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Introduction

The National Institute of Drug Abuse (NIDA) defined addiction “as a chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain. It is considered both a complex brain disorder and a mental illness.”[i] Other terminology defined by the NIDA include drug use which refers to any scope of the “use of illegal drugs: heroin use, cocaine use, tobacco use.” Drug misuse refers to the “improper or unhealthy use from use of a medication as prescribed or alcohol in moderation,” according to The Science of Use and Addiction. This includes the consistent use of drugs for pleasure, stress relief, and to alter or avoid reality. Drug misuse also includes using prescription drugs in ways other than prescribed or using someone else’s prescription. Finally, substance misuse implies that use can cause harm to the user.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a diagnostic manual of mental disorders recognized by the American Psychiatric Association (APA). The DSM-5 contains a listing of all mental disorders, their descriptions, and symptoms. However, the DSM-5 does not identify addiction as a condition due to the stigma associated with the term. In 2013, the DSM-5 was updated by the APA and replaced the conditions of “substance abuse” and “substance dependence” with “substance use disorder.”

According to the American Psychiatric Association, “substance use disorder (SUD) is a complex condition in which there is the uncontrolled use of a substance despite harmful results. Individuals with SUD have a concentrated focus on using a certain substance(s) such as alcohol, tobacco, or illicit drugs, to the extent where the person’s capability to function in daily life is impaired. People will continue to use the substance even when they know it is causing or will cause problems.[ii]  Addictions are the most severe form of SUDs. Strong desires result from changes in the brain’s structure and function.  These changes may affect an individual’s decision-making process, memory, and behavioral patterns and exist for long periods after the effects of the substance cease. Individuals can develop substance use disorders to marijuana, opioids, sedatives, alcohol, and tobacco.[iii]

According to the National Institute on Drug Abuse, individuals begin taking drugs for a variety of reasons. These include

  • to feel good,

  • to feel better,

  • to do better,

  • curiosity and peer pressure.[iv]



Physical dependence will  occur with regular use of any substance, even if a healthcare practitioner prescribed it. This dependence occurs because the body adjusts to regular contact with the substance regardless of it being a prescription, over-the-counter medication, controlled substance, or food product. When the body is no longer receiving the substance, signs may develop while the body is readjusting to the loss of the substance. In addition, withdrawal symptoms may develop when it has been withdrawn from the body. Tolerance refers to having a higher dose of medication to obtain the same effect.



Consider the following:

  • Almost 21 million Americans have at least one addiction, yet only 10% of them receive treatment.

  • Alcohol and drug addiction holds a cost of over $600 billion for the U.S. economy every year.

  • About 20% of Americans who suffer from depression or an anxiety disorder also suffer from a substance use disorder.

  • More than 90% of people who have an addiction started drinking alcohol or using drugs before the age of 18.

  • Americans between the ages of 18 and 25 are most likely to use addictive drugs.[v]


[i] NIDA. 2020. What is Drug Addiction. Retrieved from https://www.drugabuse.gov/pubNIDAlications/media-guide/science-drug-use-addiction-basics.  Accessed May 2, 2021

[ii] APA. What is substance Use Disorder? Retrieved from https://www.psychiatry.org/patients-families/addiction/what-is-addiction.  Accessed May 9, 2021

[iii] APA. 2021. What is substance Use Disorder? Retrieved from https://www.psychiatry.org/patients-families/addiction/what-is-addiction. Accessed May 9. 2021

[iv] APA. 2021. What is substance Use Disorder? Retrieved from https://www.psychiatry.org/patients-families/addiction/what-is-addiction. Accessed May 9, 2021

[v] https://www.addictioncenter.com/addiction/addiction-statistics/ Accessed May 2,2021.

Etiology



Addiction is a disease. Advances in neuroscience and imaging technology have improved our understanding of addiction and have supported the brain disease model of addiction. This model examines the genetic and environmental factors that precipitate physical changes to the brain. The brain disease model takes into consideration an individual’s genetic inclination to addiction, behavioral addictions, and psychopharmacological care  The three primary symptoms of addiction include (1)  a diminished response of stimuli  to the brain; 2) increased effect of the dependent substance on the individual  (3) declining function of areas of the brain responsible for decision making and self-control.[i]



It has been demonstrated that brain physiology plays a vital role in addiction: First, specific hereditary traits can make an individual more susceptible to developing a physical dependence after contact with a rewarding stimulus. Second, physical changes caused by this contact strengthen the dependence by declining brain function required for self-control and motivation to remain sober even in extreme consequences.



The neurotransmitter dopamine plays a crucial role in studying addiction. The release of dopamine by addictive substances in the brain results in a “high” feeling. Specific dopamine receptors known as D2 receptors  are located in specific regions of the brain.    These receptors are responsible for  motivating an  individual to sacrifice instant gratification to work toward a challenging but larger reward.[ii] Conversely, when there is a lower dopamine response among D2 receptors, individuals begin to seek experience compulsive short-term reward-seeking behavior.[iii],  Some people have a genetic tendency for fewer D2 receptors in the brain that makes them naturally inclined toward spontaneity and more susceptible to addiction.[iv]  Conversely, those individuals who have higher D2 receptor availability in the brain are more likely to be successful with behavioral interventions. .[v]

Continued alcohol or drug use results in a reduction of D2 receptors. [vi] This continued use results in the brain attempting to reduce dopamine levels in the brain resulting in the need for more of the substance to experience the associated “high” by the individual. Addiction is more likely to occur due to the loss of D2 receptors  and it becomes much more difficult for the individual to maintain sobriety. [vii] In addition, long-term drug use triggers changes in other brain chemical systems impacting functions that include learning, judgment, decision-making, memory, and stress.

Risk Factors

 Various factors influence an individual’s risk for abuse that may eventually lead to addictions. The greater number of risk factors a person possesses, the greater the chance that taking drugs can lead to addiction. Meanwhile, an individual’s risk for addictions can be reduced by possessing a large number of protective factors.  Both risk and protective factors can affect individuals at different phases of their lives. Examples of risk factors include early aggressive behavior, lack of parental support, substance abuse, drug availability, and poverty. On the other hand, protective factors such as self-control, parenteral monitoring, academic competence, and a strong neighborhood involvement can alleviate these risk factors. For example, aggressive behavior can be altered or prevented with family, school, and community interventions that focus on assisting individuals in nurturing suitable positive behaviors. If not properly dealt with, these negative behaviors can lead to more risks, such as academic failure and social difficulties, which jeopardize later drug abuse. When the presence of protective factors dominates the risk factors, the possibility of abuse and addiction diminishes.[viii]

An individual’s aggressive behavior, difficult disposition, or lack of self-control may be risk signs for drug abuse. The user’s family life may provide an environment favorable for substance abuse if they suffer from a lack of attachment and development by their parents or a parent who abuses drugs. The risk of abuse decreases when a strong bond between children and parents or parents is actively involved in their child’s life. Associating with drug-abusing peers is another risk factor for an individual. Drug availability and beliefs that drug abuse is socially accepted are risks that can influence an individual to start abusing drugs. Key risk periods for drug use occur during major transitions in an individual’s life, whether social, emotional, educational, or occupational. During these transitions, the individual may be exposed to the greater availability of drugs, social activities involving drugs, and perhaps drug abusers. These challenges can increase the possibility that the individual will abuse other substances to include alcohol and tobacco.

           

Diagnosis



Substance-use related disorders result from the use of 10 classifications of drugs: alcohol; caffeine; cannabis; hallucinogens (phencyclidine and other hallucinogens, such as LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (including amphetamine-type substances and cocaine); tobacco; and other or unknown substances. In addition, substance-related disorders can be categorized either as substance-use disorders and substance-induced disorders. Substance-use disorders (SUD) are defined as patterns of symptoms resulting from a substance that an individual continues to take, despite experiencing problems. Substance-induced disorders are specified alongside substance use disorders and include intoxication, withdrawal, and other substance/medication-induced mental disorders. [ix]



Substance use disorder is subclassified into three categories-mild, moderate and severe.  The symptoms accompanying each substance use disorder are categorized into four major groupings: impaired control, social impairment, risky use, and physical dependence  criteria. Impaired control consists of

  • Using more of a substance or using it more frequently

  • Unable to cut down usage despite wanting to do so

Social impairment includes

  • Disregarding responsibilities and relationships

  • Abandoning former activities because of substance use

  • Unable to complete tasks at home, work, or school

Risky use includes

  • Using substances in risky settings

  • Continuing to use the substance despite known problems

Physical dependence includes

  • Requiring more of the substance to experience the same effect

  • Developing withdrawal substances when the substance isn’t used

If an individual exhibits two or three criteria it is classified as a “mild disorder,”  four or five criteria indicate the SUD is classified as being  “moderate, and six or more criteria present signifies the individual’s condition is  considered  as being “severe.” [x]

Symptoms

The symptoms associated with substance use disorders can be classified into physical, behavioral, and emotional signs. Physical symptoms include:

  • dilated pupils

  • red eyes

  • excessive sniffing

  • runny nose

  • sudden weight loss or gain

  • deterioration in physical appearance

  • unusual odors or body odors due to a lack of personal hygiene

  • looking pale or undernourished

  • tremors

  • slurred speech

  • impaired coordination

  • repetitive speech patterns

  • withdrawal symptoms

  • increasing tolerance

An individual may demonstrate behavioral changes which include

  • missing work, school, or important engagements

  • frequently getting into trouble

  • relationship/marital problems

  • financial problems

  • legal issues

  • engaging in risky behaviors

  • changes in appetite or sleep patterns

  • mood swings

  • irritability

  • mania

  • apathy

  • paranoia .[xi]

Emotional signs demonstrated by an individual with substance use disorders include:

  • argumentative

  • defensiveness

  • anxious

  • Uninterested in friends and activities

  • confusion

  • denial

  • rationalizing

  • minimization

  • blaming [xii]

FORMS OF ADDICTION

Marijuana

Would you believe:

  • Fifty-five million (16.9%) American adults currently use marijuana.

  • Thirty-five million Americans use marijuana on a monthly basis.

  • 45% of American who have tried marijuana at least once.

  • 24% of 12th graders who have used in the past year (2017).

  • 72% of Americans say that regular alcohol use is more of a health risk than the everyday use of marijuana.

  • 76% of the population believe it is less harmful than tobacco

  • 67% believe the same in terms of prescription painkillers.

  • 56% of Americans believe marijuana is socially acceptable. [xiii]

Marijuana (cannabis) refers to the dried flowers and leaves  from the Cannabis sativa or Cannabis indica plant.  The Drug Enforcement Administration classifies marijuana as a Schedule I controlled substance,. Marijuana contains the mind-altering cannabinoid  THC (delta-9-tetrahydrocannabinol).  Users may smoke marijuana  as a  “joint” , in a pipe, or in a “bong.”  Some individuals use vaporizers to avoid inhaling the smoke .  Food mixed with marijuana are referred to as edibles. Edibles include brownies, candy or brewed as a tea,   Dabbing refers to smoking THC-rich resins or extracts. These extracts may be in the form of hash oil (a gooey oil), wax, or budder (a soft solid with a consistency like lip balm or shatter, a hard, amber-colored solid.

Marijuana may cause both short and long-term effects on the brain. THC acts on specific brain cell receptors that generally react to natural THC-like chemicals. These substances play a role in ordinary brain development and function. Marijuana triggers parts of the brain that contain the highest number of these receptors resulting in a “high” the individual experiences. The user may experience other short-term effects, including a distorted sense of time, impaired body movement and memory, difficulty with thinking and problem-solving, mood changes, and hallucinations.  

When an individual begins marijuana usage as a teenager, the drug may impair their thinking, memory, and learning functions. This, in turn, affects the processes used by the brain in building links between the areas of the brain necessary for these functions.

Marijuana usage may cause both physical and mental effects on the user. Marijuana smoke irritates the lungs. Frequent marijuana use may result in breathing problems comparable to those experienced by tobacco users. These problems include the presence of a cough, phlegm, lung illness, and a higher risk of lung infections. After smoking marijuana, the user may notice an increased heart rate for up to three hours which may precipitate a heart attack. Marijuana usage during pregnancy may result in lower birth weight and an increased risk of brain and behavioral problems in babies. Studies demonstrate a fetus subjected to their mother’s marijuana use have an increased risk of  attention difficulty,[xiv] and memory issues compared to an unexposed fetus.[xv]  

Moderate amounts of THC have been detected in the breast milk of nursing mothers.[xvi]  Individuals engaging in long-term marijuana usage may develop Cannabinoid Hyperemesis Syndrome, characterized by cyclic episodes of nausea and vomiting and frequent hot bathing.[xvii] In combination with alcohol, marijuana increases the heart rate and blood pressure and slows an individual’s mental processing and reaction time. It has been demonstrated that long-term marijuana usage has been associated with mental illness to include depression, anxiety, temporary paranoia, and hallucinations.

Substance use disorder may occur as a result of previous marijuana use,  Withdrawal symptoms associated with long-term marijuana usage include sleeplessness, decreased appetite, anxiety, and irritability. Currently, there are no medications approved to treat marijuana use disorder. Behavioral therapies as treatment options include cognitive-behavioral therapy (CBT), contingency management, and motivational incentives.

It is now legal in some states to purchase marijuana for medical and adult (recreational) use. Although marijuana may be used for its pleasurable “high,” it does impair short-term memory and learning, the user’s ability to focus, and coordination. In addition, marijuana usage increases the heart rate, injures the lungs and can increase the risk of psychosis in susceptible  people.   Studies indicate 30 percent of marijuana users  may have some degree of marijuana use disorder.[xviii] In addition, individuals who begin using marijuana before the age of 18 are more prone than adults to develop a marijuana use disorder.[xix]

Medical Marijuana

Many states have legalized marijuana for medical use. However, the scientific evidence to date is insufficient to obtain U.S. Food and Drug Administration (FDA) approval. There have not been enough clinical trials demonstrating the health benefits of marijuana outweigh its health risks. All medications require clinical trials to be conducted in thousands of patients to determine the help of the medications outweigh its risks. Consistency is essential with medication in choosing the correct dose, dosage form, and frequency of administration. The marijuana plant contains hundreds of chemical components that may exert different effects on an individual. Variations exist between the marijuana plant, and therefore the process of assessing the whole plant as a medication can be challenging.

The FDA has approved THC containing dronabinol (Marinol®) and nabilone (Cesamet®). Dronabinol is indicated for anorexia and weight loss associated with AIDS and chemotherapy-related nausea and vomiting, and nabilone is indicated for nausea/vomiting. Both are available as oral preparations. In addition, the FDA approved cannabidiol (Epidiolex®) which is derived from the marijuana plant and is indicated for Dravet syndrome and Lennox-Gastaut syndrome, both of which are forms of severe childhood epilepsy. Finally, Nabiximols (Sativex®), a mouth spray currently available in the United Kingdom, Canada, and several European countries. It is indicated for treating the spasticity and neuropathic pain associated with multiple sclerosis. Unfortunately, little is known about the long-term effects of medical marijuana with health and or age-related weaknesses in individuals with cardiovascular disease, multiple sclerosis, or cancer.

Synthetic cannabinoids

According to the National Institute on Drug Abuse, synthetic cannabinoids are man-made mind-altering chemicals.  These chemicals may be applied to   “dried, shredded plant material.”[xx] These synthetic cannabinoids are comparable to chemicals found in the marijuana plant  and  are advertised as safe, legal alternatives to marijuana. Synthetic cannabinoids  can be smoked or vaporized. However, their effects are often unpredictable and maybe more dangerous or even toxic compared to marijuana.  Synthetic cannabinoids are classified as new psychoactive substances (NPS). NPS are unregulated mind-altering substances available on the market and are intended to produce the same effects as illegal drugs. These cannabinoids are marketed under various names such as K2, Spice, Joker, and Black Mamba. Their easy access and the common belief that synthetic cannabinoid products are natural and therefore harmless have contributed to their popularity among young people. However, unlike marijuana which can be detected through laboratory tests, synthetic cannabinoids are not easily detected.

Synthetic cannabinoids  attach to the same brain cell receptors as THC . Much is unknown regarding the effects of synthetic cannabinoids on the human brain. Still, research has demonstrated that they bind more powerfully than marijuana to the cell receptors affected by THC and can deliver greater effects. Their effects are similar to those produced by marijuana and include an elevated mood, a sense of relaxation, and altered perception symptoms of psychosis. Psychotic effects include confusion, anxiety, and hallucinations. Individuals using synthetic cannabinoids have experienced rapid heart rates, emesis, and suicidal thoughts. Withdrawal symptoms include headaches, anxiety, depression, and irritability. Increases in emergency room visits have occurred with synthetic cannabinoid use. Withdrawal symptoms from synthetic cannabinoid use include headaches, anxiety, depression, and irritability.  An overdose of synthetic cannabinoids can result in the user experiencing hypertension, a reduced blood flow to their heart, kidney damage, and seizures.The FDA has not approved any medications to treat synthetic cannabinoid addiction.

Prescription Medications

Would you believe:

  • 16.3 million (6%) of Americans over the age of 12 abuse prescription in a year.

  • Fifty-two million or 18.4% of Americans over the age of 12 have deliberately misused prescription drugs at least once in their lifetime.

  • Fewer than 1-in-10 prescription abusers misuse drugs with the goal to get high.

  • Prescription drugs are the third-most abused illegal substance after marijuana (with 19.4% of the population using) and cocaine (with 15.9% users).

  • Prescriptions are the fifth most abused substance after alcohol (65.5% usage) and tobacco products (26.7% usage).

  • Two million (12%) of prescription drug abusers are addicted.[xxi]

Prescription medications are being misused. According to National institute on Drug Abuse prescription misuse can occur if a patient takes their medication in a way that was not prescribed to them by their physician. This includes taking more of the medication at a given time or increasing the frequency of the dose. Prescription misuse can occur if an individual takes someone else’s medication as their own. Prescription misuse occurs if an individual takes a medication to experience the euphoria which it creates.  Misuse of prescription medications can lead to addiction  and possibly causing the individual to overdose, especially with controlled substances.  A common misconception among individuals is that since physicians or qualified prescribers prescribe the medication, the medication is safe when not used as intended. Commonly misused classifications of prescription drugs include opioid pain relievers, stimulants, and central nervous system (CNS) depressants.

Opioids

Would you believe:

  • People with some college or an associate degree are most likely to use opioids, with 4.2% using in 2019.

  • Opioid use increased among college graduates (+12% from 2018) and those who did not complete high school 8.1%Over 9.3 million (3.9%) people misuse opioids yearly.

  • Opioids are a factor in 72% of overdose deaths.

  • 68% of all opioid overdose deaths are attributed to synthetic opioids

  • Fentanyl and fentanyl analogs are a factor in 19.8% of all overdose deaths.[xxii]

Opioids are a classification of drugs from finding the opium poppy plant. Prescription opioids may be made directly from the opium poppy plant, while others are made synthetically in laboratories. Opioids are often prescribed to relax the body and relieve pain. Prescription opioids are indicated to treat moderate to severe pain as a cough suppressant and act as an antidiarrheal agent. Commonly prescribed opioids include hydrocodone, oxycodone, morphine, fentanyl, and codeine. As an analgesic, prescription opioids are safe when taken for a short time as prescribed by a licensed healthcare provider. However, individuals misuse prescription opioids by taking medicine in a manner or dose other than originally prescribed, taking another person’s medication, or taking the drug to experience a “high” sensation.

Opioids attach to and stimulate the opioid receptors on cells located in the brain, spinal cord, and other organs in the body. When opioids connect to these receptors, they impede pain impulses sent from the brain to the body and discharge large amounts of dopamine throughout the body. Releasing dopamine reinforces taking the drug, compelling the user to want to repeat the experience. Although opioids relieve pain, they can exert short-term effects, including drowsiness, constipation, euphoria, slowed breathing, and death. Hypoxia may occur, resulting in psychological and neurological effects, including coma, permanent brain damage, or death. When opioids are combined with alcohol, the heart, and breathing rate decrease, whereby the individual may go into a coma or death.  Other health-related issues include miscarriage, low birth weight, neonatal abstinence syndrome during pregnancy.  A higher risk of accidental misuse occurs in older adults since patients are often prescribed multiple prescriptions for multiple conditions, resulting in increased drug-drug interactions.

Misuse of prescription opioids may lead to substance use disorder and possibly addiction. Withdrawal symptoms include severe cravings, muscle and bone pain, uncontrollable leg problems, and sleep issues.  The FDA approved Lofexidine (Lucemyra®), a non-opioid medicine designed to reduce opioid withdrawal symptoms in 2018. Other pharmacological treatments approved for opioid dependence include methadone, buprenorphine, and naltrexone.  In addition, the FDA approved the sale of a device, NSS-2 Bridge, that can help ease withdrawal symptoms.[xxiii] Opioid overdoses do occur but can be treated using naloxone.

Central Nervous System (CNS) Stimulants

Central nervous system(CNS) stimulants are medications usually indicated to treat attention-deficit hyperactivity disorder (ADHD) and narcolepsy. Common stimulants include dextroamphetamine/amphetamine, methylphenidate, and dextroamphetamine.  Dopamine and norepinephrine are catecholamines found in the brain and are stimulated by CNS stimulants.  S Dopamine is a neurotransmitter and plays an active role in anticipating pleasure from substances or activities.  On the other hand, norepinephrine affects an individual’s blood vessels, blood pressure and heart rate, blood sugar, and breathing. Thus, stimulants increase an individual’s alertness, attention span and provide sense energy.

Prescription stimulants provide an individual with a sense of euphoria. Other short-term effects include increased blood pressure and heart rate, decreased blood flow throughout the body, increased breathing rate and blood sugar levels. High doses of prescription stimulants may elevate body temperature and cause an irregular heart rate, heart failure, or seizures. Frequent misuse of prescription stimulants within a short period may trigger an individual to encounter psychosis, anger, or even paranoia. Other health-related issues affecting an individual include the risk of contracting HIV and hepatitis due to sharing needles. In combination with alcohol, CNS stimulants hide the depressant effect of alcohol, increasing the risk of an alcohol overdose. An individual can overdose on stimulants and may experience restlessness, tremors, rapid breathing, confusion, aggression, and hallucinations. Stimulant overdoses may precipitate a myocardial infarction or seizure in an individual. Misuse of stimulants can result in substance use disorder, and withdrawal symptoms include sleep disturbances, fatigue, and depression. At the presenter, there are no approved FDA medications to treat CNS stimulant addiction.

Central Nervous System (CNS) Depressants

Central nervous system depressants slow brain activity, allowing them to be used for anxiety, panic attacks, and sleep disorders. They consist of benzodiazepines, non-benzodiazepine sedative hypnotics and barbiturates.

Benzodiazepines

Non-benzodiazepine Sedatives

Barbiturates




Alprazolam (Xanax®)

Zolpidem (Ambien®)

Phenobarbital

Clonazepam (Klonopin®)

Eszopiclone (Lunesta®)

Pentobarbital sodium (Nembutal®)

Lorazepam (Ativan®)

Zaleplon (Sonata®)


Diazepam (Valium®)



Triazolam (Halcion®)



Gamma-aminobutyric acid (GABA), a chemical that inhibits brain activity, is increased by CNS depressants.   This action causes drowsy and calming effects on an individual, making it practical for anxiety and sleep disorders. Initially, the individual may experience sleepiness and feel uncoordinated for several days.  Other effects from the use and misuse of CNS depressants include slurred speech, difficulty concentration, movement and memory problems, confusion, and dizziness. Long-term use of CNS depressants may require the dose to be titrated upward to achieve the same therapeutic effect. The misuse of CNS depressants may result in the risk of HIV and hepatitis from shared needles. When alcohol is taken with CNS depressants, the individual may experience a slow heart rate and breathing, leading to death. An overdose of a CNS depressant may result in hypoxia. Flumazenil (Romazicon) is indicated in treating benzodiazepine overdoses.  Substance use disorder may occur as a result of the misuse of CNS depressants. Individuals who become addicted to CNS depressants may experience withdrawal symptoms, including seizures, anxiety, agitation, insomnia, hallucinations, and an increased heart rate, blood pressure, and temperature. There are no FDA-approved medications to address CNS depressant addiction.

Over-the-Counter Medications

Unlike prescription medications which require an individual to have a valid prescription from a provider, over the counter (OTC) medications can be sold directly to individuals without a prescription.  Some OTC medications have active ingredients that have a potential for misuse. The two most common misused ingredients in OTC medications are dextromethorphan(DMX), a cough suppressant, and loperamide, an antidiarrheal drug. In addition, pseudoephedrine, a nasal decongestant contained in many OTC cold medicines, is used to make methamphetamine. Pseudoephedrine is classified as a “behind the counter (BTC)” medication as the result of the Combat Methamphetamine Epidemic Act of 2005.   There are limits to the quantity of BTC medication that can be purchased each month. In some states, the minimum age to buy pseudoephedrine is 18 years of age.[xxiv]

DXM is an opioid without pain reduction effects and does not act on the opioid receptors. In large doses, DXM can produce both a depressant and sometimes a hallucinogenic effect. In low doses, dextromethorphan may produce short-term effects similar to a marijuana-like “high” sensation. Hallucinations, extreme panic, and anxiety may occur if DMX is taken in higher doses.  The most common sources of abused DXM include over the counter cough syrups, tablets, and gel capsules. Many medications containing  DXM may are sometimes formulated with antihistamines and decongestants to treat allergy and congestions symptoms. “Robo-tripping” or “skittling” is a method of abusing DXM by mixing it with soda for flavor.

  

When taken in large amounts and mixed with other substances, Loperamide may cause the drug to act comparably to other opioids. Opioids attach to and stimulate opioid receptors in many areas of the brain, especially those involved in feelings of pain and pleasure. These receptors are also located in the brain stem, which manages body processes, such as blood pressure and breathing. Loperamide is misused for the euphoria it produces and to reduce cravings associated with opioid withdrawal symptoms. Other health-related issues resulting from loperamide misuse include constipation, loss of consciousness, cardiovascular toxicity, and kidney failure from urinary retention. Severe anxiety, vomiting, and diarrhea are typical withdrawal symptoms associated with loperamide.

Overdoses with dextromethorphan and loperamide can occur, resulting in slow and shallow breathing. Hypoxia may occur, resulting in short and long-term mental effects, nervous system effects, coma, permanent brain damage, and possibly death. DXM overdoses can be treated with naloxone. Unfortunately, there are no FDA-approved medications to treat addiction to dextromethorphan or loperamide.

           

Nicotine

Cigarettes and e-cigarettes contain the addictive stimulant, nicotine.. Due to the nicotine’s addictive potential, many people who smoke or vape find it challenging to quit. Both tobacco and vaping devices contain other harmful chemicals; burning tobacco can create these chemicals. Vaping devices turn chemicals and flavorings into a mist that combines with synthetic nicotine. These devices permit the user to inhale an aerosol, typically containing nicotine, flavorings, and other chemicals. Vaping is popular with teenagers and serves as a gateway for teens to use other nicotine products, including cigarettes, known to cause disease and premature death

When a person vapes an e-cigarette, the nicotine in e-liquids is readily absorbed from the lungs into the bloodstream. Upon entering the bloodstream, nicotine triggers the adrenal glands to release the hormone epinephrine. Epinephrine is a central nervous system stimulant where it elevates an individual’s blood pressure and heart rate and causes shortness of breath,.[xxv] In addition, nicotine activates the brain’s reward circuits and increases dopamine levels in the brain, strengthening rewarding behaviors. Due to nicotine’s interaction with the reward circuit, an individual will continue to use nicotine despite the health risks.

The short-term health effects of nicotine use include elevated blood pressure and heart rates and breathing problems. Smoking tobacco subjects the lungs to a variety of chemicals, while vaping causes metallic vapors created by the vaping device to damage the lungs. Long-term effects due to nicotine usage increase the risk of bronchitis, emphysema, and developing lung cancer and oral cancers from chewing tobacco. In teenage users, nicotine can alter the development of brain circuits that control attention and learning. Nicotine use by pregnant women can result in miscarriages, low birth weight, learning and behavior problems for the child. Vaping products are often combined with Vitamin E acetate, leading to irritability, sleep problems, and an increased appetite due to nicotine withdrawal.

Alcohol Use Disorder

Would you believe:

  • 95,000 individuals die each year in the United States as a result of excessive alcohol use i

  • Excessive alcohol use cost the US economy $249 billion in 2010.,

  • Binge drinking is responsible for almost half the deaths and three-quarters of the costs associated with  excessive alcohol use.

  •  Binge drinking is more common in men than women [xxvi]

Alcohol use disorder (AUD) is a chronic medical condition characterized by an impaired ability to stop or control alcohol use despite unpleasant outcomes . Alcohol use disorder may affect an individual’s health, occupation or social life.   AUD is considered a brain disorder. Changes in the brain attributed to alcohol misuse may contribute to AUD and make an individual susceptible to relapse. Alcohol misuse does include “binge drinking.” The National Institute on Alcohol Abuse and Alcoholism  defines “binge drinking” as  “a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 percent—or 0.08 grams of alcohol per deciliter—or higher.” Putting this into perspective means a male would drink five or more drinks in 2 hours or a female drinking four or more drinks in the same time period.  [xxvii]  Factors contributing to the risk for AUD include the amount of alcohol consumed, frequency of consumption, how fast alcohol is consumed, drinking at an early age, genetics, family history of alcohol issues, and mental health disorders.

An individual is diagnosed with alcohol use disorder based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Assessment is based upon questions posed to the individual by a qualified healthcare practitioner. Possible questions posed might include:

  • Have you had times in the past years where you ended up drinking more or longer than you intended?

  • Have you ever wanted in the past year to cut down or stop drinking, or tried to, but couldn’t?

  • Have you found that drinking interfered with taking care of your home or family?

  • Have you ever cut back on activities that were important or interesting to you or gave you pleasure to drink?[xxviii]

Excessive alcohol use can increase the risk of many unsafe health conditions, including injuries from motor vehicle accidents, falls, unintended pregnancies, sexually transmitted infections, and poor pregnancy outcomes. Chronic health effects due to excessive alcohol use include difficulties with learning, memory, and mental health. In addition, excessive alcohol use can affect the cardiovascular (e.g., hypertension and dysrhythmias), digestive (hepatitis, fibrosis, and cirrhosis), and immune (cancers of the mouth, throat, and liver) systems.[xxix]

Substance Use Disorder Treatments

Medications and behavioral therapies are the basis for successful long-term outcomes for patients diagnosed with substance use disorder. Effective drug addiction treatment is based upon the following principles:

  1. Addiction is a  treatable disease that affects both brain function and behavior.

  2. Treatment must be individualized for the patient.

  3. Treatment needs to be readily available.

  4. Effective treatment must address all factors causing the patient’s substance use disorder. .

  5. Remaining in treatment for an adequate period of time is critical to prevent relapses.

  6. Counseling and  behavioral therapies play an important in the patient’s treatment.

  7. Medications play an important role in many patient’s treatment in conjunction with their therapy.

  8. A patient’s treatment plan must be constantly evaluated and modified to meet the patient’s needs.

  9. Many patients with substance use disorder possess  other mental disorders.

  10. Medically assisted detoxification is  the first step of addiction treatment and by itself does little to change long-term drug abuse.

  11. Effective treatment may be either voluntary or involuntary.

  12. Drug use during treatment must be monitored continuously, since  lapses may occur..

  13. Patients should be evaluated for the presence of HIV/AIDS, hepatitis B and C, tuberculosis,  and infectious disease. Counseling should be provided to patients to modify risky behaviors which place them at risk for contracting infectious diseases. [xxx]

A variety of medications are indicated for treating opioid, alcohol, and nicotine use disorders.

Medication

Indication

Dosage Form

Other Information





Buprenorphine/Naloxone

Opioid use disorder

Sublingual or buccal film tablets

Indicated for opioid dependence.

Buprenorphine Hydrochloride

Opioid use disorder

Sublingual tablets and implants



Indicated for opioid dependence induction and opioid dependence maintenance


Methadone

Opioid use disorder

Tablets, suspension, oral concentrate, oral solution

Methadone providers must be registered with an Opioid Treatment Program.

Naltrexone

Opioid use disorder; alcohol use disorder

Tablets and extended-release suspension

Antagonizes opioid receptors

Acamprosate

Alcohol use disorder

Delayed-release tablet

Used in the maintenance of alcohol abstinence.

Disulfiram

Alcohol use disorder

Tablet

Disulfiram causes nausea, flushing and heart palpitations if alcohol is consumed within the 12 past hours

Nicotine Replacement Therapies

Nicotine use disorder

Transdermal patches, gum, lozenges, and inhalers

Nicotine replacement therapy helps alleviate withdrawal symptoms

Bupropion HCl

Nicotine use disorder

Tablet

In addition to being an antidepressant bupropion HCl has shown to effective as a smoking cessation medication. in treating tobacco addiction.

Varenicline

Nicotine use disorder

Tablet

Helps reduce nicotine cravings.[xxxi]

Various behavioral therapies have shown to be beneficial in treating individuals with substance use disorders and other affective disorders.

  • Cognitive Behavioral Therapy (CBT) is designed to modify harmful beliefs and maladaptive behaviors and show strong efficacy for substance use disorders. CBT is based upon the belief that psychological problems occur as a result of faulty thinking and/or learned patterns of poor behavior. Individuals with psychological problems can benefit by developing appropriate coping mechanisms to relieve their symptoms.

    • Strategies employed in CBT treatment are directed toward changing an individual’s thinking patterns and include:

    • Learning to acknowledge one’s distortions in thinking which are producing problems, and then reexamining them.

    • Developing a better understanding of the behavior and motivation of others.

    • Utilizing problem-solving skills to manage difficult situations.

    • Developing a sense of confidence in one’s talents.[xxxii]

  • Assertive Community Treatment (ACT) programs integrate behavioral treatments for severe mental illnesses such as schizophrenia and co-occurring substance use disorders. ACT is based on the that people receive optimum care when their mental health care providers work together. The patient is assisted by others in addressing every facet t of their life, whether it be medication, therapy, social support, employment, or housing. An ACT program benefits patients who have been transferred from an inpatient facility but still require a similar level of care but in a more relaxed environment. [xxxiii] 

  • Dialectical Behavior Therapy (DBT) is a form of cognitive-behavioral therapy where the patient learns to live in the moment, develops healthy ways to handle stress, controls their emotions, and develops healthy relationships with others. By learning these techniques, the individual is able to reduce their self-destructive behaviors, which may include continued drug use, suicidal thoughts and/or attempts. . DBT can occur in private, group, or private sessions. Strategies employed include developing mindfulness skills where the individual learns to “live in the moment, build distress tolerance skills to accept yourself and your current situation, acquire interpersonal skills that allow you to become more assertive and improve emotion regulation techniques which allow you to direct your strong feelings effectively. [xxxiv]

  • Therapeutic Communities (TC) area long-term residential treatment facility for patients diagnosed with substance use disorders. TCs promote a complete lifestyle and identify areas for change in the patient’s life that can lead to substance misuse. The therapeutic community model focuses on the use of the community as a therapist and teacher in the treatment process and an extremely organized and continuous process of self-reliant operation.[xxxv] In addition, the therapeutic community introduces the patient to new values and practices to replace those practices that led to their substance misuse. Evidence suggests that TCs may be beneficial for adolescents who have received treatment for substance use and addiction.

  • Contingency Management (CM) or Motivational Incentives (MI) is used as an adjunct to treatment. Voucher-based reinforcement (VBR) or prize-incentive CM stems reward patients who practice healthy behaviors and reduce unhealthy behaviors, including smoking and drug use. A voucher is issued to the patient for every drug-free urine collected from the patient and can be exchanged for food or other services. The VBR system voucher values gradually increase as the number of repeated drug-free urine samples increases; positive urine samples readjust the value of the vouchers to the initial value. Prize incentive CM-based treatments are effective for improving treatment compliance and reducing tobacco and other drug use. They can be incorporated into behavioral health treatment programs for individuals with co-occurring disorders. It is similar to the VBR system but uses opportunities to win cash prizes as an alternative to the value of a voucher. Each time a drug-negative urine or breath sample is collected from the patient, they become eligible for a monetary prize. Completing counseling sessions or meeting weekly goals qualifies the individual for additional drawings. In addition, individuals may also be eligible for additional drawings for attending counseling sessions and completing weekly goal-related activities. Failing to have successive negative drug tests resets to start again.[xxxvi]

Conclusion

An addiction is a compulsive psychological need for a habit-forming substance that upon discontinuation results in withdrawal symptoms. They can involve legal and illegal substances. Addictions may occur with prescription, over the counter, and behind-the-counter medications. Addiction may cause both short and long-term effects on the user. Addictions can be treated with medications and behavioral therapies.  



[i] Butler Center for Research. 2016. The Brain Disease Model of Addiction. Retrieved from  https://www.hazeldenbettyford.org/education/bcr/addiction-research/brain-disease-model-ru-316.   Accessed May 5, 2021

[ii] Trifilieff, P. & Martinez, D. (2014). Imaging addiction: D2 receptors and dopamine signaling in the striatum as biomarkers for impulsivity. Neuropharmacology, 76, 498–509. Accessed May 2, 2021.

[iii] Kenny, P. J., Voren, G., & Johnson, P. M. (2013). Dopamine D2 receptors and striatopallidal transmission in addiction and obesity. Current Opinion in Neurobiology, 23, 535–538. Accessed May 2, 2021.

[iv] Belcher, A. M., Volkow, N. D., Moeller, F. G., & Ferré, S. (2014). Personality traits and vulnerability or resilience to substance use disorders. Trends in Cognitive Sciences, 18(4), 211–217. Accessed May 2, 2021.

[v] Trifilieff, P. & Martinez, D. (2014). Imaging addiction: D2 receptors and dopamine signaling in the striatum as biomarkers for impulsivity. Neuropharmacology, 76, 498–509. Accessed May 2, 2021.

[vi] Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016). Neurobiologic advances from the brain disease model of addiction. The New England Journal of Medicine, 374(4), 363–371. Accessed May 2. 2021.

[vii] Belcher, A. M., Volkow, N. D., Moeller, F. G., & Ferré, S. (2014). Personality traits and vulnerability or resilience to substance use disorders. Trends in Cognitive Sciences, 18(4), 211–217. Accessed May 2, 2021

[viii] NIDA. 2020, May 25. What are risk factors and protective factors? Retrieved from https://www.drugabuse.gov/publications/preventing-drug-use-among-children-adolescents/chapter-1-risk-factors-protective-factors/what-are-risk-factors  Accessed May 2, 2021

[ix] Hartney, E. 2021, March 21. DSM 5 Criteria for Substance Use Disorders. Retrieved from https://www.verywellmind.com/dsm-5-criteria-for-substance-use-disorders-21926  Accessed May 3, 2021

[x] NIDA. 2020, June 25. The Science of Drug Use and Addiction: The Basics. Retrieved from https://www.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics  Accessed May 3, 2021

[xi] MentalHealth.gov 2019. Mental Health and Substance Use Disorders. Retrieved from https://www.mentalhealth.gov/what-to-look-for/mental-health-substance-use-disorders   Accessed May 5, 2021

[xii] MARR. 2021. Identifying Addictions. Retrieved from https://www.marrinc.org/signs-and-symptoms/  Accessed May 6, 2021

[xiii] NCDAS . 2019. Marijuana Addiction: Rates & Usage Statistics. Retrieved from https://drugabusestatistics.org/marijuana-addiction/  Accessed May 6, 2021

[xiv] Goldschmidt L, Day NL, Richardson GA. Effects of prenatal marijuana exposure on child behavior problems at age 10. Neurotoxicol Teratol. 2000;22(3):325-336. Accessed May 6, 2021.

[xv] Richardson GA, Ryan C, Willford J, Day NL, Goldschmidt L. Prenatal alcohol, and marijuana exposure: effects on neuropsychological outcomes at 10 years. Neurotoxicol Teratol. 2002;24(3):309-320. Accessed May 6, 2021.

[xvi] Perez-Reyes M, Wall ME. Presence of delta9-tetrahydrocannabinol in human milk. N Engl J Med. 1982;307(13):819-820. doi:10.1056/NEJM198209233071311. Accessed May 6, 2021.

[xvii] Galli, JA, Sawaya RA, Friedenberg FK. Cannabinoid Hyperemesis Syndrome. Curr Drug Abuse. 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576702/. Accessed May 7, 2021.

[xviii] Hasin DS, Saha TD, Kerridge BT, et al. Prevalence of Marijuana Use Disorders in the United States Between 2001–2002 and 2012–2013. JAMA Psychiatry. 2015;72(12): 1235-1242. doi:10.1001/jamapsychiatry.2015.1858. Accessed May 9, 2021.

[xix] Winters KC, Lee C-YS. Likelihood of developing an alcohol and cannabis use disorder during youth: Association with recent use and age. Drug Alcohol Depend. 2008;92 (1-3):239-247. doi:10.1016/j.drugalcdep.2007.08.005. Accessed May 9, 2021.

[xx] NIDA. 2018, February 5. Synthetic Cannabinoids (K2/Spice) DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/synthetic-cannabinoids-k2spice  Accessed May 24, 2021.

[xxi] NCDAS. 2019.  Prescription Drug Abuse Statistics. Retrieved from https://drugabusestatistics.org/prescription-drug-abuse-statistics/  Accessed May 10, 2021

[xxii] NCDAS. 2019. Opioid Epidemic: Addiction Statistics. Retrieved from https://drugabusestatistics.org/opioid-epidemic/  Accessed May 11, 2021

[xxiii] NIDA. 2020, May 27. Prescription Opioids DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/prescription-opioids  Accessed May 13, 2021

[xxiv]NIDA. 2017, December 17. Over-the-Counter Medicines DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/over-counter-medicines   Accessed May 13, 2021

[xxv] NIDA. 2020, January 8. Vaping Devices (Electronic Cigarettes) DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/vaping-devices-electronic-cigarettes

 Accessed May 14, 2021

[xxvi] CDC. 2020, September 21. Excessive Alcohol. Retrieved from https://www.cdc.gov/chronicdisease/resources/publications/factsheets/alcohol.htm on 2021  Accessed May 15, 2021

[xxvii] NIAA. 2021, April. Understanding Alcohol Use Disorder. Retrieved from https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder on 2021, Accessed May 15, 2021

[xxviii] NIAA. 2021, April. Understanding Alcohol Use Disorder. Retrieved from https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder on 2021, Accessed May 15, 2021

[xxix] CDC. 2020, September 21. Excessive Alcohol Use. Retrieved from https://www.cdc.gov/chronicdisease/resources/publications/factsheets/alcohol.htm on 2021. Accessed May 16, 2021

[xxx] APA. 2021. What is Substance Use Disorder? Retrieved from https://www.psychiatry.org/patients-families/addiction/what-is-addiction  Accessed May 15, 2021

[xxxi] NIDA. 2021, April 13. What are the treatments for comorbid substance use disorder and mental health conditions? Retrieved from https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/what-are-treatments-comorbid-substance-use-disorder-mental-health-conditions   Accessed May 14, 2021

[xxxii] APA. 2021. What is Cognitive Behavioral Therapy? Retrieved from https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral   Accessed May 15, 2021

[xxxiii] NAMI. Psychosocial Treatments. Retrieved from https://www.nami.org/About-Mental-Illness/Treatments/Psychosocial-Treatments   Accessed May 15, 2021

[xxxiv] Schimelpfening, N. 2021, May 6. What is Dialectical Behavior Therapy (DBT). Retrieved from https://www.verywellmind.com/dialectical-behavior-therapy-1067402#what-is-dialectical-behavioral-therapy   Accessed May 15, 2021

[xxxv] Treatment of Adolescents with Substance Use Disorders. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK64342/  Accessed on May 15, 2021

[xxxvi] NIDA. 2018. Contingency Management Interventions/Motivational Incentive (Alcohol, Stimulants, Opioids, Marijuana, Nicotine) Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies/contingency-management-interventions-motivational-incentives Accessed  May 15, 2021