Abuse, substance

On October 19, 2007, a freshman at the Westminster Choir College in Princeton, NJ, a talented cellist and pianist, injected himself with heroin provided by a classmate. He passed out and was driven to a friend s apartment where he lay unconscious for several hours. His friends noticed that he was not breathing and called 911. He was found dead when help arrived. 

The abuse of opiates has a long history. Thomas De Quinqr, in his book, Confessions of an English Opium Eater, describes how he was able to buy laudanum without a prescription in London in 1804. Laudanum is a tincture of opium in alcohol. A painting by Andre Gide entitled The Pleasures of Constantinople depicts an ancient Turk smoking opium. 

Cocaine, like opium, also was widely dispensed at pharmacies in solutions of alcohol. Queen Victoria was fond of marijuana. Thomas Jefferson smoked marijuana grown on his plantation. He believed that marijuana should be sold at grocery stores the same as beer or wine. 

Billions of dollars are invested every year to develop drugs that affect behavior. A third of all the prescription drugs taken in the United States are given to affect mental activity. Millions of people ingest narcotics, tranquillizers, stimulants and sleeping pills, often harming themselves. 

Morphine, heroin, and methadone bind to opiate receptors to varying degrees, reflecting their chemical affinity. 

The basic addiction pathway in the brain is a dopamine pathway. Activation of this pathway accounts for the positive reinforcement feeling and makes us want to repeat the action that triggered that feeling. 

When activated by environmental stimuli, this pathway helps to make behavior adaptive and goal directed. 

Ingestion of chemicals gives the positive reinforcement without the linkage to environmental stimuli and can make behavior less and less environmentally responsive over time. 

This addiction pathway is activated by all substances that produce psychological dependence. 

Serotonin (5-HT) also plays a role in the addiction process owing to its regulation of impulse control 

Increased absenteeism Poor decisions and ineffectiveness on the job Poor quantity and/or quality in production High accident rates 

Late three times more often than other workers 

Uses three times more sick leave than others 

Five times more likely to file a workers compensation claim 

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CJ-Receptors are localized ia the brain stem and limbic stmcture, regions associated with endocrine function (76). In the periphery, CJ-receptors are found in the Hver, heart, ileum, vas deferens, and on lymphocytes and thymocytes. Although there is insufficient evidence to clearly define the functional role of CNS CJ-sites, based on the effects of PCP and the interaction of haloperidol with CJ-sites, CJ-receptor ligands may be antipsychotics or used for the treatment of substance abuse. Several CJ-receptor ligands have shown neuroprotective effects in vivo. Ifenprodil (315) and CNS 1102 (316) are being developed for treatment of stroke (Table 18). 

Is there an alcohol, drugs and substance abuse policy ... 

Check that there is an alcohol, drug and substance abuse policy that gives clear guidelines on handling the issues, dismissal, and rehabilitation. 

Benzodiazepines and other anxiolytics. Although benzodiazepines are widely used in the treatment of acute alcohol withdrawal, most nonmedical personnel involved in the treatment of alcoholism are opposed to the use of medications that can induce any variety of dependence to treat the anxiety, depression, and sleep disturbances that can persist for months following withdrawal. Researchers have debated the pros and cons of the use of benzodiazepines for the management of anxiety or insomnia in alcoholic patients and other substance abuse patients during the postwithdrawal period (Ciraulo and Nace 2000 Posternak and Mueller 2001). 

Ciraulo DA, Jaffe JH Tricyclic antidepressants in the treatment of depression associated with alcoholism. Clin Psychopharmacol 1 146—150, 1981 Ciraulo DA, Nace E Benzodiazepine treatment of anxiety or insomnia in substance abuse patients. Am J Addict 9 276—284, 2000 Ciraulo DA, Barnhill JG, Jaffe JH, et al Intravenous pharmacokinetics of 2-hydroxy-imipramine in alcoholics and normal controls. J StudAlcohol 51 366-372, 1990 Ciraulo DA, Knapp CM, LoCastro J, et al A benzodiazepine mood effect scale reliability and validity determined for alcohol-dependent subjects and adults with a parental history of alcoholism. Am J Drug Alcohol Abuse 27 339—347, 2001 Collins MA Tetrahydropapaveroline in Parkinson s disease and alcoholism a look back in honor of Merton Sandler. Neurotoxicology 25 117-120, 2004 COMBINE Study Research Group Testing combined pharmacotherapies and behavioral interventions in alcohol dependence rationale and methods. Alcohol Clin Exp Res 27 1107-1122, 2003a... 

Cowley DS Alcohol abuse, substance abuse, and panic disorder. Am J Med 92(suppl) 41S 8S, 1992... 

Kranzler HR, Rosenthal RN Dual diagnosis alcoholism and co-morbid psychiatric disorders. Am J Addict 12 (suppl 1) S26—S40, 2003 Kranzler HR, Tinsley JA (eds) Dual Diagnosis Substance Abuse andComorbid Medical and Psychiatric Disorders, 2nd Edition. New York, Marcel Dekker, 2004... 

Substance Abuse and Mental Health Services Administration Results from the 2002 National Survey on Drug Use and Health National Findings (DHHS Publ No SMA 03-3836). Rockville, MD, Substance Abuse and Mental Health Services Administration, 2003. Available at http //oas.samhsa.gov/nhsda/2k2nsduh/ Results/2k2Results.htm chap3. Accessed November 5, 2004. 

Therapeutic communities are supervised communal drug-free living situations for opioid and nonopioid drug abusers. Because substance abuse is viewed as a disorder of the whole person, the goal is a dramatic alteration of the addict s entire lifestyle (DeLeon 1985). Addicts are expected to five in these communities for 6—18 months. Therefore, they are not indicated for people who have a strong intimate relationship or stable employment. The community is a surrogate fam-... 

Comparable findings for lifetime prevalence of psychiatric disorders were obtained in another study of 133 persons, which also found that 47% received a concurrent DSM-III diagnosis of substance abuse or dependence (Khantzian and Treece 1985). The most frequently abused substances were sedative-hypnotics (23%), alcohol (14%), and cannabis (13%). Similar rates of psychiatric disorders were found in other studies of drug abusers (Mirin et al. 1986 Woody et al. 1983). Although such diagnoses do not imply causality, and, in many cases, opioid dependence causes or exacerbates psychiatric problems, some causal link seems likely (Regier et al. 1990). 

Ciraulo DA, Ciraulo AN Substance abuse, in Handbook of Clinical Psychopharmacology. Edited by TupinJP, Shader RI, Harnett DS.Northvale,NJ, Jason Aronson, 1988, p 143... 

Jaffe JH Drug dependence opioids, nonnarcotics, nicotine (tobacco), and caffeine, in Comprehensive Textbook of Psychiatry, 5th Edition, Vol 1. Edited by Kaplan HI, Sadock BJ. Baltimore, Williams c Wilkins, 1989, pp 642-686 Jaffe J, Knapp CM, Ciraulo DA Opiates clinical aspects, in Substance Abuse A Comprehensive Textbook. Edited by Lowinson JH, Ruiz P, Millman RB, et al. New York, Lippincott Williams and Wilkins, 2004, pp 158—165 Jarvis MA, Schnoll SH Methadone use dming pregnancy. NIDA Res Monogr 149 58— 77, 1995... 

McLellan AT Psychiatric severity as a predictor of outcome from substance abuse treatments, in Psychopathology and Addictive Disorders. Edited by Meyer RE. New York, Guilford, 1986, pp 97-139... 

McNicholas L, Howell EF Buprenorphine Clinical Practice Guidelines, Field Review Draft November 17, 2000. Rockville, MD, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Office of Pharmacologic and Alternative Therapies, 2000... 

Menk EJ, Baumgarten RK, Kingsley CP, et al Success of reentry into anesthesiology training programs by residents with a history of substance abuse. JAMA 263 3060-3062, 1990... 

Mirin SM, Weiss RD, Michael J Psychopathology in substance abusers diagnosis and treatment. Am J Drug Alcohol Abuse 14 139—157, 1988... 

Source. From the results of the 2002 National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration 2003). 

In the absence of a diagnosis of substance abuse, most patients taking benzodiazepines continue to benefit ftom treatment over extended periods of... 

A dramatically different pattern is found in surveys of drug abuse treatment facilities. Substance abuse treatment centers have reported that more than 20% of patients use benzodiazepines weekly or more frequently, with 30%— 90% of opioid abusers reporting illicit use (Iguchi et al. 1993 Stitzer et al 1981). Methadone clinics reported that high proportions ofurine samples are positive for benzodiazepines (Darke et al. 2003 Dinwiddle et al. 1996 Ross and Darke 2000 Seivewright 2001 Strain et al. 1991 Williams et al. 1996). The reasons for the high rates of benzodiazepine use in opioid addicts include self-medication of insomnia, anxiety, and withdrawal symptoms, as well as attempts to boost the euphoric effects of opioids. 

Limited results from clinical laboratory evaluations suggested that the GABAj l agonists zaleplon (Rush et al. 1999b) and Zolpidem (Rush et al. 1999a) produce effects that are consistent with abuse potential comparable to that of the benzodiazepine triazolam. The reported incidence of dependence on Zolpidem in the medical literature is low, compared with that for benzodiazepines, and is characterized by use of high doses, often in individuals with a history of substance abuse (Hajak et al. 2003 Vartzopoulos et al. 2000). 

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