohol-abuse disorders is to study prealcoholic personali-ties-individuals who are at high risk for substance abusebut who are not yet affected by alcohol. The heritability ofpersonality characteristics has been widely explored(Bouchard & Loehlin, 2001). An alcohol-risk personalityhas been described as an individual (usually an alcoholic'schild) who has an inherited predisposition toward alcoholabuse and who is impulsive, prefers taking high risks, andis emotionally unstable.

Research has shown that prealcoholic men (thosewho are genetically predisposed to developing drug oralcohol problems but who have not acquired the problem)show different physiological patterns than nonalcoholicmen in several respects. Prealcoholic men tend to experi-ence a greater lessening of feelings of stress with alcoholingestion than do nonalcoholic men (Finn, Sharkansky, etal., 1997). They also show different alpha wave patterns onEEGs (Stewart, Finn, & Pihl, 1990). Prealcoholic men werefound to show larger conditioned physiological responsesto alcohol cues than individuals who were considered at alow risk for alcoholism, according to Earleywine and Finn(1990). These results suggest that prealcoholic men may

be more prone to develop tolerance for alcohol than low-risk men.

Some research has suggested that certain ethnicgroups, particularly Asians and Native Americans, haveabnormal physiological reactions to alcohol-a phenome-non referred to as "alcohol flush reaction." Fenna and col-leagues (1971) and Wolff (1972) found that Asian andEskimo subjects showed a hypersensitive reaction includ-ing flushing of the skin, a drop in blood pressure, heart pal-pitations, and nausea following the ingestion of alcohol(see also Gill, Eagle" et al., 1999). This physiological reac-tion is found in roughly half of all Asians (Chen & Yeh,1997) and results from a mutant enzyme that fails to breakdown alcohol molecules in the liver during the metabolicprocess (Takeshita et al., 1993). Although cultural factorsmay also playa role, the relatively lower rates of alcoholismamong Asian groups might be related to the extreme dis-comfort associated with the alcohol flush reaction (Higuci,Matsushita, et al., 1994).

GENETICS- THE WHOLE STORY? As with the otherdisorders described in this book, genetics alone is not thewhole story, and the exact role it plays in the developmentof alcoholism remains unclear. This issue continues to bedebated, and some experts are not convinced of the pri-mary role of genetics in alcoholism. The genetic mecha-nism or model for the generally agreed-upon observationthat alcoholism is familial is insufficient to explain thebehavior fully. That is, genetic transmission in the case ofalcoholism does not follow the hereditary pattern found instrictly genetic disorders. Some investigators haveemployed the evidence that genetics appears to play a5tronger role in men than in women (Merikangus &Swendsen, 1997) to question the relative power of geneticsas an explanatory factor in substance abuse. Searles (1991)points to the ambiguous evidence for the genetics of alco-holism and cautions against interpreting genetics as acausal factor in its development. Negative results have beenfound in both twin and adoptive studies and in studiesdesigned to follow up the behavior of high-risk individu-als. The great majority of children who have alcoholic par-ents do not themselves become alcoholics-whether ornot they are raised by their real parents. The children ofalcoholics who make successful life adjustments have notbeen sufficiently studied. In one study of high-risk chil-dren of alcoholics, a group of young men 19 to 20 years ofage who were presumably at high risk for developing alco-holism were carefully studied for symptoms of psy-chopathology. Schulsinger and colleagues (1986) foundthat they did not differ in psychopathology or in alcohol-abuse behavior from a control sample similar to the gen-eral population. In another study of high-risk individuals,Alterman, Searles, and Hall (1989) failed to find differ-ences in drinking behavior or alcohol-related symptomsbetween a group of high-risk subjects (those who had alco-holic fathers) and a group of non-high-risk subjects.

Although much evidence implicates genetic factors inthe etiology of alcoholism, we do not know what preciserole they play. At present, it appears that the genetic inter-pretation of alcoholism remains an attractive hypothesis;however, additional research is needed for us to hold thisview with confidence. It is not likely that genetics alone willaccount for the full range of alcohol and drug problems.Social circumstances are still considered powerful forces inproviding both the availability and the motivation to usealcohol and other drugs. McGue (1998) has noted that themechanisms of genetic influence should be viewed as com-patible, rather than competitive, with psychological andsocial determinants of this disorder.

GENETIC INFLUENCES AND LEARNING When we talkabout familial or constitutional differences, we are notstrictly limiting our explanation to genetic inheritance.Rather, learning factors appear to play an important partin the development of constitutional reaction tendencies.Having a genetic predisposition or biological vulnerabilityto alcohol abuse, of course, is not a sufficient cause of thedisorder. The person must be exposed to the substance to asufficient degree for the addictive behavior to appear. Inthe case of alcohol, almost everyone in America is exposedto the drug to some extent-in most cases through peerpressure, parental example, and advertising. The develop-ment of alcohol-related problems involves living in anenvironment that promotes initial as well as continuinguse of the substance. People become conditioned to stim-uli and tend to respond in particular ways as a result oflearning. Learning appears to play an important part in thedevelopment of substance abuse and antisocial personalitydisorders (see Chapter 11). There clearly are numerousreinforcements for using alcohol in our social environ-ments and everyday lives. However, research has alsoshown that psychoactive drugs such as alcohol containintrinsic rewarding properties-apart from the social con-text or the drug's operation to diminish worry or frustra-tion. As we saw earlier, the drug stimulates pleasure centersin the brain and develops a reward system of its own.

Psychosocial Causal Factors inAlcohol Abuse and DependenceNot only do alcoholics become physiologically dependenton alcohol, they develop a powerful psychological depen-dence as well-they become socially dependent on thedrug to help them enjoy social situations. Because exces-sive drinking is ultimately so destructive to a person's totallife adjustment, the question of how psychological depen-dence is learned arises (Gordis, 2000). A number of psy-chosocial factors have been advanced as possible answers.

FAILURES IN PARENTAL GUIDANCE Stable family rela-tionships and parental guidance are extremely importantmolding influences for children (Ramirez, Crano, et al.,

2004), and this stability is often lacking in families ofsubstance abusers. Children who have parents who areextensive alcohol or drug abusers are vulnerable to devel-oping substance-abuse and related problems themselves(Erblich, Earleywine, & Erblich, 2001). The experiencesand lessons we learn from important figures in our earlyyears have a significant impact on us as adults. Parent sub-stance use is associated with early adolescent substance use(Brown, Tate, et al., 1999). Children who are exposed tonegative role models and family dysfunction early in theirlives or experience other negative circumstances becausethe adults around them provide limited guidance oftenfalter on the difficult steps they must take in life (Fischer,Pidcock, et al., 2005). These formative experiences canhave a direct influence on whether a youngster becomesinvolved in maladaptive behavior such as alcohol or drugabuse. And negative parental models can have longer-range negative consequences once children leave the fam-ily situation. For example, in a study of the health behaviorof college students, college freshmen from families withalcohol-abusing parents viewed their families as lesshealthy and had more problematic family relationshipsthan those with non-alcohol-abusing parents (Deming,Chase, & Karesh, 1996).

In one sophisticated program of research aimed atevaluating the possibility that negative socialization fac-tors influence alcohol use, Chassin and colleagues (1993;Trim & Chassin, 2004) replicated findings that alcoholabuse in parents was associated with substance use in ado-lescents. They then evaluated several possible mediatingfactors that can affect whether adolescents start usingalcohol. They found that parenting skills or parentalbehavior was associated with substance use in adolescents.Specifically, alcohol-abusing parents are less likely to keeptrack of what their children are doing, and this lack ofmonitoring often leads to the adolescents' affiliation with

Parent substance use is associated with early adolescentsubstance use, and negative parental models can have longer-range negative consequences once children leave home.

drug-using peers. In addition, Chassin and colleagues(1993) found that stress and negative affect (more preva-lent in families with an alcoholic parent) were associatedwith alcohol use in adolescents. They reported that"parental alcoholism was associated with increases in neg-ative uncontrollable life events which, in turn, were linkedto negative affect, to associations with drug-using peers,and to substance use" (p. 16). In a follow-up study, Chas-sin et al. (1996) reported that the direct effect of fathers'alcohol abuse was strong, even after controlling for stressand negative affect. Extremely stressful childhood experi-ences such as child sexual abuse might make a person vul-nerable to later problems. Women who have a history ofchild sexual abuse are at risk for developing a wide rangeof psychological problems including substance abuse(Kendler, Bulik, et al., 2000).

PSYCHOLOGICAL VULNERABILITY Is there an "alco-holic personality" -a type of character organization thatpredisposes a person to use alcohol rather than adopt someother defensive pattern of coping with stress? Do someindividuals self-medicate or reduce their discomfort byexcessive use of alcohol? In efforts to answer this question,investigators have found that many potential alcoholabusers tend to be emotionally immature, expect a greatdeal of the world, require an inordinate amount of praiseand appreciation, react to failure with marked feelings ofhurt and inferiority, have low frustration tolerance, andfeel inadequate and unsure of their abilities to fulfillexpected male or female roles. Persons at high risk fordeveloping alcohol-related problems are significantly moreimpulsive and aggressive than those at low risk for abusingalcohol (Morey, Skinner, & Blashfield, 1984).

In recent years, substantial research has focused on thelink between alcohol-abuse disorders and such other dis-orders as antisocial personality, depression, and schizo-phrenia. About half of the persons with schizophrenia haveeither alcohol or drug abuse or dependence as well(Kosten, 1997). By far, most of the research on comorbid-ity has related antisocial personality (discussed in Chapter11) and addictive disorders, where about 75 to 80 percentof the studies have shown a strong association (Alterman,1988), and conduct disorder (Slutsky, Heath, et al., 1998).Interestingly, antisocial personality disorder, alcohol, andaggression are strongly associated (Moeller & Dougherty,2001). High rates of substance abuse are found amongantisocial personalities (Clark, Watson, & Reynolds, 1995),and in a survey of eight alcohol treatment programs, Mor-ganstern, Langenbucher, and colleagues (1997) found that57.9 percent had a personality disorder, with 22.7 percentmeeting criteria for antisocial personality disorder.

Considerable research has suggested that there is arelationship between depressive disorders and alcoholabuse, and there may be gender differences in the associa-tion between these disorders (Kranzler et al., 1997). Onegroup of researchers (Moscato, Russell, et al., 1997) found

the degree of association between depression and alcohol-abuse problems stronger among women. For whatever rea-son they co-occur, the presence of other mental disordersin alcohol- or drug-abusing patients is a very importantconsideration when it comes to treatment, as will be dis-cussed later in this chapter (Petrakis, Gonzalez, et aI.,2002; Samet, Liu, & Hasin, 2004). In order to ensure moreeffective treatment with these complicated problems,Brems and Johnson (1997) recommended that treatmentof co-occurring mental health problems involve morecross-disciplinary collaboration, greater integration ofsubstance-abuse and mental health treatments, and modi-fication of training of caregivers to sensitize them to thedifficulties of treating patients with comorbid disorders.

STRESS, TENSION REDUCTION, AND REINFORCE-MENT A number of investigators have pointed out thatthe typical alcohol abuser is discontented with his or herlife and is unable or unwilling to tolerate tension and stress(Rutledge & Sher, 200l). For example, Hussong, Hicks,et ai. (2001) and Kushner, Thuras, et ai. (2000) reported ahigh degree of association between alcohol consumptionand negative affectivity such as anxiety and somatic com-plaints. In other words, alcoholics drank to relax. In thisview, anyone who finds alcohol tension-reducing is in dan-ger of becoming an alcoholic, even without an especiallystressful life situation. However, the tension reductioncausal model is difficult to accept as a sole explanatoryhypothesis. If this process were a main cause, we wouldexpect alcoholism to be far more common than it is,because alcohol tends to reduce tension for most peoplewho use it. In addition, this model does not explain whysome excessive drinkers are able to maintain control overtheir drinking and continue to function in society, whereasothers are not.

Cox and Klinger (1988) and Cooper (1994) describe amotivational model of alcohol use thatplaces a great deal of responsibility on theindividual. According to this view, thefinal common pathway of alcohol use ismotivation; that is, a person decides, con-sciously or unconsciously, whether toconsume a particular drink of alcohol.Alcohol is consumed to bring aboutaffective changes, such as the mood-altering effects, and even indirect effects,such as peer approval. In short, alcohol isconsumed because it is reinforcing.

pie, especially young adolescents, expect that alcohol usewill lower tension and anxiety and increase sexual desireand pleasure in life (Seto & Barbaree, 1995). According tothe reciprocal influence model, adolescents begin drinkingas a result of expectations that using alcohol will increasetheir popularity and acceptance by their peers. Research hasshown that expectancies of social benefit can influence ado-lescents' decisions to start drinking and predict their con-sumption of alcohol (Christiansen et aI., 1989).

This view gives professionals an important and poten-tially powerful means of deterring drinking among youngpeople, or at least of delaying its onset. From this perspec-tive, alcohol use in teenagers can be countered by provid-ing young people with more effective social tools and withways of altering these expectancies before drinking begins.Smith and colleagues (1995) have suggested that preven-tion efforts should be targeted at children before theybegin to drink so that the positive feedback cycle of recip-rocal reinforcement between expectancy and drinking willnever be established (see the discussion on prevention ofalcohol use in Chapter 18).

Time and experience do have moderating influenceson these alcohol expectancies. In a longitudinal study ofcollege drinking, Sher, Wood, and colleagues (1996) foundthat there was a significant decrease in outcome expectancyover time. Older students showed less expectation of thebenefits of alcohol than beginning students (see The WorldAround Us 12.2 on p. 424).

MARITAL AND OTHER INTIMATE RELATIONSHIPSAdults with less intimate and supportive relationships tendto show greater drinking following sadness or hostilitythan those with close peers and with more positive rela-tionships (Hussong et aI., 200l). Excessive drinking oftenbegins during crisis periods in marital or other intimatepersonal relationships, particularly crises that lead to hurt

and self-devaluation. The marital rela-tionship may actually serve to maintainthe pattern of excessive drinking. (SeeCase Study on p. 425.) Marital partnersmay behave toward each other in waysthat promote or enable a spouse's exces-sive drinking. For example, a husbandwho lives with an alcoholic wife is oftenunaware of the fact that, gradually andinevitably, many of the decisions hemakes every day are based on the expec-tation that his wife will be drinking.These expectations, in turn, may makethe drinking behavior more likely. Even-tuallyan entire marriage may center onthe drinking of an alcoholic spouse. Insome instances, the husband or wifemay also begin to drink excessively.Thus

one important concern in many treatment programs todayinvolves identifying the personality or lifestyle factors in a

. .•llltli . •moderating

A moderating variable is a variablethat influences the associationbetween two other variables. Forexample, depression is commonafter bereavement. However, menwho have lost a spouse tend tobe more likely to be depressedthan women who have lost aspouse. In this case, gender is akey moderating variable for thebe reave men t-depressionrelationship.

EXPECTATIONS OF SOCIAL SUCCESSA number of investigators have beenexploring the idea that cognitive expec-tation may play an important role bothin the initiation of drinking and in themaintenance of drinking behavior once the person hasbegun to use alcohol (Marlatt, Baer, et aI., 1998). Many peo-

12.2Two alcohol-related student deaths shocked

the Colorado college community in the fall of2004. Lynn B., an entering freshman at the Uni-versity of Colorado, drank so much whiskeyand wine during a fraternity initiation that he

became unconscious and died as a result of alcohol poi-sioning. This tragic incident occurred just 2 weeks after a19-year-old sophomore, Samantha S. at Colorado StateUniversity, died of alcohol poisoning after a party in whichshe consumed an estimated 40 drinks (Sink, 2004).

How extensive is college binge drinking? In spite of thefact that alcohol use is illegal for most undergraduates,binge drinking on campus is widespread (Rabow & Duncan-Schill, 1995). According to a survey by Wechsler, Davenport,et al. (1994),44 percent of college students in the UnitedStates are binge drinkers, and Goodwin (1992) reports that98 percent of fraternity and sorority members drink someamount every week. Some research has suggested, how-ever, that the pattern of drinking can vary widely with bingedrinking being more of an occasional rather than a regularevent (Del Boca, Darkes, et aI., 2004). Wechsler and col-leagues (1994) conducted a nationwide survey of 140 col-lege campuses in 40 states and obtained surveyinformation pertaining to the drinking behavior and healthconsequences of drinking on 17,592 students (with approxi-matelya 69 percent response rate). Students completed a20-page survey of their drinking practices, including suchinformation as recency of last drink, how many times theyhad five drinks or more in a row, and how many times theyhad four drinks in a row. They were also asked to provideinformation as to whether they experienced any of the fol-lowing consequences after drinking: had a hangover,missed a class, got behind in schoolwork, did somethingthey later regretted, forgot where they were or what theydid, argued with friends, engaged in unplanned sexualactivities, failed to use protection when having sex, dam-aged property, got into trouble with the campus police, gothurt, or required medical treatment for an alcohol overdose.

The colleges surveyed in the study varied widely inthe extent of binge drinking among the student body. Asone might expect-some colleges earn reputations asbeing "party schools" -some institutions had a large num-ber of students (70 percent) heavily involved in alcohol andbinge drinking, but the problem occurred to some degree

relationship that tend to foster the drinking in the alcohol-

abusing person. Of course, such relationships are not

restricted to marital partners but may also occur in those

involved in love affairs or close friendships.

Excessive use of alcohol is one of the most frequent

causes of divorce in the United States (Perreira & Sloan,

across most college campuses. What are the reasons forthe widespread problem of binge drinking in college? Manyfactors can be cited such as students' expressing indepen-dence from parental influence (Turrisi, Wiersma, & Hughes,2000); peer group and situational influences (Read, Wood,et aI., 2003); developing and asserting gender role, partic-ularly for men adopting a "macho" role (Capraro, 2000);and holding beliefs that alcohol can help make positivetransformations (e.g., "having a few drinks to celebratespecial occasions"; Turrisi, 1999). The consequences of col-lege binge drinking can be far-reaching. In their survey,Wechsler and colleagues (1994) reported a strong associa-tion between the frequency of binge drinking and alcohol-related health and life problems. In fact, binge drinkerswere nearly ten times more likely than those who did notindulge in binge drinking to engage in unplanned sexualactivity, not to use protection when having sex, to get intotrouble with campus police, to damage property, and to gethurt after drinking. Men and women tended to report simi-lar problems, except that men engaged in more propertydamage than women. Over 16 percent of the men and 9percent of the women reported having gotten in troublewith the campus police. About 47 percent of the frequentbinge drinkers, compared with 14 percent of the nonbingedrinkers, indicated that they had experienced five or moreof the problems surveyed. In a recent follow-up survey ofcollege drinking in 1997, Wechsler and colleagues (1998)reported strikingly similar results.

The results of studies bearing on the long-range con-sequences of college drinking have been somewhat equiv-ocal (Granfield, 2005). One recent study suggested thatextensive drinking in college, even among the heaviestdrinkers from sororities and fraternities, might be deter-mined to a great extent by situational factors. In a follow-up study of drinking behavior a year after graduation,Sher, Bartholow, and Nanda (2001) reported that being amember of a fraternity or sorority did not predict postcol-lege drinking. Interestingly, a long-term follow-up of over11years has shown that the heavy drinking during collegedid not relate to heavy drinking during later years(Bartholow, Sher, & Krull, 2003). These investigators foundthat heavy drinking that is associated with Greek societyinvolvement does not generally lead to sustained heavydrinking in later life.

2001) and is often a hidden factor in the two most com-

mon causes-financial and sexual problems. The deterio-

ration in alcoholics' interpersonal relationships, of course,

further augments the stress and disorganization in their

lives. The breakdown of marital relationships can be a

highly stressful situation for many people. The stress of

divorce and the often erratic adjustment period that fol-lows can lead to increased substance abuse.

Family relationship problems have also been found tobe central to the development of alcoholism. In a classiclongitudinal study of possible etiologic factors in alcoholabuse, Vaillant, Gale, and Milofsky (1982) described sixfamily relationship factors that were significantly associ-ated with the development of alcoholism in the individualsthey studied. The most important family variables thatwere considered to predispose the individual to substance-use problems were the presence of an alcoholic father,acute marital conflict, lax maternal supervision and incon-sistent discipline, many moves during the family's earlyyears, lack of "attachment" to the father, and lack of familycohesiveness.

The Drunken Wifeand Mother

Evelyn c., a 36-year-old homemaker and mother of twoschool-age children (from a previous marriage), began todrink to excess especially following intense disagree-ments with her husband, John, a manager of a retail busi-ness. Over the past several months, she began drinkingduring the day when her children were at school and ontwo occasions was inebriated when they came home. Onone recent occasion, Evelyn failed to pick up her olderdaughter after an after-school event. Her daughter calledJohn's cell phone (he was out of town on a business trip),and he had an assistant pick her up. When they arrivedhome, Evelyn(apparently unaware of the problem she hadcaused) created a scene and was verbally abusive towardthe assistant. Her out-of-control drinking increased whenher husband of 3 years began staying out all night. Theseemotionally charged encounters resulted in John's physi-cally abusing her one morning when he came back homeafter a night away. John moved out of the house and filedfor divorce.

Alcohol use is a pervasive component in the social life inWestern civilization. Social events often revolve aroundalcohol use, and alcohol use before and during meals iscommonplace. Alcohol is often seen as a "social lubricant"or tension reducer that enhances social events. Thus inves-tigators have pointed to the role of sociocultural as well asphysiological and psychological factors in the high rate ofalcohol abuse and dependence among Americans (Vegaet aI., 1993).

The effect of cultural attitudes toward drinking is wellillustrated by Muslims and Mormons, whose religious val-

The cultural influences on alcoholism are clear when one looks at theextremely low incidence of alcoholism among Muslims, Mormons, andorthodox jews, whose religious values prohibit social drinking.

ues prohibit the use of alcohol, and by orthodox Jews, whohave traditionally limited its use largely to religious rituals.The incidence of alcoholism among these groups is mini-mal. In comparison, the incidence of alcoholism is highamong Europeans. For example, one survey showed thehighest alcohol-use rates among young people to be inDenmark and Malta, where one in five students reportedhaving drunk alcohol ten times within the past 30 days(ESPAD, 2000). Interestingly, Europe and six countries thathave been influenced by European culture-Argentina,Canada, Chile, Japan, the United States, and NewZealand-make up less than 20 percent of the world's pop-ulation yet consume 80 percent of the alcohol (Barry,1982). Alcohol abuse continues to be a problem in Europe,and these problems greatly enhance accidents (Lehto,1995), crime (Rittson, 1995), liver disease (Medical Councilon Alcoholism, 1997), and the extent to which young peo-ple are becoming involved in substance-use problems(Anderson & Lehto, 1995). The French appear to have thehighest rate of alcoholism in the world, approximately 15percent of the population. France has both the highest percapita alcohol consumption and the highest death ratefrom cirrhosis of the liver (Noble, 1979). In addition,France shows the highest prevalence rates: In a broad sur-vey of hospital patients, 18 percent (25 percent for men and7 percent for women) were reported to have alcohol-usedisorders, although only 6 percent of admissions were foralcohol problems (Reynaud, Leleu, et aI., 1997). In Sweden,another country with high rates of alcoholism, 13.2 percentof men's hospital admissions, and 1.1 percent of women's,were attributed to alcohol (Andreasson & Brandt, 1997).Thus it appears that religious sanctions and social customscan influence whether alcohol is one of the coping methodscommonly used in a given group or society.

The behavior that is manifested under the influence ofalcohol seems to be influenced by cultural factors. Lindmanand Lang (1994), in a study of alcohol-related behavior ineight countries, found that most people expressed the viewthat aggressive behavior frequently followed their drinking"many" drinks. However, the expectation that alcohol leadsto aggression is related to cultural traditions and earlyexposure to violent or aggressive behavior.

In sum, we can identify many reasons why peopledrink-as well as many conditions that can predisposethem to do so and reinforce drinking behavior-but theexact combination of factors that result in a person'sbecoming an alcoholic are still unknown.

Alcohol abuse and dependence are difficult to treatbecause many alcoholics refuse to admit that they have aproblem or to seek assistance before they "hit bottom;' andmany that do go into treatment leave before therapy iscompleted. DiClemente (1993) refers to the addictions as"diseases of denial." However, in a review of several largealcohol-treatment studies, Miller, Walters, and Bennett(2001) reported that two-thirds of studies show large andsignificant decreases in drinking and related problems. Inthis section, we will examine both biological and psy-chosocial treatment strategies. As we will see, some treat-ment approaches appear to reduce drinking-relatedproblems more effectively than others (Miller & Wilbourne,2002; Zweben, 2001). In general, a multidisciplinaryapproach to the treatment of drinking problems appears tobe most effective, because the problems are often complex,requiring flexibility and individualization of treatmentprocedures (Margolis & Zweben, 1998). Also, a substanceabuser's needs change as treatment progresses. Treatmentobjectives usually include detoxification, physical rehabili-tation, control over alcohol-abuse behavior, and the indi-vidual's realizing that he or she can cope with the problemsof living and lead a much more rewarding life withoutalcohol. Traditional treatment programs usually have astheir goal abstinence from alcohol (Ambrogne, 2002).However, some programs attempt to promote controlleddrinking as a treatment goal for problem drinkers. Nomatter what the treatment method, relapse is common,and many in the field see relapse as a factor that must beaddressed in the treatment and recovery process (Tims,Leukefeld, & Platt, 2001).

USE OF MEDICATIONS IN TREATING ALCOHOLABUSERS Biological approaches include a variety oftreatment measures such as medications to reduce crav-ings, to ease the detoxification process, and to treat co-occurring health (National Institutes of Health, 2001) andmental health problems that may underlie the drinkingbehavior (Romach & Sellers, 1998).

MEDICATIONS TO BLOCK THE DESIRE TO DRINKDisulfiram (Antabuse), a drug that causes violent vomitingwhen followed by ingestion of alcohol, may be adminis-tered to prevent an immediate return to drinking (Nieder-hofer & Staffen, 2003). However, such deterrent therapy isseldom advocated as the sole approach, because pharmaco-logical methods alone have not proved effective in treatingalcoholism (Gorlick, 1993). For example, because the drugis usually self-administered, an alcohol-dependent personmay simply discontinue the use of Antabuse when he or sheis released from a hospital or clinic and begins to drinkagain. In fact, the primary value of drugs of this type seemsto be their ability to interrupt the alcohol-abuse cycle for aperiod of time, during which therapy may be undertaken.Uncomfortable side effects may accompany the use ofAntabuse; for example, alcohol-based aftershave lotion canbe absorbed through the skin, resulting in illness. More-over, the cost of Antabuse treatment, which requires carefulmedical maintenance, is higher than for many other, moreeffective treatments (Holder et al., 1991).

Another type of medication that has been used in apromising line of research (Kranzler, Armeli, et al., 2004;O'Malley, Krishnan-Sarin, et al., 2002) is naltrexone, anopiate antagonist that helps reduce the "craving" for alco-hol by blocking the pleasure-producing effects of alcohol(NIAAA, 2004). O'Malley, Jaffe, Rode, and Rounsaville(1996) have shown that naltrexone reduced the alcoholintake and lowered the incentive to drink for alcoholabusers, compared with a control sample given a placebo.Some research has suggested that naltrexone is particularlyeffective with individuals who have a high level of craving(Monterosso, Flannery, et al., 2001). Some research, how-ever, has failed to find naltrexone effective at reducingcraving (Krystal, Cramer, et al., 2001), so confidence in itsuse for this purpose must await further research.

MEDICATIONS TO REDUCE THE SIDE EFFECTS OFACUTE WITHDRAWAL In acute intoxication, the initialfocus is on detoxification (the elimination of alcoholic sub-stances from an individual's body), on treatment of thewithdrawal symptoms described earlier, and on a medicalregimen for physical rehabilitation. One of the primarygoals in treatment of withdrawal symptoms is to reduce thephysical symptoms characteristic of the syndrome such asinsomnia, headache, gastrointestinal distress, and tremu-lousness. Central to the medical treatment approaches arethe prevention of heart arrhythmias, seizures, delirium, anddeath (Bohn, 1993). These steps can usually best be handledin a hospital or clinic, where drugs such as Valium havelargely revolutionized the treatment of withdrawal symp-toms. Such drugs overcome motor excitement, nausea, andvomiting; prevent withdrawal delirium and convulsions;and help alleviate the tension and anxiety associated withwithdrawal. Pharmacological treatments with long-lastingbenzodiazepines such as diezepam to reduce the severity of

withdrawal symptoms have been shown to be effective(Malcolm, 2003).

Concern is growing, however, that the use of tranquil-izers at this stage does not promote long-term recoveryand may foster addiction to another substance. Accord-ingly, some detoxification clinics are exploring alternativeapproaches including a gradual weaning from alcoholinstead of a sudden cutoff. Maintenance doses of mildtranquilizers are sometimes given to patients withdrawingfrom alcohol to reduce anxiety and help them sleep. Suchuse of tranquilizers may be less effective than no treatmentat all, however. Usually patients must learn to abstain fromtranquilizers as well as from alcohol, because they tend tomisuse both. Further, under the influence of tranquilizers,patients may even return to alcohol use.

PSYCHOLOGICAL TREATMENT APPROACHES Detox-ification is optimally followed by psychological treatment,including family counseling and the use of communityresources related to employment and to other aspects of aperson's social readjustment. Although individual psy-chotherapy is sometimes effective, the focus of psycho-social measures in the treatment for alcohol-relatedproblems often involves group therapy, environmentalintervention, behavior therapy, and the approach used byAlcoholics Anonymous and family groups such as Al-Anon and Alateen.

Group Therapy Group therapy has been shown to beeffective for many clinical problems (Pines & Schlapober-sky, 2000), especially substance-abuse disorders (Velasquez,Maurer, et al., 2001). In the confrontational give-and-takeof group therapy (see Chapter 17), alcohol abusers areoften forced (perhaps for the first time) to face their prob-lems and their tendencies to deny or minimize them. Thesegroup situations can be extremely difficult for those whohave been engrossed in denial of their own responsibilities,but such treatment also helps them see new possibilities forcoping with circumstances that have led to their difficul-ties. Often, though not always, this paves the way to learn-ing more effective ways of coping and other positive stepstoward dealing with their drinking problem.

In some instances, the spouses of alcohol abusers andeven their children may be invited to join in group therapymeetings. In other situations, family treatment is itself thecentral focus of therapeutic efforts. In that case, the alcoholabuser is seen as a member of a disturbed family in whichall the members have a responsibility for cooperating intreatment. Because family members are frequently thepeople most victimized by the alcohol abuser's addiction,they often tend to be judgmental and punitive, and theperson in treatment, who has already passed harsh judg-ment on himself or herself, may tolerate this further sourceof devaluation poorly. In other instances, family membersmay unwittingly encourage an alcohol abuser to remain

addicted-for example, a man with a need to dominate hiswife may find that a continually drunken and remorsefulspouse best meets his needs.

ENVIRONMENTAL INTERVENTION As with other seri-ous maladaptive behaviors, a total treatment program foralcohol abuse usually requires measures to alleviate apatient's aversive life situation. Environmental support hasbeen shown to be an important ingredient of an alcoholabuser's recovery (Booth et al., 1992a, 1992b). People oftenbecome estranged from family and friends because of theirdrinking and either lose or jeopardize their jobs. As aresult, they are often lonely and live in impoverishedneighborhoods. Typically, the reaction of those aroundthem is not as understanding or as supportive as it wouldbe if the alcohol abuser had a physical illness of compara-ble magnitude. Simply helping people with alcohol-abuseproblems learn more effective coping techniques may notbe enough if their social environment remains hostile andthreatening. For those who have been hospitalized, halfwayhouses-designed to assist them in their return to familyand community-are often important adjuncts to theirtotal treatment program.

BEHAVIORAL AND COGNITIVE-BEHAVIORAL THERAPYOne interesting and often effective form of treatment foralcohol-abuse disorders is behavioral therapy, of whichseveral types exist (see Chapter 17). One is aversive condi-tioning, which involves the presentation of a wide range ofnoxious stimuli with alcohol consumption in order tosuppress drinking behavior. For example, the ingestion ofalcohol might be paired with an electric shock or a drugthat produces nausea. A variety of pharmacological andother deterrent measures can be used in behavioral therapyafter detoxification. One approach involves an intramuscu-lar injection of emetine hydrochloride, an emetic. Beforeexperiencing the nausea that results from the injection, apatient is given alcohol, so that the sight, smell, and taste ofthe beverage become associated with severe retching andvomiting. That is, a conditioned aversion to the taste andsmell of alcohol develops. With repetition, this classicalconditioning procedure acts as a strong deterrent to furtherdrinking-probably in part because it adds an immediateand unpleasant physiological consequence to the more gen-eral socially aversive consequences of excessive drinking.

One of the most effective contemporary procedures fortreating alcohol abusers has been the cognitive-behavioralapproach recommended by Alan Marlatt (1985) andWitkiewitz and Marlatt (2004). This approach combinescognitive-behavioral strategies of intervention with social-learning theory and modeling of behavior. The approach,often referred to as a "skills training procedure:' is usuallyaimed at younger problem drinkers who are considered tobe at risk for developing more severe drinking problemsbecause of an alcohol-abuse history in their family or their

heavy current consumption. This approach relies on suchtechniques as imparting specific knowledge about alcohol,developing coping skills in situations associated withincreased risk of alcohol use, modifying cognitions andexpectancies, acquiring stress-management skills, and pro-viding training in life skills (Connors & Walitzer, 2001).Cognitive-behavioral treatments have been shown to beeffective; for example, O'Farrell, Murphy, et al. (2004)reported that partner violence was significantly reducedfollowing cognitive-behavioral treatment.

Self-control training techniques (Miller, Brown, et aI.,1995), in which the goal of therapy is to get alcoholics toreduce alcohol intake without necessarily abstaining alto-gether, have a great deal of appeal for some drinkers. Thereis now even a computer-based self-control training pro-gram available that has been shown to reduce problemdrinking in a controlled study (Hester & Delaney, 1997;Neighbors, Larimer, & Lewis, 2004). It is difficult, ofcourse, for individuals who are extremely dependent onthe effects of alcohol to abstain totally from drinking.Thus many alcoholics fail to complete traditional treat-ment programs.

CONTROLLED DRINKING VERSUS ABSTINENCE Otherpsychological techniques have also received attention inrecent years, partly because they are based on the hypothe-sis that some problem drinkers need not give up drinkingaltogether but, rather, can learn to drink moderately(Miller, Walters, & Bennett, 2001; Sobell & Sobell, 1995).Several approaches to learning controlled drinking havebeen attempted (McMurran & Hollin, 1993), and researchhas suggested that some alcoholics can learn to controltheir alcohol intake (Senft, Polen, et aI., 1997). Miller andcolleagues (1986) evaluated the results of four long-termfollow-up studies of controlled-drinking treatment pro-grams. Although they found a clear trend of increasednumbers of abstainers and relapsed cases at long-term fol-low-up, they also found that a consistent percentage(15 percent) of subjects across the four studies controlledtheir drinking. The researchers concluded that controlleddrinking was more likely to be successful in persons withless severe alcohol problems. The finding that some indi-viduals are able to maintain some control over their drink-ing after treatment (without remaining totally abstinent)was also reported in a classic study by Polich, Armor, andBraiker (1981). These researchers found that 18 percent ofthe alcoholics they studied had reportedly been able todrink socially without problems during the 6-monthfollow-up of treatment.

However, many people in the field have rejected theidea that alcohol abusers can learn to control their drink-ing, and these theorists insist on a total abstinenceapproach. The debate over whether problem drinkers canlearn moderate drinking continues after 25 years. Someresearchers (Heather, 1995; Kahler, 1995; Sobell & Sobell,1995) maintain the efficacy of controlled drinking. Others

such as Glatt (1995) point to difficulties that alcoholabusers have in maintaining control. And some groups,such as Alcoholics Anonymous, are adamant in theiropposition to programs aimed at controlled drinking foralcohol-dependent individuals.

ALCOHOLICS ANONYMOUS A practical approach toalcoholism that has reportedly met with considerable suc-cess is that of Alcoholics Anonymous (AA). This organiza-tion was started in 1935 by two men, Dr. Bob and Bill W.,in Akron, Ohio. Bill W. recovered from alcoholism througha "fundamental spiritual change" and immediately soughtout Dr. Bob, who, with Bill's assistance, achieved recovery.They in turn began to help other alcoholics. Since thattime, AA has grown to over 51,000 groups in the UnitedStates and Canada, with an annual growth rate of about 6to 7 percent (Alcoholics Anonymous, 2002). In addition,there are over 5,000 AA groups in Canada and over 41,000groups in many other countries.

Alcoholics Anonymous operates primarily as a self-help counseling program in which both person-to-person and group relationships are emphasized. AA acceptsboth teenagers and adults with drinking problems, hasno dues or fees, does not keep records or case histories,does not participate in political causes, and is not affili-ated with any religious sect, although spiritual develop-ment is a key aspect of its treatment approach. To ensureanonymity, only first names are used. Meetings aredevoted partly to social activities, but they consist mainlyof discussions of the participants' problems with alcohol,often with testimonials from those who have stoppeddrinking. Such members usually contrast their livesbefore they broke their alcohol dependence with the livesthey now live without alcohol. We should point out herethat the term alcoholic is used by AA and its affiliates torefer either to persons who currently are drinking exces-sively or to people who have stopped drinking but must,according to AA philosophy, continue to abstain fromalcohol consumption in the future. That is, in the AAview, one is an alcoholic for life, whether or not one isdrinking; one is never "cured" of alcoholism but is instead"in recovery."

An important aspect ofAXs rehabilitation program isthat it appears to lift the burden of personal responsibilityby helping alcoholics accept that alcoholism, like manyother problems, is bigger than they are. Henceforth, theycan see themselves not as weak-willed or lacking in moralstrength, but rather simply as having an affliction-theycannot drink-just as other people may not be able to tol-erate certain types of medication. Through mutual helpand reassurance from group members who have had simi-lar experiences, many alcoholics acquire insight into theirproblems, a new sense of purpose, greater ego strength,and more effective coping techniques. Continued partici-pation in the group, of course, can help prevent the crisis ofa relapse.

These people are participating in an Alcoholics Anonymous (AA)meeting. AA accepts both teenagers and adults, has no dues orfees, does not keep records or case histories, does not participatein political causes, and is not affiliated with any religious sect,although spiritual development is a key aspect of its treatmentapproach. To ensure anonymity, only first names are used atmeetings. AA is one of the most popular alcohol treatmentprograms, promoting total abstinence rather than controlleddrinking.

Affiliated movements such as Al-Anon family groupsand Alateen (which has over 35,000 groups in the UnitedStates and Canada) are designed to bring family memberstogether to share experiences and problems, to gain under-standing of the nature of alcoholism, and to learn tech-niques for dealing with their own problems living in a familywith one or more affected individuals. The reported successof Alcoholics Anonymous is based primarily on anecdotalinformation rather than on objective study of treatmentoutcomes, because AA does not directly participate in exter-nal comparative research efforts. However, several studieshave found "A1\.' conditions effective in helping people avoiddrinking (Gossop, Harris, et aI., 2003; McCrady, Epstein, &Kahler, 2004). In a classic study, Brandsma, Maultsby, andWelsh (1980) included an AA program in their extensivecomparative study of alcoholism treatments. The success ofthis treatment method with severe alcoholics was quite lim-

ited. One important finding was that the AA method hadhigh dropout rates compared with other therapies. Abouthalf of the people who go to AA drop out of the programwithin 3 months. Chappel (1993) attributes the very highdropout rate to alcoholics' denial that they have problems,resistance to external pressure, and resistance to AA itself.Apparently many alcoholics are unable to accept the quasi-religious quality of the sessions and the group-testimonialformat that is so much a part of the AA program. In theBrandsma study, the participants who were assigned to theAA group subsequently encountered more life difficultiesand drank more than people in other treatment groups. Onthe positive side, however, a study by Morganstern, Labou-vie, and colleagues (1997) reported that affiliation with AAafter alcohol treatment was associated with better outcomesthan no such involvement, and a study by Tonigan, Toscova,and Miller (1995) found that AA involvement was stronglyassociated with success in outpatient samples.

OUTCOME STUDIES AND ISSUES IN TREATMENTThe outcome of alcoholism treatment varies considerably,depending on the population studied and on the treat-ment facilities and procedures employed. Results rangefrom low rates of success for hard-core substance abusersto recovery rates of 70 to 90 percent where modern treat-ment and aftercare procedures are used. Substanceabusers who are also diagnosed as having a personalitydisorder or affective disorder tended to have poorer out-comes in alcohol treatment than those for whom the diag-nosis was simply alcohol-abuse problems (Woelwer,Burtscheidt, et aI., 2001). Treatment is most likely to beeffective when an individual realizes that he or she needshelp, when adequate treatment facilities are available, andwhen the individual attends treatment regularly. Having apositive relationship with the therapist was associatedwith better treatment outcome (Connors et aI., 1997).One important new treatment strategy is aimed at rein-forcing treatment motivation and abstinence early in thetreatment process by providing "check-up" follow-ups ondrinking behavior. Miller, Benefield, and Tonigan (1993)reported that "Drinking Check-Up" sessions during theearly stages of therapy resulted in a reduction of drinkingin the first 6 weeks of therapy, compared with clients whodid not have check-up sessions.

Some researchers have maintained that treatment foralcohol-use and -abuse disorders would be more effective ifimportant patient characteristics were taken into account(Mattson, Allen, Longabaugh, et al., 1994). That is, patientswith certain personality characteristics or with differingdegrees of severity might do better in one specific therapeu-tic approach rather than in another. This view was evaluatedin a study of patient-treatment matching (referred to as"Project MATCH") that was sponsored by the NationalInstitute on Alcohol Abuse and Alcoholism (NIAAA, 1997).This extensive study, initiated in 1989, involved 1,726patients who were treated in 26 alcohol-treatment programs

in the United States by 80 different therapists representingthree treatment approaches. The research design includedboth an inpatient and an outpatient treatment component.

Project MATCH compared the treatment effectivenessof three different approaches to alcohol treatment: (1) a12-step program along the lines of Alcoholics Anonymous(but not sponsored by AA) and referred to as "Twelve-StepFacilitation Therapy" (TSF); (2) a cognitive-behavioraltherapy program (CBT); and (3) a treatment techniquereferred to as "Motivational Enhancement Therapy"(MET), which attempts to get clients to assume responsi-bility for helping themselves. These approaches werechosen because they were considered effective in treatingalcoholics and had been reported to have potential forclear matching (Gordis, 1997). The researchers in ProjectMATCH evaluated patients on ten characteristics that hadbeen shown in the literature to be related to treatment out-come (Babor, 1996; Project MATCH Group, 1997): diag-nosis as alcoholics, cognitive impairment, conceptualability level, gender, desire to seek meaning in life, motiva-tion, psychiatric severity, severity of alcohol involvement,social support for drinking versus abstinence, and pres-ence of sociopathy (personality disorder).

The results of this study were unexpected: Matchingthe patients to particular treatments did not appear to beimportant to having an effective outcome. The treatmentsstudied all had equal outcomes. Gordis (1997) concludedthat patients from competently run alcoholism treatmentprograms will do as well in any of the three treatmentsstudied.

RELAPSE PREVENTION One of the greatest problemsin the treatment of addictive disorders is maintainingabstinence or self-control once the behavioral excesseshave been checked (Tims, Leukefeld, & Platt, 2001). Mostalcohol-treatment programs show high success rates in"curing" the addictive problems, but many programs showlessening rates of abstinence or controlled drinking at var-ious periods of follow-up. Many treatment programs donot pay enough attention to maintaining effective behav-ior and preventing relapse into previous maladaptive pat-terns (Miller & Rollnick, 2003).

Given that alcohol-dependent people are highly vul-nerable to relapse, some researchers have focused on theneed to help them remain abstinent. In one cognitive-behavioral approach, relapse behavior is a key factor inalcohol treatment (Marlatt &Vandenbos, 1997; Witkiewitz& Marlatt, 2004). The behaviors underlying relapse areseen as "indulgent behaviors" that are based on an indi-vidual's learning history. When an individual is abstinentor has an addiction under control, he or she gains a senseof personal control over the indulgent behavior. Thelonger the person is able to maintain this control, thegreater the sense of achievement-the self-efficacy orconfidence-and the greater the chance that he or she

Appealing advertisements and displays that encourage drinkingcan make abstinence particularly difficult and can contribute, atthe very least on a subconscious level, to a relapse.

will be able to cope with the addiction and maintain con-trol. However, a person may violate this rule of absti-nence through a gradual, perhaps unconscious, processrather than through the sudden "falling off the wagon"that constitutes the traditional view of craving andrelapse. In the cognitive-behavioral view, a person may,even while maintaining abstinence, inadvertently make aseries of mini-decisions that begin a chain of behaviorsthat render relapse inevitable. For example, an abstinentalcohol abuser who buys a quart of bourbon just in casehis friends drop by is unconsciously preparing the wayfor relapse.

Another type of relapse behavior involves the "absti-nence violation effect," in which even minor transgressionsare seen by the abstainer as having drastic significance. Theeffect works this way: An abstinent person may hold thathe or she should not, under any circumstance, transgressor give in to the old habit. Abstinence-oriented treatmentprograms are particularly guided by this prohibitive rule.What happens, then, when an abstinent man becomessomewhat self-indulgent and takes a drink offered by anold friend or joins in a wedding toast? He may lose some ofthe sense of self-efficacy-the confidence-needed to con-trol his drinking. Feeling guilty about having technicallyviolated the vow of abstinence, he may rationalize that he"has blown it and become a drunk again, so why not go allthe way?"

In relapse prevention treatment, clients are taught torecognize the apparently irrelevant decisions that serve asearly warning signals of the possibility of relapse. High-risk situations such as parties or sports events are targeted,and the individuals learn to assess their own vulnerabilityto relapse. Clients are also trained not to become so dis-couraged, if they do relapse, that they lose their confi-dence. Some cognitive-behavioral therapists have evenincorporated a "planned relapse" phase into the treatment.Research with relapse prevention strategies has shownthem to be effective in providing continuing improvementover time (Rawson et al., 2002). In other words, whenpatients are taught to expect a relapse, they are better ableto handle it.

In ReVIew~ What is the difference between alcohol

abuse and alcohol dependence?~ What are the three major physiological

effects of alcohol?~ Identify the physical, interpersonal, and

social! occupational problems that can resultfrom chronic alcohol abuse.

~ What are five major psychosocial factors thatmay contribute to alcohol dependence?

~ Describe four psychosocial interventionsused to treat alcohol dependence.

12.3

The DSM-IV-TRincludes addictions to twolegally available and widely used substances:caffeine and nicotine. Although these sub-stances do not represent the extensive andself-destructive problems found in drug and

alcohol disorders, they create important physical and men-tal health problems in our society for several reasons:

These drugs are easy to abuse. It is easy to becomeaddicted to them because they are widely used andmost people are exposed to them early in life.

These drugs are readily available to anyone whowants to use them; in fact, because of peer pressure,it is usually difficult to avoid using them in oursociety.Both caffeine and nicotine have clearly addictiveproperties; use of them promotes further use, untilone craves a regular "fix" in one's daily life.

It is difficult to quit using these drugs both because oftheir addictive properties and because they are soembedded in the social context. (Nicotine use, how-ever, is falling out of favor in many settings.)

The extreme difficulty most people have in dealingwith the withdrawal symptoms when trying to "breakthe habit" often produces considerable frustration.

DRUG ABUSE ANDDEPENDENCE ~_.Aside from alcohol, the psychoactive drugs most com-monly associated with abuse and dependence in our soci-ety appear to be (1) narcotics such as opium and itsderivatives, which include heroin; (2) sedatives such asbarbiturates; (3) stimulants such as cocaine and ampheta-mines; (4) anti-anxiety drugs such as benzodiazepines;(5) pain killers such as OxyContin; and (6) hallucinogenssuch as LSD and PCP. (The effects of these and other drugsare summarized in Table 12.2 on p. 434.)

Caffeine and nicotine are also drugs of dependence,and disorders associated with tobacco withdrawal and caf-feine intoxication are included in the DSM-IV-TR diag-nostic classification system. The World Around Us 12.3discusses these drugs further.

~ The health problems and side effects of these drugs,particularly nicotine, have been widely noted (USD-HHS, 1994). One in seven deaths in the United Statesis associated with cigarette consumption.

Because of their tenacity as habits and their contribu-tions to many major health problems, we will examine eachof these addictions in more detail.

The chemical compound caffeine is found in many com-monly available drinks and foods. Although the consump-tion of caffeine is widely practiced and socially promoted incontemporary society, problems can result from excessivecaffeine intake. The negative effects of caffeine involveintoxication rather than withdrawal. Unlike addiction todrugs such as alcohol or nicotine, withdrawal from caffeinedoes not produce severe symptoms, except for headache,which is usually mild.

As described in DSM-IV-TR,caffeine-induced organicmental disorder (also referred to as "caffeinism") involvessymptoms of restlessness, nervousness, excitement, insom-nia, muscle twitching, and gastrointestinal complaints. It fol-lows the ingestion of caffeine-containing substances, suchas coffee, tea, cola, and chocolate. The amount of caffeinethat results in intoxication differs among individuals.

(continued)

The poisonous alkaloid nicotine is the chief active ingredi-ent in tobacco; it is found in such items as cigarettes,chewing tobacco, and cigars, and it is even used as aninsecticide.

Strong evidence exists for a nicotine-dependence syn-drome (Malin, 2001; Watkins, Koob, & Markou, 2000),which nearly always begins during the adolescent yearsand may continue into adult life as a difficult-to-break andhealth-endangering habit. The surgeon general's report(USDHHS, 1994) estimates that there are 3.1 million ado-lescents and 25 percent of 17- to 18-year-olds who are cur-rent smokers. The "nicotine withdrawal disorder," as it iscalled in DSM-IV-TR, results from ceasing or reducing theintake of nicotine-containing substances after an individualhas developed physical dependence on them. The diagnos-tic criteria for nicotine withdrawal include (1) the daily useof nicotine for at least several weeks, and (2) the followingsymptoms after nicotine ingestion is stopped or reduced:craving for nicotine; irritability, frustration, or anger; anxi-ety; difficulty concentrating; restlessness; decreased heartrate; and increased appetite or weight gain. Several otherphysical concomitants are associated with withdrawal fromnicotine including decreased metabolic rate, headaches,insomnia, tremors, increased coughing, and impairment ofperformance on tasks requiring attention.

These withdrawal symptoms usually continue for sev-eral days to several weeks, depending on the extent of thenicotine habit. Some individuals report a desire for nicotinecontinuing for several months after they have quit smok-ing. In general, nicotine withdrawal symptoms operate in amanner similar to other addictions-they are "time limitedand abate with drug replacement or gradual reduction"(Hughes, Higgins, & Hatsukami, 1990, p. 381).

Over the past three decades, since the surgeon general'sreport that detailed the health hazards of smoking ciga-rettes, numerous treatment programs have been devel-oped to help smokers quit (Curry, 1993; McEwen, Preston,& West, 2002; Smith, Reilly, et al., 2002). Such programsuse many different methods including social supportgroups; various pharmacologic agents that replace ciga-rette consumption with safer forms of nicotine such ascandy or gum; self-directed change which involves givingindividuals guidance in changing their own behaviors; andprofessional treatment using psychological.proceduressuch as behavioral or cognitive-behavioral interventions.

An estimated 28 million people worldwide incur sig-

nificant health risks by using various psychoactive sub-

stances other than alcohol, tobacco, and volatile solvents

such as glue (World Health Organization, 1997). The

extent of drug abuse in the population is likely to be

Because they are socially acceptable and readilyavailable, caffeine and nicatine can be insidiouslyaddictive substances. Though they do not representthe same kind of extensive, self-destructive problemsas alcohol and drug disorders, caffeine and nicotineaddiction can cause a myriad af health problems, andare now included in the DSM-IV-TR.

One recent study provided smokers with ultrasound pho-tographs of their carotid and femoral arteries along withquit-smoking counseling. This group showed higher quitrates than controls (Bovet, Perret, et al., 2002).

In general, tobacco dependence can be successfullytreated, and most of the quit-smoking programs enjoy somesuccess. They average only about a 20 to 25 percent suc-cess rate, however, although rates have been reported to behigher with treatment (Hays et al., 2001). This same level ofsuccess appears to result from the use of nicotine replace-ment therapy (NRT). Killen, Fortmann, and colleagues(1997) found that a controlled study of nicotine replacementtreatment that employed a nicotine patch as well as videoand printed materials for self-study produced a significantabstinence rate at 2 months (36 percent compared with 20percent for the placebo condition). However, this absti-nence rate dropped to only 22 percent at 6 months and wasequal to that of the placebo or control sample. Recently,encouraging results have been reported on the use of thedrug bupropion (Zyban) in preventing relapse for smokerstrying to quit smoking. The drug reduced relapse as long asthe person was taking it, but relapse rates were similar tothose of other treatments once the drug was discontinued(Barringer & Weaver, 2002). The highest self-reported quitrates for smokers were reportedly among patients whowere hospitalized for cancer (63 percent), cardiovasculardisease (57 percent), or pulmonary disease (46 percent;Smith, Reilly, et al., 2002).

underestimated because many abusers do not seek help. In

fact, one recent study (Newcomb, Galaif, & Locke, 2001)noted that one-third of abusers remitted without treat-

ment. Although they may occur at any age, drug abuse and

dependence are most common during adolescence and

young adulthood (NIAAA, 2002; Smith, 1989) and varyaccording to metropolitan area, race and ethnicity, laborforce status, and other demo-graphic characteristics (Hughes,1992). Substance-abuse problemsare relatively more prominent ineconomically depressed minoritycommunities (Akins, Mosher, etal., 2003; Beauvais, 1998). Thereasons for this will be discussedlater in this section.

The extent to which drugabuse has become a problem forsociety is reflected in a study ofdrug involvement among appli-cants for employment at a largeteaching hospital in Maryland(Lange et al., 1994). Beginningin 1989, and for a 2-year period,all applicants for employmentwere screened through a preem-ployment drug-screening program (individuals were notidentified in the initial study). Of 593 applicants, 10.8percent were found to have detectable amounts of illicitdrugs in their systems. The most frequently detecteddrug was marijuana (55 percent of those who tested pos-itively), followed by cocaine (36 percent) and opiates(28 percent). The impact of drug use among employedpeople has also been reported to be significant. In a studyof job satisfaction in a community sample of 470 adults,Galaif, Newcomb, and Carmona (2001) found thatpolydrug use (that is, use of multiple drugs) predictedimpaired work functioning and job dissatisfaction 4 yearslater.

Among those who abuse drugs, behavior patterns varymarkedly, depending on the type, amount, and duration ofdrug use; on the physiological and psychological makeupof the individual; and, in some instances, on the social set-ting in which the drug experience occurs. Thus it appearsmost useful to deal separately with some of the drugs thatare more commonly associated with abuse and depen-dence in contemporary society.

Even today, opium derivatives are still used for some of theconditions Galen mentioned.

Opium is a mixture of about18 chemical substances known as"alkaloids." In 1805 the alkaloidpresent in the largest amount(10 to 15 percent) was found tobe a bitter-tasting powder thatcould serve as a powerful sedativeand pain reliever; it was namedmorphine after Morpheus, godof sleep in Greek mythology. Thehypodermic needle was intro-duced in America around 1856,allowing morphine to be widelyadministered to soldiers duringthe Civil War-not only to thosewounded in battle but also tothose suffering from dysentery. Asa consequence, many Civil Warveterans returned to civilian life

addicted to the drug, a condition euphemistically referredto as "soldier's illness."

Scientists concerned with the addictive properties ofmorphine hypothesized that one part of the morphinemolecule might be responsible for its analgesic properties(that is, its ability to eliminate pain without inducingunconsciousness) and another for its addictiveness. Atabout the turn of the century, it was discovered that ifmorphine was treated with an inexpensive and readilyavailable chemical called "acetic anhydride;' it would beconverted into another powerful analgesic called heroin.Heroin was hailed enthusiastically by its discoverer, Hein-rich Dreser (Boehm, 1968). Leading scientists of his timeagreed on the merits of heroin, and the drug came to bewidely prescribed in place of morphine for pain relief andrelated medicinal purposes. However, heroin was a crueldisappointment, for it proved to be an even more danger-ous drug than morphine, acting more rapidly and moreintensely and being equally if not more addictive. Eventu-ally, 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 theHarrison Act in 1914. Under this and later legislation, theunauthorized sale and distribution of certain drugs becamea federal offense; physicians and pharmacists were heldaccountable for each dose they dispensed. Thus, overnight,the role of a chronic narcotic user changed from that ofaddict-whose addition was considered a vice, but wastolerated-to that of criminal. Unable to obtain drugsthrough legal sources, many turned to illegal channels, andeventually to other criminal acts, as a means of maintainingtheir suddenly expensive drug supply.

In one survey, about 2.4 million Americans acknowl-edged having tried heroin, and almost a quarter of a million

In one study, applicants for employment at a largeteaching hospital were put through a pre-employment drug-screening program. Nearly 11

percent of the applicants were found to havedetectable amounts of illicit drugs in their systems,including marijuana, cocaine, and opiates.

Opium and Its Derivatives (Narcotics)People have used opium and its derivatives for over 5,000years. Galen (A.D. 130-201) considered theriaca, whoseprincipal ingredient was opium, to be a panacea:

It resists poison and venomous bites, cures inveterateheadache, vertigo, deafness, epilepsy, apoplexy, dimnessof sight, loss of voice, asthma, coughs of all kinds, spit-ting of blood, tightness of breath, colic, the iliac poisons,jaundice, hardness of the spleen, stone, urinary com-plaints, fevers, dropsies, leprosies, the trouble to whichwomen are subject, melancholy and all pestilences. (SeeBrock, 1979 for a discussion of Galen)

ClassificationSedatives

DrugAlcohol (ethanol)

BarbituratesNembutal (pentobarbital)Seconal (secobarbital)Veronal (barbital)Tuinal (secobarbital and amobarbital)

AmphetaminesBenzedrine (amphetamine)Dexedrine (dextroamphetamine)Methedrine (methamphetamine)Cocaine (coca)

Opium and its derivativesOpiumMorphineCodeineHeroin

Methadone (synthetic narcotic)

CannabisMarijuanaHashish

Mescaline (peyote)Psilocybin (psychotogenic mushrooms)LSD (lysergic acid diethylamide-25)PCP (phencyclidine)

Librium (chlordiazepoxide)Miltown (meprobamate)Valium (diazepam)Xanax

Psychedelics andhallucinogens

Antianxiety drugs(minor tranquilizers)

Reduce tensionFacilitate social interaction"Blot out" feelings or eventsReduce tension

Increase feelings of alertnessand confidence

Decrease feelings of fatigueStay awake for long periodsIncrease enduranceStimulate sex drive

Alleviate physical painInduce relaxation and pleasant reverieAlleviate anxiety and tension

Treatment of heroin dependence

Induce changes in mood, thought,and behavior

"Expand" one's mindInduce stupor

Alleviate tension and anxietyInduce relaxation and sleep

Note: This list is by no means complete; for example, it does not include newer drugs, such as Ritalin, which are designed to produce multipleeffects; it does not include the less commonly used volatile hydrocarbons, such as glue, paint thinner, gasoline, cleaning fluid, and nail polishremover, which are highly dangerous when sniffed for their psychoactive effects; and it does not include the antipsychotic and antidepressantdrugs, which are abused, but relatively rarely. We shall deal with these and the antianxiety drugs in our discussion of drug therapy in Chapter 17.

"skin popping," or "mainlining," the last two being meth-ods of introducing the drug via hypodermic injection. Skinpopping is injecting the liquefied drug just beneath theskin, and mainlining is injecting the drug directly into thebloodstream. In the United States, a young addict usuallymoves from snorting to mainlining.

Among the immediate effects of mainlined or snortedheroin is a euphoric spasm (the rush) lasting 60 seconds

people admitted to using it within the past 12 months (U.S.Department of Health and Human Services, 1997). In 2000,heroin overdose accounted for 16 percent of all drug-relatedemergency room admissions (DAWN Report, 2001).

BIOLOGICAL EFFECTS OF MORPHINE AND HEROINMorphine and heroin are commonly introduced into thebody by smoking, snorting (inhaling the powder), eating,

or so, which many addicts compare to a sexual orgasm.However, vomiting and nausea have also been known to bepart of the immediate effects of heroin and morphine use.This rush is followed by a high, during which an addicttypically is in a lethargic, withdrawn state in which bodilyneeds, including needs for food and sex, are markedlydiminished; pleasant feelings of relaxation, euphoria, andreverie tend to dominate. These effects last from 4 to 6hours and are followed-in addicts-by a negative phasethat produces a desire for more of the drug.

The use of opium derivatives over a period of timegenerally results in a physiological craving for the drug.The time required to establish the drug habit varies, but ithas been estimated that continual use over a period of 30days is typically sufficient. Users then find that they havebecome physiologically dependent on the drug in the sensethat they feel physically ill when they do not take it. Inaddition, users of opium derivatives gradually build up atolerance to the drug, so increasingly larger amounts areneeded to achieve the desired effects.

When people addicted to opiates do not get a dose ofthe drug within approximately 8 hours, they start to expe-rience withdrawal symptoms. The character and severityof these reactions depend on many factors including theamount of the narcotic habitually used, the intervalsbetween doses, the duration of the addiction, and espe-cially the addict's health and personality.

Withdrawal from heroin is not always dangerous oreven very painful. Many addicted people withdraw withoutassistance. Withdrawal can, however, be an agonizing expe-rience for some people, with symptoms including runnynose, tearing eyes, perspiration, restlessness, increased res-

The adalescent shown here is injecting the drug heroin-adangerous and highly addictive substance that is widely availableto adolescents today.

piration rate, and an intensified desire for the drug. As timepasses, the symptoms may become more severe. Typically, afeeling of chilliness alternates with flushing and excessivesweating, vomiting, diarrhea, abdominal cramps, pains inthe back and extremities, severe headache, marked tremors,and varying degrees of insomnia. Beset by these discom-forts, an individual refuses food and water, and this, cou-pled with the vomiting, sweating, and diarrhea, results indehydration and weight loss. Occasionally, symptomsinclude delirium, hallucinations, and manic activity. Car-diovascular collapse may also occur and can result in death.If morphine is administered, the subjective distress experi-enced by an addict temporarily ends, and physiological bal-ance is quickly restored.

Withdrawal symptoms are usually on the decline bythe third or fourth day and by the seventh or eighth dayhave disappeared. As the symptoms subside, the personresumes normal eating and drinking and rapidly regainslost weight. After withdrawal symptoms have ceased, theindividual's former tolerance for the drug is reduced; as aresult, there is a risk that taking the former large dosagemight result in overdose.

SOCIAL EFFECTS OF MORPHINE AND HEROINTypically, the life of a narcotics addict becomes increas-ingly centered on obtaining and using drugs, so the addic-tion usually leads to socially maladaptive behavior as theindividual is eventually forced to lie, steal, and associatewith 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 financ-ing their addictions.

Along with the lowering of ethical and moralrestraints, addiction has adverse physical effects on anindividual's well-being-for example, disruption of theimmune system (Theodorou & Haber, 2005). Lifestyle fac-tors can lead to further problems; an inadequate diet, forexample, may lead to ill health and increased susceptibilityto a variety of physical ailments. The use of unsterileequipment may also lead to various problems includingliver damage from hepatitis and transmission of the AIDSvirus. In addition, the use of such a potent drug withoutmedical supervision and government controls to ensure itsstrength and purity can result in fatal overdose. Injectionof too much heroin can cause coma and death. In fact,heroin-related deaths have shown an increase in citieswhere data are collected (National Institute for DrugAbuse, 1998). The most common drug-related deaths inthe United States involve combinations of heroin, cocaine,and alcohol (DAWN, 2002). Women who use heroin dur-ing pregnancy subject their unborn children to the risk ofdire consequences. One tragic outcome is premature babieswho are themselves addicted to heroin and vulnerable to anumber of diseases (Anand & Arnold, 1994).

Addiction to opiates usually leads to a gradual deteri-oration of well-being (Brown & Lo, 2000). The ill health

and general personality deterioration often found inopium addiction do not result directly from the pharma-cological effects of the drug but, rather, are usually prod-ucts of the sacrifices of money, proper diet, social position,and self-respect as an addict becomes more desperate toprocure the required daily dosage.

CAUSAL FACTORS IN OPIATE ABUSE AND DEPEN-DENCE No single causal pattern fits all addictions to nar-cotic drugs. A study by Fulmer and Lapidus (1980)concluded that the three most frequently cited reasons forbeginning to use heroin were pleasure, curiosity, and peerpressure. Pleasure was the single most widespread reason-given by 81 percent of addicts. Heavy opiate use may insome part be influenced by genetic inheritance (Kendler,Karkowski, et al., 2000), perhaps through inheritance ofpersonality characteristics (Bouchard & Loehlin, 2001).Other reasons such as a desire to escape life stress, personalmaladjustment, and sociocultural conditions also playapart (Bry, McKeon, & Pandina, 1982).

NEURAL BASES FOR PHYSIOLOGICAL ADDICTIONResearch teams have isolated and studied receptor sites fornarcotic drugs in the brain (Goldstein et al., 1974; Office ofTechnology Assessment, 1993; Pert & Snyder, 1973). Suchreceptor sites are specific nerve cells into which given psy-choactive drugs fit like keys into the proper locks. Thisinteraction of drug and brain cells apparently results in adrug's action and, in the case of narcotic drugs, may lead toaddiction. The repeated use of opiates results in changesin neurotransmitter systems that regulate incentive/motivation and the ability to manage stress (DeVries &Shippenberg,2002).

The human body produces its own opium-like sub-stances, called endorphins, in the brain and pituitarygland. These substances are produced in response to stim-ulation and are believed to playa role in an organism'sreaction to pain (Bolles & Fanselow, 1982). Some investi-gators have suspected that endorphins playa role in drugaddiction, speculating that chronic underproduction ofendorphins leads to a craving for narcotic drugs. Researchon the role of endorphins in drug addiction has generallybeen inconclusive, and no effective treatment has resultedfrom this line of research.

ADDICTION ASSOCIATED WITH PSYCHOPATHOLOGYA high incidence of antisocial personality has been foundamong heroin addicts (Alterman, McDermott, et al.,1998). In a comparison between a group of 45 young insti-tutionalized male addicts and a control group of nonad-dicts, Gilbert and Lombardi (1967) found that thedistinguishing features were "the addict's antisocial traits,his depression, tension, insecurity, and feelings of inade-quacy, and his difficulty in forming warm and lastinginterpersonal relationships" (p. 536). Meyer and Mirin(1979) found that opiate addicts were highly impulsiveand unable to delay gratification. Kosten and Rounsaville

(1986) reported that about 68 percent of heroin abuserswere also diagnosed as having a personality disorder. As inthe case of alcoholism, however, it is essential to exercisecaution in distinguishing between personality traits beforeand after addiction; the high incidence of psychopathologyamong narcotics addicts may in part result from, ratherthan precede, the long-term effects of addiction.

ADDICTION ASSOCIATED WITH SOCIOCULTURAL FAC-TORS In our society, a so-called "narcotics subculture"exists in which addicts can obtain drugs and protect them-selves against society's sanctions. The decision to join thisculture has important future implications, for from thatpoint on, addicts' activities will revolve around their drug-user role. In short, addiction becomes a way of life. In asurvey of three large cities in Texas, Maddux and col-leagues (1994) found that the majority of illicit drug injec-tors were undereducated and unemployed individuals fromminority groups.

With time, most young addicts who join the drug cul-ture become increasingly withdrawn, indifferent to theirfriends (except those in the drug group), and apatheticabout sexual activity (Tremble, Padillo, & Bell, 1994). Theyare likely to abandon scholastic and athletic endeavors andto show a marked reduction in competitive and achieve-ment strivings. Most of these addicts appear to lack clearsex-role identification and to experience feelings of inade-quacy when confronted with the demands of adulthood.They feel progressively isolated from the broader culture,but their feelings of group belongingness are bolstered bycontinued association with the addict milieu. At the sametime, they come to view drugs both as a means of revoltagainst authority and conventional values and as a devicefor alleviating personal anxieties and tensions.

TREATMENTS AND OUTCOMES Treatment for nar-cotics addiction is initially similar to that for alcoholism inthat it involves building up an addict both physically andpsychologically and providing help through the with-drawal period. Addicts often dread the discomfort of with-drawal, but in a hospital setting it is less abrupt and usuallyinvolves the administration of medication that eases thedistress.

After physical withdrawal has been completed, treat-ment focuses on helping a former addict make an ade-quate adjustment to his or her community and abstainfrom the further use of narcotics. Traditionally, however,the prognosis has been unfavorable, with many clientsdropping out of treatment (Katz, Brown, et al., 2004).Withdrawal from heroin does not remove the craving forthe drug. A key target in treatment of heroin addictionmust be the alleviation of this craving. One approach todealing with the physiological craving for heroin was pio-neered by a research team at Rockefeller University in NewYork. It involved the use of the drug methadone in con-junction with a rehabilitation program (counseling,group therapy, and other procedures) directed toward the

"total resocialization" of addicts. Methadone hydrochlo-ride is a synthetic narcotic that is related to heroin and isequally addictive physiologically. Its usefulness in treat-ment lies in the fact that it satisfies an addict's craving forheroin without producing serious psychological impair-ment, if only because it is administered as a "treatment" ina formal clinical context (see the Unresolved Issues at theend of this chapter).

Other medications, such as buprenorphine, have beenused to treat heroin addiction. It promises to be as effectivea substitute for heroin as methadone but has fewer sideeffects (Kamien, Mikulich, & Amass, 1999). Buprenor-phine operates as a partial antagonist to heroin (Lewis &Walter, 1992) and produces the "feelings of contentment"associated with heroin use (Mendelson & Mello, 1992). Yetthe drug does not produce the physical dependence that ischaracteristic of heroin (Grant & Sonti, 1994) and can bediscontinued without severe withdrawal symptoms. Likemethadone, buprenorphine appears to work best at main-taining abstinence if it is provided along with behaviortherapy (Bickel, Amass, et a!., 1997).

Cocaine and Amphetamines(Stimulants)In contrast to narcotics, which depress (slow down) theaction of the central nervous system, cocaine and amphet-amines stimulate it (speed it up).

COCAINE Like opium, cocaine is a plant product discov-ered in ancient times and used ever since. It was widelyused in the pre-Columbian world of Mexico and Peru(Guerra, 1971). Because for many years it was typicallyvery costly in the United States, cocaine was considered asthe "high" for the affluent. However, with more widespreadavailability and lowering of prices, the drug's use increasedsignificantly in the United States during the 1980s and1990s-to the point where its use was considered epi-demic, especially among middle- and upper-incomegroups. "Crack" is the street name that is applied to cocainethat has been processed from cocaine hydrochloride to afree base for smoking. The name refers to the cracklingsound emitted when the mixture is heated.

In 2003, there were an estimated 2.3 million peopleusing cocaine and over 600,000 people reported usingcrack cocaine during that time (Substance Abuse andMental Health Services Administration, 2004). Cocaine-related emergency room visits increased substantiallybetween 1978 and 2000. In 2000, there were 71 cocaine-related emergency room visits per 100,000 drug-relatedadmissions, or about 29 percent (DAWN Report, 2001).

Like the opiates, cocaine may be ingested by sniffing,swallowing, or injecting. Also like the opiates, it precipi-tates a euphoric state of 4 to 6 hours' duration, duringwhich a user experiences feelings of confidence and con-tentment. However, this blissful state may be preceded byheadache, dizziness, and restlessness. When cocaine is

chronically abused, acute toxic psychotic symptoms mayoccur including frightening visual, auditory, and tactualhallucinations similar to those in acute schizophrenia.

Unlike the opiates, cocaine stimulates the cortex of thebrain, inducing sleeplessness and excitement as well as stim-ulating and accentuating sexual feelings. Dependence oncocaine also differs somewhat from dependence on opiates.It was formerly believed that tolerance was not increasedappreciably with cocaine use. However, acute tolerance hasnow been demonstrated, and some chronic tolerance, amore persistent habituation, may occur as well (Jones,1984). Moreover, cognitive impairment associated withcocaine abuse is likely to be an important consideration inlong-term effects of the drug (Abi-Saab, Beauvais, et a!.,2005; Mann, 2004). The previous view that cocaine abusersdid not develop physiological dependence on the drug alsohas changed. Gawin and Kleber (1986) demonstrated thatchronic abusers who become abstinent develop uniform,depression-like symptoms, but the symptoms are transient.Our broadened knowledge about cocaine abuse, particu-larly with respect to the many health and social problemsresulting from dependence on the drug, has resulted in con-siderable modification of professional views of cocaine overthe past 20 years. For example, the modifications in theDSM -IV-TR diagnostic classification reflect a significantincrease in our knowledge of cocaine's addictive properties.A new disorder is described-cocaine withdrawal-thatinvolves symptoms of depression, fatigue, disturbed sleep,and increased dreaming (Foltin & Fischman, 1997). Thepsychological and life problems experienced by cocaineusers are often great. Employment, family, psychological,and legal problems are all more likely to occur among

Yasmine Bleeth, madel and actress best known for her role onBaywatch, "never expected to get into drugs." But aver the courseof several years cocaine became a serious addiction and all shecould think about. At one point, cocaine use had eaten a hole thesize of a dime in her nose. Her dress size dropped from size 6 tosize 2. After a car accident and subsequent arrest in September2001, Yasmine stopped all cocaine use, gained 20 pounds, andmarried a man she met while in rehab.

cocaine and crack users than among nonusers. Many lifeproblems experienced by cocaine abusers result in partfrom the considerable amounts of money that are requiredto support their habits. Increased sexual activity, often trad-ing sex for drugs, has been associated with crack cocaine use(Weatherby et aI., 1992), as has engaging in sexual activitywith anonymous partners (Balshem et aI., 1992). Problemsin sexual functioning have been reported to be associatedwith crack cocaine use. Kim and colleagues (1992) reportedthat most users lose interest in sex and develop sexual dys-function with prolonged usage.

Women who use cocaine when they are pregnant placetheir babies at risk for both health and psychological prob-lems. Although recent research has suggested that there isno "fetal crack syndrome" similar to what has been shownwith alcohol-abusing mothers (Azar, 1997), children ofcrack-using mothers are at risk of being maltreated asinfants as well as of losing their mothers during infancy.Wasserman and Leventhal (1993) studied a group ofcocaine-exposed children and a control sample of nonex-posed children for a 24-month period following their birth.They found that children who were regularly exposed tococaine in utero were more likely to be mistreated (23 per-cent compared with only 4 percent of controls). The courtstoday are beginning to take a stern stance with respect tomothers who use cocaine during pregnancy to the detri-ment of their fetus. In one case, a woman who lost her fetusas a result of crack use faced a murder charge for killing herunborn child (Associated Press, 1997). She pleaded guiltyto involuntary manslaughter and received a 3-year sus-pended sentence.

TREATMENT AND OUTCOMES Treatment for depen-dence on cocaine does not differ appreciably from that forother drugs that involve physiological dependence. Kosten(1989) reported that effective cocaine-abuse treatmentincludes the medications such as desipramine and nal-trexone (Kosten et aI., 1992) to reduce cravings and psy-chological therapy to ensure treatment compliance, anddisulfiram has been used to reduce alcohol use (Carroll,Fenton, et aI., 2004). The feelings of tension and depressionthat accompany absence of the drug have to be dealt withduring the immediate withdrawal period.

Some success in the treatment of cocaine abusers hasbeen reported. Siqueland, Crits-Cristoph, and colleagues(2002) found that patients who remained in drug treat-ment longer used drugs less often after treatment thanthose who dropped out; and Stewart, Gossop, and Marsden(2002) found that patients who completed therapy hadlower rates of drug overdose than those who failed to com-plete treatment. Carroll, Powers, et al. (1993) have shownthat many cocaine abusers did well in maintaining treat-ment goals, and one-third were abstinent at a 12-monthfollow-up. They found several factors associated withpoorer outcomes: severity of abuse, poorer psychiatricfunctioning, and presence of concurrent alcoholism. Hig-gins, Badger, and Budney (2000) found that people who

were not able to sustain abstinence during the treatmenthad poorer outcomes following therapy.

One of the problems clinicians face in working withcocaine abusers is "dropping out": Only 42 percent of thosein one study remained in treatment for six or more sessions(Kleinman et aI., 1992). Another problem encountered indrug treatment is that many of the cocaine-dependentpatients have severe antisocial personality disorder-a situ-ation resulting in treatment resistance (Conway, Kane,et aI., 2003; Leal, Ziedonis, & Kosten, 1994)-or are "psy-chosis-prone" personalities (Kwapil, 1996). Arndt and col-leagues (1994) found that cocaine-dependent patients withantisocial personality characteristics made few therapeuticgains, whereas those without antisocial features made sig-nificant progress.

Is treatment always necessary for cocaine abusers torecover? An interesting study suggested that some abuserscan improve without therapy. Toneatto, Sobell, et al.(1999) described a study of natural (nontreated) recoveryamong cocaine abusers. They reported that abusers whoresolved their dependence on cocaine were similar to thosewho did not resolve their cocaine problems in terms ofdemographic characteristics, substance abuse, and psychi-atric history. The successful abstainers considered their"improved self-concept" crucial to their success.

AMPHETAMINES The earliest amphetamine to beintroduced-Benzedrine, or amphetamine sulfate-wasfirst synthesized in 1927 and became available in drugstoresin the early 1930s as an inhalant to relieve stuffy noses.However, the manufacturers soon learned that some cus-tomers were chewing the wicks in the inhalers for "kicks."Thus the stimulating effects of amphetamine sulfate werediscovered by the public before the drug was formally pre-scribed as a stimulant by physicians. In the late 1930s, twonewer amphetamines were introduced-Dexedrine (dex-troamphetamine) and Methedrine (methamphetaminehydrochloride, also known as "speed"). The latter prepara-tion is a far more potent stimulant of the central nervoussystem than either Benzedrine or Dexedrine and hence isconsidered more dangerous. In fact, its abuse can be lethal.

Initially these preparations were considered to be"wonder pills" that helped people stay alert and awake andfunction temporarily at a level beyond normal. DuringWorld War II, military interest was aroused in the stimu-lating effects of these drugs, and they were used by bothAllied and German soldiers to ward off fatigue (Jarvik,1967). Similarly, among civilians, amphetamines came tobe widely used by night workers, long-distance truck dri-vers, students cramming for exams, and athletes strivingto improve their performances. It was also discovered thatamphetamines tended to suppress appetite, and theybecame popular with people trying to lose weight. In addi-tion, they were often used to counteract the effects of bar-biturates or other sleeping pills that had been taken thenight before. As a result of their many uses, amphetamineswere widely prescribed by doctors.

Today amphetamines are occasionally used medicallyfor curbing the appetite when weight reduction is desir-able; for treating individuals suffering from narcolepsy, adisorder in which people cannot prevent themselves fromcontinually falling asleep during the day; and for treatinghyperactive children. Curiously enough, amphetamineshave a calming rather than a stimulating effect on many ofthese youngsters (see Chapter 16). Amphetamines are alsosometimes prescribed for alleviating mild feelings ofdepression, relieving fatigue, and maintaining alertness forsustained periods of time. By far, however, the most fre-quent use of amphetamines is for recreational purposes,the most typical user being a young person interested inthe high that the drug induces (Klee, 1998).

Since the passage of the Controlled Substance Act of1970 (Drug Enforcement Administration, 1979), amphet-amines have been classified as Schedule II controlled sub-stances-that is, drugs with high abuse potential thatrequire a prescription for each purchase. As a result, med-ical use of amphetamines has declined in the United Statesin recent years, and they are more difficult to obtain legally.However, it is often easy to find illegal sources of ampheta-mines, which thus remain among the most widely abuseddrugs. Amphetamines are among the most widely usedillicit drugs in other countries as well-for example, inAustralia (Lintzeris, Holgate, & Dunlop, 1996). In 2000,2.4 percent of drug-related emergency room visits involvedamphetamine or methamphetamine (DAWN Survey, 2000;see The World Around Us 12.4 on p. 440).

EFFECTSOF AMPHETAMINE ABUSE Despite their legit-imate medical uses, amphetamines are not a magical sourceof extra mental or physical energy. Instead, they push userstoward greater expenditures of their own resources-oftento the point of hazardous fatigue. Amphetamines are psy-chologically and physically addictive, and the body rapidlybuilds up tolerance to them (Wise, 1996). Thus habituatedabusers may use the drugs in amounts that would be lethalto nonusers. In some instances, users inject the drug to getfaster and more intense results.

For a person who exceeds prescribed dosages, amphet-amine consumption results in heightened blood pressure,enlarged pupils, unclear or rapid speech, profuse sweating,tremors, excitability, loss of appetite, confusion, and sleep-lessness. Injected in large quantities, Methedrine can raiseblood pressure enough to cause immediate death. Inaddition, chronic abuse of amphetamines can result inbrain damage and a wide range of psychopathology,including a disorder known as "amphetamine psychosis,"which appears similar to paranoid schizophrenia. Suicide,homicide, assault, and various other acts of violence areassociated with amphetamine abuse.

TREATMENTS AND OUTCOMES Research on the effec-tiveness of various treatments for withdrawing patientsfrom amphetamine is scarce (Baker & Lee, 2003).Although withdrawal from amphetamines is usually safe,

some evidence suggests that physiological dependenceupon the drug is an important factor to consider in treat-ment (Wise & Munn, 1995). In some instances, abruptwithdrawal from the chronic, excessive use of ampheta-mines can result in cramping, nausea, diarrhea, and evenconvulsions. Moreover, abrupt abstinence commonlyresults in feelings of weariness and depression. The depres-sion usually peaks in 48 to 72 hours, often remains intensefor a day or two, and then tends to lessen gradually over aperiod of several days. Mild feelings of depression and las-situde may persist for weeks or even months. If brain dam-age has occurred, the residual effects may include impairedability to concentrate, learn, and remember, with resultingsocial, economic, and personality deterioration.

Barbiturates (Sedatives)In the 1930s, powerful sedatives called barbiturates weredeveloped. Although barbiturates have legitimate medicaluses, they are extremely dangerous drugs commonly asso-ciated with both physiological and psychological depen-dence and lethal overdoses.

EFFECTS OF BARBITURATES Barbiturates were oncewidely used by physicians to calm patients and induce sleep.They act as depressants-somewhat like alcohol-to slowdown the action of the central nervous system (Nemeroff,2003) and significantly reduce performance on cognitivetasks (Pickworth et al., 1997). Shortly after taking a barbitu-rate, an individual experiences a feeling of relaxation inwhich tensions seem to disappear, followed by a physicaland intellectual lassitude and a tendency toward drowsinessand sleep-the intensity of such feelings depends on thetype and amount of the barbiturate taken. Strong dosesproduce sleep almost immediately; excessive doses are lethalbecause they result in paralysis of the brain's respiratorycenters. Pentobarbital, a common barbiturate, appears tohave even more sedating characteristics than alcohol(Mintzer, Guarino, et al., 1997). Impaired decision makingand problem solving, sluggishness, slow speech, and suddenmood shifts are also common effects of barbiturates.

Excessive use of barbiturates leads to increased toler-ance as well as to physiological and psychological depen-dence. It can also lead to brain damage and personalitydeterioration. Unlike tolerance for opiates, tolerance forbarbiturates does not increase the amount needed to causedeath. This means that users can easily ingest fatal over-doses, either intentionally or accidentally.

CAUSAL FACTORS IN BARBITURATE ABUSE ANDDEPENDENCE Although many young people experi-ment with barbiturates, or "downers," most do not becomedependent. In fact, the people who do become dependenton barbiturates tend to be middle-aged and older peoplewho often rely on them as "sleeping pills" and who do notcommonly use other classes of drugs (except possibly alco-hol and minor tranquilizers). These people have been

12.4ethamphetamine, referred to on the

streets as "crystal" or "ice" because ofits appearance, is a highly addictivestimulant drug that can provide a quickand long-lasting "high." However, it is

one of the most dangerous illegal drugs because of itstreacherous properties and its unwelcome results.Methamphetamine is a form of amphetamine that can be"cooked" up in large quantities in makeshift laboratories inout-of-the-way places that defy and frustrate detection.This drug is relatively cheap to manufacture and is oftenreferred to as "poor people's cocaine." It can be manufac-tured, for example, in a portable cooler with ingredientsthat can be legally obtained from any drugstore. The drugcan be ingested in a variety of ways, through smoking,snorting, swallowing, or injecting. The drug's effects can bealmost instantaneous if it is smoked or injected.

Methamphetamine operates by increasing the level ofdopamine in the brain, and prolonged use of the drug pro-duces structural changes in the brain (Maxwell, 2005; Wang,Volkow, et aI., 2004). The severity of psychiatric symptomsassociated with the drug is significantly related to the dura-tion of use (Yoshimoto et aI., 2002). Moreover, discontinuingthe drug after the person has become habituated can resultin problems with learning, memory, and cognitive dysfunc-tion (Cretzmeyer, Sarrazin, et aI., 2003; Rothman et aI.,2000) and severe mental health problems such as paranoidthinking and hallucinations (Brecht, O'Brien, et aI., 2004;Srisurapanont, Ali, et aI., 2003). This drug is metabolizedmore slowly than other drugs such as cocaine and producesa high for a longer period of time. When the drug wears offor when users "come down from the high," they are likely tofeel extremely weak, lethargic, sleepy, and depressed. Egan(2002) provided the following descriptions of two methusers from the State of Washington:

Lacy B., 26, drives around in the rain, her skin twitching,her mind racing, her nails bitten to a pulp. She has beentrying to shed her addiction and is awaiting counseling.But she also carries a grocery list under the seat of hercar, with all the ingredients for cooking meth.

"Solvents from the paint store, lithium from batter-ies, Sudafed -I know a lot of this stuff could kill me,"

referred to as "silent abusers" because they take the drugs

in the privacy of their homes and ordinarily do not

become public nuisances.Barbiturates are commonly used with alcohol. Some

users claim they can achieve an intense high by combining

barbiturates, amphetamines, and alcohol. However, one

possible effect of combining barbiturates and alcohol is

Methamphetamine-Is "Ice"Really Cool?

Ms. B. said in an interview. "But I also know that it getsme through. There are times when I don't feel normalwithout meth."

Another Snohomish County woman, a Bertina P.,33, has been drug-free for two years, but she still shud-ders at her low point. "I took a pocket knife and tried tolance an abscess in my mouth." She said, "I was doingmy own dentistry. Lucky I didn't kill myself." (33)

Use of the drug has increased substantially over thepast 10 years. Over 4.9 million people in the United States(2.3 percent of the population) had tried methampheta-mine by 1998 (NIDA, 2002). In a recent survey of almost630,000 high school students, Oetting et al. (2000)reported that methamphetamine use more than doubledbetween 1989 and 1996. In 1996, 1.8 percent of ninth-grade, 1.9 percent of tenth-grade, 2.5 percent of eleventh-grade, and 2.1 percent of twelfth-grade boys reportedhaving used methamphetamine in the past 30 days.Although use among girls was less, the trend over the 7-year time span paralleled the boys' increasing use. Theincreasing use among women might result from one of theside effects of the drug. Wermuth (2000) pointed out that"an additional attraction is the appetite suppressanteffects, especially attractive to women trying to stay thin."Interestingly, the use of methamphetamine in the UnitedStates has been somewhat of a regional phenomenon;most use has occurred in the Southwest, on the WestCoast, and in Hawaii and very little use in the North, South,and Midwest (DAWN, 2001). This situation results from thefact that meth labs have been concentrated in Mexico, Cali-fornia, and Hawaii.

There is some evidence that people become morequickly addicted to methamphetamine and require treat-ment sooner than those using cocaine (Castro et aI., 2000).Addicted methamphetamine users are highly resistant totreatment, and post-treatment relapse is common. In oneCalifornia study of 98 methamphetamine abusers, theinvestigators reported that over half of the participants hadreturned to methamphetamine use by the time they wereinterviewed 2 to 3 years following therapy; 36 percentreported that they had returned to methamphetamine usewithin 6 months of therapy (Brecht et aI., 2000).

death, because each drug potentiates (increases the action

of) the other. See The World Around Us 12.5 for a discus-

sion of pain medications abuse.

TREATMENTS AND OUTCOMES As with many other

drugs, it is often essential in treatment to distinguish

between barbiturate intoxication, which results from the

12.5any people become addicted to pain

medication in the course of treatmentfor chronic pain (Isaacson, 2004). Therehas been a significant increase in life-time nonmedical use of pain relievers,

with between 29 and 31 million persons age 12 or olderusing such drugs (Substance Abuse and Mental Health Ser-vices Administration, 2004). Pain killers such as OxyContincontain an opiate that is similar to morphine and codeine.When these substances attach to receptors in the spinalcord and brain, they block transmission of pain (FDA,2003).

Opiate medications have a high potential for abuse becausethey are widely available in tablet form through medicalprescription for pain and are becoming more accessiblethrough a growing illegal market. Pain killers such as Oxy-Contin, Vicodin, and Darvon, often referred to as "hillbillyheroin," "coties," "demmies," or "dillies" on the street, arebecoming a major drug problem today (FDA,2003). Thesedrugs are highly dangerous and can seriously affect one'slifestyle as well as producing serious health consequences,even death (Pinsky, 2004).

The media frenzy over iconic talk show host RushLimbaugh's alleged illegal use of pain killers (OxyContin,Lorcet, and hydrocodone) in 2003 has prompted broaderattention to addiction to opoids that are widely prescribedfor pain.

Rush Limbaugh was reported to authorities by his for-mer housekeeper, who was supplying him with large quan-

toxic effects of overdose, and the symptoms associatedwith drug withdrawal, because different procedures arerequired. With barbiturates, withdrawal symptoms aremore dangerous, severe, and long-lasting than in opiatewithdrawal. A patient going through barbiturate with-drawal becomes anxious and apprehensive and manifestscoarse tremors of the hands and face; additional symptomscommonly include insomnia, weakness, nausea, vomiting,abdominal cramps, rapid heart rate, elevated blood pres-sure, and loss of weight. An acute delirious psychosis maydevelop.

For persons used to taking large dosages, withdrawalsymptoms may last for as long as a month, but usually theytend to abate by the end of the first week. Fortunately, thewithdrawal symptoms in barbiturate addiction can beminimized by administering increasingly small doses ofthe barbiturate itself or another drug that produces similareffects. The withdrawal program is still a dangerous one,however, especially if barbiturate addiction is complicatedby alcoholism or dependence on other drugs.

Pain Killers: Consequences andPain of Medications Abuse

Talkshow host, Rush Limbaugh, became addicted to painkiller OxyContin and was investigated for allegedly buyingthousands of addictive pain-killers from a black-marketdrug ring in 2003.

tities of OxyContin for several years. She obtained thesedrugs through illegal prescriptions to her and her husband.Limbaugh's excessive use of pain killers allegedly resultedin his going through detoxification on two occasions (Con-nor, 2003).

LSD and Related Drugs(Hallucinogens)The hallucinogens are drugs that are thought to inducehallucinations. However, these preparations usually do notin fact "create" sensory images but distort them, so that anindividual sees or hears things in different and unusualways. These drugs are often referred to as "psychedelics."The major drugs in this category are LSD (lysergic aciddiethylamide), mescaline, and psilocybin.

LSD The most potent of the hallucinogens, the odorless,colorless, and tasteless drug LSD can produce intoxicationwith an amount smaller than a grain of salt. It is a chemi-cally synthesized substance first discovered by the Swisschemist Albert Hoffman in 1938. Hoffman was not awareof the potent hallucinatory qualities of LSD until he swal-lowed a small amount. This is his report of the experience:

Last Friday, April 16, 1943,1 was forced to stop my workin the laboratory in the middle of the afternoon and to

go home, as I was seized by a peculiar restlessness asso-ciated with a sensation of mild dizziness. On arrivinghome, I lay down and sank into a kind of drunkennesswhich was not unpleasant and which was characterizedby extreme activity of imagination. As I lay in a dazedcondition with my eyes closed (I experienced daylight asdisagreeably bright) there surged upon me an uninter-rupted stream of fantastic images of extraordinary plas-ticity and vividness and accompanied by an intensekaleidoscope-like play of colors. This condition gradu-ally passed off after about two hours. (Hoffman, 1971,p.23)

Hoffman followed up this experience with a series ofplanned self-observations with LSD, some of which hedescribed as "harrowing." Researchers thought LSD mightbe useful for the induction and study of hallucinogenicstates or "model psychoses:' which were thought to berelated to schizophrenia. About 1950, LSD was introducedinto the United States for purposes of such research and toascertain whether it might have medical or therapeuticuses. Despite considerable research, however, LSD did notprove to be therapeutically useful.

After taking LSD, aperson typically goesthrough about 8 hours ofchanges in sensory per-ception, mood swings,and feelings of deperson-alization and detachment.The LSD experience is notalways pleasant. It can beextremely traumatic, andthe distorted objects andsounds, the illusory colors,and the new thoughts canbe menacing and terrify-ing. For example, whileunder the influence ofLSD, a British law studenttried to continue time byusing a dental drill to borea hole in his head (Rorvik,1970). In other instances,people undergoing badtrips have set themselvesaflame, jumped from high

places, and taken other drugs that proved lethal in combi-nation with LSD.

An interesting and unusual phenomenon that mayoccur some time following the use of LSD is the flashback,an involuntary recurrence of perceptual distortions or hal-lucinations weeks or even months after the individual hastaken the drug. Flashbacks appear to be relatively rareamong people who have taken LSD only once-althoughthey do sometimes occur. Even if no flashbacks occur, onestudy found that continued effects on visual function were

LSD is the most potent of thehallucinogens. It is odorless, colorless,and tasteless. An amount smaller than agrain of salt can produce intoxication.These LSD "decals" are one way ofdistributing the drug to users.

apparent at least 2 years after LSD use. In this study, Abra-ham and Wolf (1988) reported that individuals who hadused LSD for a week had reduced visual sensitivity to lightduring dark adaptation and showed other visual problemscompared with controls.

MESCALINE AND PSILOCYBIN Two other hallucino-gens are mescaline, which is derived from the small, disc-like growths (mescal buttons) at the top of the peyotecactus, and psilocybin, which is obtained from a variety of"sacred" Mexican mushrooms known as Psilocybe mexi-cana. These drugs have been used for centuries in the cere-monial rites of Native peoples living in Mexico, theAmerican Southwest, and Central and South America. Infact, they were used by the Aztecs for such purposes longbefore the Spanish invasion. Both drugs have mind-alteringand hallucinogenic properties, but their principal effectappears to be enabling an individual to see, hear, and other-wise experience events in unaccustomed ways-transport-ing him or her into a realm of "non ordinary reality." As withLSD, no definite evidence shows that mescaline and psilo-cybin actually "expand consciousness" or create new ideas;rather, they mainly alter or distort experience.

EcstasyThe drug Ecstasy, or MDMA (3,4-methylenedioxy-methamphetamine), is both a hallucinogen and a stimu-lant that is popular as a party drug among young adults.The drug was originally patented in 1913 by the pharma-ceutical company Merck, supposedly to be sold as a dietpill, but the company decided against marketing the drugbecause of the side effects. The drug was further evaluatedand tested during the 1970s and 1980s as a potential med-ication for use in psychological treatment for a wide rangeof conditions such as post-traumatic stress, phobias, psy-chosomatic disorders, depression, suicidality, drug addic-tion, and relationship difficulties (Grob, 2000). However,its value in this capacity was not supported. At present, thisdrug is considered a "dangerous" drug and is listed in themost restricted category by the Drug Enforcement Admin-istration (Murray, 2001). It is currently available in theUnited States only through illicit means.

Ecstasy is chemically similar to methamphetamineand to the hallucinogen mescaline and produces effectssimilar to those of other stimulants, although someresearch has suggested that the drug's hallucinogenic prop-erties exceed those of mescaline (Kovar, 1998; Parrott &Stuart, 1997). Usually about 20 minutes after ingestingEcstasy (typically in pill form), the person experiences a"rush" sensation followed by a feeling of calmness, energy,and well-being. The effects of Ecstasy can last for severalhours. People who take the drug often report an intenseexperience of color and sound and mild hallucinations(Fox, Parrott, & Turner, 2001; Lieb, Schuetz, et al., 2002;Soar, Turner, & Parrott, 2001) in addition to the high levelsof energy and excitement that are produced. The drug

The Ecstasy drug (MDMA - 3,4-Methylenedioxy-N-Methylamphetamine) is taken in pill form and is often used at"raves" or night clubs to enhance mood. Ecstasy is an illegalsubstance and manufacturers do not follow regulation and qualitycontrol. Thepopular "rave drug" is often modified to contain a mixof MDMA;MDEA and other ingredients or are made up entirely ofother psychoactive substances such as amphetamine (speed) orLSD (acid).

MDMA is an addictive substance, but it is not thought tobe as addictive as cocaine. Use of the drug is accompaniedby a number of adverse consequences such as nausea,sweating, clenching of teeth, muscle cramps, blurredvision, and hallucinations (Parrott, 2001).

Ecstasy has been used increasingly among college stu-dents and young adults as a party enhancement or "rave"drug at dances (Boys, Lenton, & Norcross, 1997). In a sur-vey of 14,000 college students, Strote, Lee, and Wechsler(2002) found that between 1997 and 1999, Ecstasy useincreased 69 percent, from 2.8 percent to 4.7 percent.Ecstasy reportedly grew in use among eighth, tenth, andtwelfth graders, as noted by the Monitoring the Futurestudy, in which nearly 5 percent of tenth and twelfthgraders and about 2 percent of eighth graders reportedlyhad used MDMA in the past year. However, the rate ofincrease slowed in the most recent survey (SubstanceAbuse and Mental Health Services Administration, 2004),and its frequency of use is considerably less than otherdrugs of abuse (Yacoubian, 2003).

As with many other illicit drugs, the recreational use ofEcstasy has been associated with personality characteristicsof impulsivity and poor judgment (Morgan, 1998). Ecstasyusers have been found to be more likely to use marijuana,engage in binge drinking, smoke cigarettes, and have mul-tiple sexual partners (Strote, Lee, & Wechsler, 2002). How-ever, Ecstasy use is also found among naive partygoers whoare provided the drug as a means of staying awake whilesocializing (Boys, Marsden, & Strang, 2001).

The negative psychological and health consequences(including death) of using Ecstasy have been widely

reported in the literature. One recent study reported on thecase of a 21-year-old man who developed panic disorderafter taking Ecstasy (Windhaber, Maierhofer, & Danten-dorfer, 1998); in another case study, an 18-year-old womanreportedly developed a prolonged psychosis after a singlerecreational use of Ecstasy (Van Kampen & Katz, 2001).The use of Ecstasy has been found to be associated withmemory impairment. Parrott, Lees, and colleagues (1998)found that users of MDMA showed significantly less recallthan controls participating in a memory experiment. Moresevere organic brain problems have also been reported.Granato, Weill, and Revillon (1997) described a case inwhich a 20-year-old male suffered from cerebrovascularinjury after taking Ecstasy. The youth went into a comaabout a minute or so after taking the drug. Upon awaken-ing, he was found to have dissociation, delirium, visual hal-lucinations, and poor memory for past events. Subsequentexamination showed damage to his frontal lobes and hisright temporal lobe.

MarijuanaAlthough marijuana may be classified as a mild hallu-cinogen, there are significant differences between thenature, intensity, and duration of its effects and thoseinduced by LSD, mescaline, and other major hallucino-gens. Marijuana comes from the leaves and flowering topsof the hemp plant, Cannabis sativa. This plant grows inmild climates throughout the world including parts ofIndia, Africa, Mexico, South America, and the UnitedStates. In its prepared state, marijuana consists chiefly ofthe dried green leaves-hence the colloquial name grass. Itis ordinarily smoked in the form of cigarettes (variouslyreferred to as "reefers," "joints," "stash," "weed;' etc.) or inpipes. In some cultures the leaves are steeped in hot waterand the liquid is drunk, much as one might drink tea.Marijuana is related to a stronger drug, hashish, which isderived from the resin exuded by the cannabis plant andmade into a gummy powder. Hashish, like marijuana, isusually smoked.

Both marijuana use and hashish use can be traced farback into history. Cannabis was apparently known inancient China (Blum, 1969; Culliton, 1970) and was listedin the herbal compendiums of the Chinese Emperor ShenNung, written about 2737 B.C. Until the late 1960s, mari-juana use in the United States was confined largely to mem-bers of lower-socioeconomic and minority groups and topeople in entertainment and related fields, but marijuanause is commonplace today. In 2003, over 3.1 million peo-ple over 12 years of age reportedly used marijuana daily(National Survey on Drug Use and Health, 2004). The U.S.Department of Justice Statistics for 2004 (Bureau of JusticeStatistics, 2004) reported that 34.9 percent of high schoolseniors had used marijuana within the past 12 months.

Although teen drug use declined somewhat over thepast 8 years (NIDA, 2003), it has been estimated thatabout 7,000 Americans tried marijuana for the first time in

2003; about two-thirds of these were under age 18. In arecent national survey (Substance Abuse and MentalHealth Services Administration,2004), there were 2.6 million newmarijuana users in 2002. Minoritygroup members and Caucasianshave been shown to have compara-ble rates of use (Brown, Flory,et aI., 2004). In a separate surveyof drug-related visits to the emer-gency room (DAWN Report,2001), 16 percent were for mari-juana abuse. Many of these emer-gency room visits, as one mightsuspect, involved the use of othersubstances along with marijuana.

may also be affected, as when one notices that a bite hasbeen taken out of a sandwich but does not remember

having taken it. For most users,pleasurable experiences, includingsexual intercourse, are reportedlyenhanced. When smoked, mari-juana is rapidly absorbed and itseffects appear within seconds tominutes but seldom last more than2 to 3 hours.

Marijuana may lead tounpleasant as well as pleasantexperiences. For example, if aperson uses the drug while in anunhappy, angry, suspicious, orfrightened mood, these feelingsmay be magnified. With higherdosages and with certain unstableor susceptible individuals, mari-juana can produce extremeeuphoria, hilarity, and overtalka-tiveness, but it can also produceintense anxiety and depression aswell as delusions, hallucinations,and other psychotic-like experi-ences. Evidence suggests a strongrelationship between daily mari-juana use and the occurrence ofpsychotic symptoms (Raphaelet aI., 2005).

Marijuana's short-range physiological effects includea moderate increase in heart rate, a slowing of reactiontime, a slight contraction of pupil size, bloodshot and itchyeyes, a dry mouth, and increased appetite. Furthermore,marijuana induces memory dysfunction and a slowing ofinformation processing (Pope, Gruber, et aI., 2001). Con-tinued use of high dosages over time tends to producelethargy and passivity along with reduced life success(Lane, Cherek, et aI., 2005). In such cases marijuanaappears to have a depressant and a hallucinogenic effect.The effects of long-term and habitual marijuana use arestill under investigation, although a number of possibleadverse side effects have been related to the prolonged,heavy use of marijuana (Earleywine, 2002). For example,marijuana use tends to diminish self-control. One studyexploring past substance-use history in incarcerated mur-derers reported that among men who committed murder,marijuana was the most commonly used drug. One-thirdindicated that they used the drug before the homicide, andtwo-thirds were experiencing some effects of the drug atthe time of the murder (Spunt et aI., 1994).

Some research has reported that many marijuana useabstainers reported having uncomfortable withdrawal-likesymptoms such as nervousness, tension, sleep problems,and appetite change (Budney, Moore, et aI., 2003; Zickler,2002). One study of substance abusers reported that mar-ijuana users were more ambivalent and less confident

EFFECTS OF MARIJUANA Thespecific effects of marijuana varygreatly, depending on the qualityand dosage of the drug, the per-sonality and mood of the user, theuser's past experiences with thedrug, the social setting, and theuser's expectations. However, con-siderable consensus exists amongregular users that when marijuanais smoked and inhaled, a state ofslight intoxication results. Thisstate is one of mild euphoria dis-tinguished by increased feelings of well-being, heightenedperceptual acuity, and pleasant relaxation, often accompa-nied by a sensation of drifting or floating away. Sensoryinputs are intensified. Marijuana has the effect on the brainof altering one's internal clock (O'Leary, Block, et aI.,2003). Often a person's sense of time is stretched or dis-torted, so that an event that lasts only a few seconds mayseem to cover a much longer span. Short-term memory

These demonstrators ore marching to City Hall inNew York City to call for the legalization ofmarijuana.

Marijuana can praduce extreme euphoria, hilarity, and hyper-talkativeness, but it can also produce intense anxiety anddepression as well as delusions, hallucinations, and otherpsychotic-like behavior.

about stopping use than were cocaine abusers (Budney,Radonovich, et aI., 1998).

Psychological treatment methods have been shown tobe effective in reducing marijuana use in adults who aredependent on the drug (Marijuana Treatment ProjectResearch Group, 2004) although some data suggest thatmany patients do not show a positive treatment response(McRae, Budney, & Brady, 2003). As with other addictivedrugs, there may be among the users many individualswith serious antisocial or "psychosis-prone" personalities(Kwapil, 1996). Treatment of marijuana use is hamperedby the fact that there might be an underlying personality

12.65l11thOUgh pathological gambling does not

involve a chemically addictive substance,it can be considered an addictive disorderbecause of the personality factors thattend to characterize compulsive gam-

blers, the difficulties attributable to compulsive gambling,and the treatment problems involved (Grant, Kushner, &Kim, 2002). Like other addictions, pathological gamblinginvolves behavior maintained by short-term gains despitelong-term disruption of an individual's life. Judging fromwritten history and the studies of anthropologists, gam-bling occurs in nearly all cultures and among all socialstrata. Pathological gambling, also known as "compulsivegambling," is a progressive disorder characterized by con-tinuous or periodic loss of control over gambling, a preoc-cupation with gambling and with obtaining money forgambling, irrational behavior, and continuation of the gam-bling behavior in spite of adverse consequences. Estimatesplace the number of pathological gamblers in the UnitedStates at between 1.2 and 2.3 percent of the adult popula-tion (Volberg, 1990). Both men and women appear to bevulnerable to pathological gambling (Hing & Breen, 2001).One recent study of elderly African-Americans from twosenior citizen centers documented the extent of gamblingproblems in this population; 17 percent were found to beheavy pathological gamblers (Bazargan, Bazargan, &Akanda 2001).

Gambling in our society takes many forms includingcasino gambling, betting on horse races (legally or other-wise), numbers games, lotteries, dice, bingo, and cards.Whatever an individual gambler's situation, compulsivegambling significantly affects the social, psychological, andeconomic well-being of the gambler's family (Lorenz &Shuttlesworth, 1983). In fact, one study found that a highproportion of pathological gamblers commit crimes thatare related to gambling (Blaszczynski, McConaghy, &Frankova, 1989).

disorder. One study compared the effectiveness of twotreatments, Relapse Prevention (RP) and Support Group(SSP), with marijuana-dependent adults (Stephens, Roff-man, & Simpson, 1994). Both treatment conditionsresulted in substantial reduction in marijuana use in the 12months following treatment. Relapse prevention and sup-port discussion sessions were equally effective in bringingabout changes in marijuana use.

Not all addictive disorders involve the use of sub-stances with chemical properties that induce dependence.As discussed in The World Around Us 12.6, people candevelop "addictions" to certain activities that can be just as

Pathological gambling seems to be a learned patternthat is highly resistant to extinction. Some research sug-gests that control over gambling is related to duration andfrequency of playing (Scannell, Quirk, et aI., 2000). How-ever, many people who become pathological gamblers wona substantial sum of money the first time they gambled;chance alone would dictate that a certain percentage ofpeople would have such "beginner's luck." The reinforce-ment a person receives during this introductory phase maybe a significant factor in later pathological gambling.Because everyone is likely to win from time to time, theprinciples of intermittent reinforcement-the most potentreinforcement schedule for operant conditioning (seeChapter 3) - could explain an addict's continued gamblingdespite excessive losses.

Despite their awareness that the odds are againstthem, and despite the fact that they rarely or never repeattheir early success, compulsive gamblers continue togamble avidly. To "stake" their gambling, they often dissi-pate their savings, neglect their families, default on bills,and borrow money from friends and loan companies.Some resort to embezzlement, writing bad checks, orother illegal means of obtaining money. In a pioneeringstudy of former pathological gamblers, Rosten (1961)found that as a group, they tended to be rebellious,unconventional individuals who did not seem to under-stand fully the ethical norms of society. Half of the groupdescribed themselves as "hating regulations." Often theyhad the unshakable feeling that "tonight is my night."Typically, they had also followed the so-called "MonteCarlo fallacy" -that after so many losses, their turn wascoming up and they would hit it big. Many of the men dis-cussed the extent to which they had "fooled themselves"by elaborate rationalizations. For example, one gamblerdescribed his previous rationalizations as covering allcontingencies: "When I was ahead, I could gamblebecause I was playing with others' money. When I was

(continued)

behind, I had to get even. When I was even, I hadn't lostany money" (Rosten, 1961, p. 67). It is of interest to notethat within a few months after the study, 13 of Rosten's 30subjects had returned to heavy gambling, had started todrink excessively, or had not been heard from and werepresumed to be gambling again.

Later studies strongly support Rosten's findings. Theydescribe pathological gamblers as typically immature,rebellious, thrill·seeking, superstitious, basically antiso-cial, and compulsive (Hollander, Buchalter, et aI., 2000).Research has shown that pathological gambling frequentlyco-occurs with other disorders particularly substanceabuse such as alcohol and cocaine dependence (Kausch,2003; Welte, Barnes, et aI., 2004) and impulse disorders(Grant & Kim, 2003). Those with co·occurring substance-abuse disorders typically have the most severe gamblingproblems (Ladd & Petry, 2003).

The causes of impulse-driven behavior such as we seein pathological gambling are complex. Although learningundoubtedly plays an important part in the development ofpersonality factors underlying the "compulsive" gambler,recent research in brain mechanisms that are involved inmotivation, reward, and decision making could influencethe underlying impulsivity in personality (Chambers &Potenza, 2003). These investigators have suggested thatimportant neurodevelopmental events during adolescenceoccur in brain regions associated with motivation andimpulsive behavior. Cultural factors also appear to beimportant in the development of gambling problems.Research with Southeast Asian refugee populations high-lights the role of cultural influences in gambling. Pathologi-cal gambling is a particular problem among SoutheastAsian refugees, especially those from Laos. Surveys ofmental health problems have reported almost epidemiccompulsive gambling among such groups (Aronoff, 1987;Ganju & Quan, 1987). Gambling is reportedly commonwithin Southeast Asian cultures, but these refugees' gam-

bling problems have apparently become more serious andmore widespread in the United States.

Treatment of pathological gamblers has tended toparallel that of other addictive disorders. The most exten-sive treatment approach used with pathological gamblersis cognitive-behavioral therapy (Breen, Kruedelbach, &Walker, 2001). For example, Sylvain, Ladouceur, andBoisvert (1997) provided cognitive-behavioral therapy for58 pathological gamblers recruited through the media.Although 18 participants dropped out at the start and 11quit during therapy, those who remained in treatmentshowed significant improvement. Of those who completedtherapy, 86 percent were considered "no longer" patholog-ical gamblers at a 1-year follow-up. However, one recentstudy (Hodgins & el-Guebaly, 2004) reported very highrelapse rates among pathological gamblers-only 8 per-cent were free of gambling 12 months after treatment.

Some pathological gamblers who want to change findhelp through membership in Gamblers Anonymous. Thisorganization, modeled after Alcoholics Anonymous, wasfounded in 1957 in Los Angeles by two pathological gam-blers who found that they could help each other control theirgambling by talking about their experiences. Since then,groups have been formed in most major American cities.

Pathological gambling is on the increase in the UnitedStates (Potenza, 2002; Stinchfield, 2002), particularly withthe widely available gambling opportunities on the Internet(Griffiths, 2003). Liberalized gambling legislation has per-mitted state-operated lotteries, horse racing, and gamblingcasinos in an effort to increase state tax revenues. In thecontext of this apparent environmental support and "offi-cial" sanction for gambling, it is likely that pathologicalgambling will increase substantially as more and morepeople "try their luck." Given that pathological gamblersare resistant to treatment, our future efforts to developmore effective preventive and treatment approaches willneed to be increased as this problem continues to grow.

life-threatening as severe alcoholism and just as damag-ing, psychologically and socially, as drug abuse. One suchaddiction, pathological gambling, is in many ways similarto substance abuse. The maladaptive behaviors involvedand the treatment approaches shown to be effective sug-gest that these addictive disorders are quite similar to thevarious drug-use and drug-induced disorders.

In ReVIew~ What are the major physical and psychologi-

cal effects of morphine and heroin use?~ What are three major causal factors in the

development of opiate dependence?~ Describe the psychosocial and biological

treatments for opiate dependence.~ What are the physical risks of taking Ecstasy?~ What is methamphetamine? What are the

major health factors related tomethamphetamine use?

Exchanging Addictions:Is This an Effective Approach?

rw ithdrawal from heroin can be extremely dif-ficult because of the intense craving thatdevelops for the drug. Wouldn't it be greatif we had a magic bullet-a medication-that would allow people who are addicted

to heroin to withdraw from it painlessly? One approach thathas been used for several decades involves the administra-tion of methadone (methadone hydrochloride, a syntheticnarcotic that is as addictive as heroin), often in conjunctionwith a psychological or social rehabilitation program that isaimed at resocialization of the abuser. The value of this treat-ment comes from the fact that methadone satisfies anaddict's craving for heroin without producing serious psycho-logical impairment.

Many researchers have concluded that in addition tofacilitating psychological or social rehabilitation, this drug iseffective at reducing the dependence on heroin (Byrne, 2000;Silverman, Higgins, Brooner, & Montoya, 1996). Thus itenables many people to experience reduced craving, allowingthem to alter somewhat the often desperate life circum-stances they find themselves in through trying to supporttheir expensive and all-consuming habit.

The idea that addicts may need to be maintained for lifeon methadone, itself a powerful and addicting drug, has beenquestioned both on moral and practical grounds. Methadoneadvocates, however, point out that addicts on methadone canfunction normally and hold jobs, which is not possible formost heroin addicts. In addition, methadone is availablelegally, and its quality is controlled by government standards.Advocates for methadone programs point out that it is notnecessary to increase the dosage over time as it is with heroinuse. In fact, some patients can eventually stop takingmethadone without danger of relapse to heroin addiction.

However, negative consequences are sometimes associ-ated with the use of methadone (Miller & Lyon, 2003).Methadone patients are at increased risk for health problemssuch as hepatitis (McCarthy & Flynn, 2001) and cognitiveimpairment (Scheurich, 2005; Verdejo, Toribio, et aI., 2005).

~ Addictive disorders such as alcohol or drug abuse areamong the most widespread and intransigent mentalhealth problems facing us today.

~ Many problems of alcohol or drug use involvedifficulties that stem solely from the intoxicatingeffects of the substances.

In addition, many social problems, such as trading sex fordrugs, persist (EI-Bassel, Simoni, et aI., 2001); some addictsget involved with other drugs such as cocaine (Avants, Mar-golin, et aI., 1998; Silverman et aI., 1996); suicide attemptsare common (Darke & Ross, 2001); and violent deaths anddrug overdoses are common among methadone patients(Sunjic & Zabor, 1999).

A great deal of research has shown that administeringpsychotherapy along with methadone increases the effective-ness of treatment (Woody et aI., 1987). However, a persistentproblem of methadone maintenance programs has been therelatively high dropout rate. Several variations in methadonemaintenance programs have aimed at keeping addicts in ther-apy. These variations include the use of such additional drugsas clonidine (an antihypertensive drug used to treat essentialhypertension and prevent headache), which aid in the detoxi-fication process and reduce the discomfort of withdrawalsymptoms. In one study, the joint use of tranquilizers such asdiazepam was shown to decrease the amount of methadoneconsumed (Spiga et al., 2001). Another approach involves theuse of behavioral shaping through contingent reinforcers(monetary vouchers) to reward abstinent patients (Preston,Umbricht, et aI., 2001).

A new approach to treating opioid dependence is onethat promotes drug abstinence for addicts rather than per-manent maintenance on methadone (Kosten, 2003; Reilly etaI., 1995). This program, referred to as "methadone transi-tion treatment" (MTT), involves several elements over the180-day course of treatment. During the first 100 days, theaddict is provided a stable dose of methadone to begin thewithdrawal from heroin. During this period the addict alsoreceives a psychosocial intervention that includes weeklypsychoeducational classes, biweekly group therapy, and 6months of individual therapy that continues after drug main-tenance has terminated. The program ends with 80 days ofphaseout in which the addict is "weaned" from methadonethrough systematically decreasing the doses (Piotrowski,Tusel, et aI., 1999).

~ Dependence occurs when an individual develops atolerance for the substance or exhibits withdrawalsymptoms when the substance is not available.

~ Several psychoses related to alcoholism have beenidentified: idiosyncratic intoxication, withdrawaldelirium, chronic alcoholic hallucinosis, and dementiaassociated with alcoholism.

~ Drug abuse disorders may involve physiological the body, has led to speculation that a biochemicaldependence on substances, such as opiates- basis of drug addiction may exist.particularly heroin -or barbiturates; however, ~ The so-called "pleasure pathway" -thepsychological dependence may also occur with any of mesocorticolimbic dopamine pathway (MCLP)- hasthe drugs that are commonly used today-for come under a great deal of study in recent years asexample, marijuana. the possible potential anatomic site underlying the

~ A number of factors are considered important in the addictions.etiology of substance-abuse disorders. Some ~ The treatment of individuals who abuse alcohol orsubstances, such as alcohol and opium, stimulate drugs is generally difficult and often fails. The abusebrain centers that produce euphoria-which then may reflect a long history of psychologicalbecomes a desired goal. difficulties; interpersonal and marital distress may

~ It is widely believed that genetic factors play some be involved; and financial and legal problems may berole in causing susceptibility through such biological present.avenues as metabolic rates and sensitivity to alcohol. ~ In addition, all such problems must be dealt with by

~ Psychological factors-such as psychological an individual who may deny that the problems existvulnerability, stress, and the desire for tension and who may not be motivated to work on them.reduction -and disturbed marital relationships are ~ Several approaches to the treatment of chronicalso seen as important etiologic elements in alcohol or drug abuse have been developed-forsubstance-use disorders. example, medication to deal with withdrawal

~ Although the existence of an "alcoholic personality symptoms and withdrawal delirium, and dietarytype" has been disavowed by most theorists, a evaluation and treatment for malnutrition.variety of personality factors apparently play an ~ Psychological therapies such as group therapy andimportant role in the development and expression of behavioral interventions may be effective with someaddictive disorders. alcohol- or drug-abusing individuals. Another source

~ Sociocultural factors such as attitudes toward alcohol of help for alcohol abusers is Alcoholics Anonymous;may predispose individuals to alcoholism. however, the extent of successful outcomes with this

~ Possible causal factors in drug abuse include the program has not been sufficiently studied.

influence of peer groups, the existence of a so-called ~ Most treatment programs require abstinence;"drug culture," and the availability of drugs as however, over the past 20 years, research hastension reducers or pain relievers. suggested that some alcohol abusers can learn to

~ Some recent research has explored a possible control their drinking while continuing to drink

physiological basis for drug abuse. The discovery of socially. The controversy surrounding controlled

endorphins, morphine-like substances produced by drinking continues.

addictive behavior (P. 412)

alcoholism (p, 413)

amphetamine (P. 438)

barbiturates (P. 439)

caffeine (p, 431)

cocaine (p, 437)

Ecstasy (p, 442)

endorphins (P. 436)

flashback (P. 442)

hallucinogens (P. 441)

hashish (p, 443)

heroin (P. 433)

LSD (P. 441)

marijuana (P. 443)

mescaline (P. 442)

mesocorticolimbic dopaminepathway (MCLP) (p.419)

methadone (P. 436)

morphine (P. 433)

nicotine (P. 431)

opium (P. 433)

pathological gambling (P. 445)

psilocybin (P. 442)

psychoactive drugs (P. 412)

substance abuse (P. 412)

substance dependence (p, 412)

tolerance (P. 412)

toxicity (P. 412)

withdrawal symptoms (P. 412)