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1. Substance Abuse and Dependence (a) Definitions i. Abuse A. definitions vary; generally, abuse is defined as substance use which may result in dependence, drug tolerance, and withdrawal symptoms (addiction). B. Usually applies to illicit substances (i.e., drugs, or other controlled substances) but can also refer to unsanctioned use of otherwise legal products such as paint, glue, or gasoline C. Abuse is not coextensive with actual addiction, but abuse often precipitates addiction ii. Dependence A. a physical, psychological, or behavioral state where the substance is necessary in order to function normally B. Occurs as a result of habituation; the “high” is reduced as the body acclimates to the drug. In some cases, the body stops producing certain chemicals to counterbalance the drug. When that occurs, weaning off the drug will produce withdrawal symptoms until the body re-adjusts C. Example: while cocaine, heroin, and alcohol create physical dependence, behavioral dependence is much more common among marijuana users. In those cases, “withdrawal” is experienced as a sense of anxiety or uncertainty about what to do with yourself during times when you would have otherwise smoked, and increased anxiety due to the need for other coping mechanisms besides marijuana. iii. Tolerance A. A physical state where increasing dosages are required to achieve the same effect as the initial dose B. “Chasing the Dragon” – as the body becomes more tolerant to the drug, the drug loses its potency, creating a need to increase the dose C. Overdoses occur for two reasons: either because of an unexpectedly pure or potent dose, OR because of intentionally increasing the dosage to counteract the tolerance effect iv. Withdrawal and the Rebound Effect A. Withdrawal symptoms are prima fascie evidence of dependence B. usually they take the form of the opposite of the drug’s effect (rebound) example: alcohol withdrawal results in tremors, agitation, sweating, anxiety, and CNS activation example: caffeine withdrawal results in crankiness, lack of concentration, drowsiness, and migraines C. Negative Reinforcement addiction becomes negatively reinforced when the illicit substance relieves the uncomfortable symptoms of withdrawal (b) Common Psychoactive Substances i. Depressants – reduce CNS activity by acting as a GABA agonist, producing relaxation, sedation, euphoria, amnesia, and in toxic doses, coma and respiratory arrest A. HIGH potential for dependence and tolerance due to anxiety and physical discomfort of withdrawal symptoms Alcohol alcohol withdrawal can cause “delirium tremens,” an extremely dangerous symptom which has a relatively high fatality rate Benzodiazepenes anti-anxiety medications (Xanax, Ativan) and the date-rape drug (rohypnol/flunitrazopam) Barbituates Tranquilizers; generally not used for anxiety due to possibility of overdose Inhalants paint, gasoline, glue, rubber cement, etc. greater possibility of brain damage due to direct aspiration of chemicals into the olfactory neurons B. Anti-Histamines produce sedative effects by blocking the action of histamines, rather than GABA receptors includes diphenhydramine (benadryl), which is sometimes prescribed off-label for anxiety and insomnia (DO NOT DO THIS, YOU COULD DIE) ii. Opiates A. produce euphoria and pain relief (analgesia) by acting on opiate receptors in the nucleus accumbens and sensory nerves B. HIGH probability of dependence and addiction due to (a) positive reinforcement of euphoria and (b) negative reinforcement of pain relief C. withdrawal symptoms include severe, intractable pain which is usually not harmful but which lasts for the duration of the withdrawal period due to temporary reduction in endorphin production. This reduction MAY be permanent D. substances include opium and its derivatives (morphine, heroin, oxycodone, hydrocodone) E. Overdose causes CNS arrest, coma, and death iii. Stimulants A. produce feelings of alertness, energy, resistance to fatigue, and positive mood by far the most commonly abused substances legal stimulants have mild withdrawal symptoms and low use cost, reducing incentive to stop using Action varies by substance B. Caffeine blocks adenosine receptors, which normally signal fatigue increases dilation of blood vessels in the body decreases dilation of cranial blood vessels, reducing headaches found in OTC migraine preparations, usually with acetaminophen, and in prescription migraine medication such as Fioricet (with acetaminophen and bulbital, a barbituate). Withdrawal CREATES migraines C. Methylphenidate (Ritalin) and Amphetamine/Dextroamphetamine (Adderall/Dexadrine) used to treat attention deficit disorder if abused, creates dependency and contributes to behavioral problems dopamine and norepinephrine agonists D. Ephedrine and Psuedoephedrine stimulate cranial nerves to reduce inflammatory responses (used as decongestants), and used in the creation of methamphetamine E. Nicotine acetylcholine agonist highly addictive F. Cocaine Dopamine and Norepinephrine RI and increases DO and NE production G. Amphetamines (and derivatives) includes methamphetamine, crystal meth, MDMA (Ecstasy) H. Withdrawal symptoms include sluggishness, depression I. Can cause “stimulant induced psychosis” due to increase in dopamine iv. Psychedelics A. increase dopamine and serotonin, thereby increasing euphoria and sensory awareness B. Generally not physically addictive due to varying experiences (i.e., the possibility of a “bad trip”) C. LSD increases dopamine and serotonin, producing perceptual hallucinations can also cause paranoia and terror (the bad trip) D. THC low-dose hallucinogen which produces vague feelings of wellbeing as well as heightened perceptual experiences E. Psylocibin (Mushrooms) F. Mescaline G. Bufotenin with DMT, the hallucinogenic compound found in cane toad secretions (Bufo means “toad”) H. Ayahuasca brewed from plants containing dimethyltryptamine (DMT) combined with a plant which yields an MAOI (which potentates the effect) v. Dissociatives A. produce out-of-body experiences, blackouts, anaesthesia (insensitivity to pain) B. Ketamine better tolerated as an anaesthetic than PCP C. Phencyclidine (PCP) initially used as an anaesthetic, but not tolerated well produces dissociative states and insensitivity to pain, causing individuals to be extremely violent and unpredictable since they are not stopped by normal pain stimuli