Social Science

Chapter 2

Classification of Drugs

MyCounselingLab™

Visit the https://portal.phoenix.edu/content/ebooks/9780132613248-substance-abuse.-information-for-school-counselors/jcr:content/images/mycoulab.jpg site (www.MyCounselingLab.com) for Substance Abuse: Information for School Counselors, Social Workers, Therapists, and Counselors, Fifth Edition, to enhance your understanding of chapter concepts. You’ll have the opportunity to practice your skills through video- and case-based Assignments and Activities as well as Building Counseling Skills units and to prepare for your certification exam with Practice for Certification quizzes.

Case Examples

https://portal.phoenix.edu/content/ebooks/9780132613248-substance-abuse.-information-for-school-counselors/jcr:content/images/one.jpg Casey is a 48-year-old male who visits his primary care physician. He complains of insomnia, anxiety, frequent acid indigestion, and fatigue. On his blood panel, he shows some impairment in his liver functioning. He is borderline diabetic and has hypertension.
https://portal.phoenix.edu/content/ebooks/9780132613248-substance-abuse.-information-for-school-counselors/jcr:content/images/two.jpg Matilda is a 33-year-old female who comes in to an emergency room complaining of severe lower back pain. An x-ray is negative. She is restless and agitated, has a runny nose, and complains of an upset stomach. Her vital signs are normal.
https://portal.phoenix.edu/content/ebooks/9780132613248-substance-abuse.-information-for-school-counselors/jcr:content/images/three.jpg Chris and his wife are seeing you for marriage and family therapy. Chris works in the financial industry in a high-paced, stressful environment. His wife says Chris hardly sleeps and does not eat regularly. His moods are erratic. The couple has some financial problems, which Chris attributes to bad investments. The couple was court-ordered to counseling following a domestic violence incident.

As we noted in Chapter 1, this textbook is designed for the mental health professional (e.g., school counselor, mental health counselor, rehabilitation counselor, social worker, marriage and family therapist) who will encounter AOD problems with clientele but who, generally, will not provide treatment for these problems. Therefore, the goal of this chapter is to provide an overview of the drugs (including alcohol and tobacco) that are most often abused and drugs that are used in the treatment of some mental disorders. However, a thorough understanding of the pharmacology of drugs and related issues (e.g., medical management of overdose, use of psychotropic medications in the treatment of mental disorders) would require far more attention than one chapter can offer. Also, information in this area changes rapidly as a result of research. For example, there is no medication that has been found to be effective in significantly reducing cocaine craving. However, there is considerable research in this area. By the time you read this book, there may be pharmacological management of cocaine withdrawal that does not currently exist. We are including an additional reading list at the end of this chapter if you want to acquire more comprehensive information on the topics discussed. In addition, we encourage you to develop contacts with AOD treatment providers who are likely to remain current with regard to research in this area. This will reduce the probability that you will pass along misinformation or outdated information to your clients.

Different methods exist that are used to classify drugs. We will use the method that classifies drugs by their pharmacological similarity. Drugs exist that do not fit nicely into one classification, and these will be noted. For each drug classification, we will mention the common drugs contained in the classification and some common street names, the routes of administration, major acute and chronic effects, signs of intoxication, signs of overdose, tolerance, and withdrawal. First however, we will present information on the federal schedule of drugs, a discussion of the concept of “dangerousness,” some simple definitions of terms that will be helpful in understanding the rest of the chapter, and a brief overview of the neurobiology of drugs.

Comprehensive Drug Abuse Prevention and Control Act

In 1970, the Comprehensive Drug Abuse Prevention and Control Act (often referred to as the Controlled Substances Act) was passed by the U.S. Congress. As part of this law, drugs are placed in one of five “schedules,” with regulatory requirements associated with each schedule. Schedule I drugs have a high potential for abuse, no currently accepted medical use in treatment in the United States, and a lack of a safe level of use under medical supervision. Drugs on Schedule I include heroin, methaqualone (Quaalude), LSD, and marijuana. Schedule II drugs also have a high abuse potential and can lead to psychological or physical dependence. However, these drugs have an accepted medical use in treatment. These drugs include morphine, PCP, cocaine, and methamphetamine. As you can probably surmise, the criteria for the other schedules involve less abuse potential, increased medical uses, and less likelihood of psychological and physical dependence.

As you will see from our discussion of the classification of drugs, the way some drugs are classified is clearly illogical. For example, benzodiazepines such as Valium and Xanax are Schedule IV drugs, with part of the criteria for inclusion being that the drugs have a lower abuse potential than drugs on Schedules I, II, and III. In reality, these drugs have at least the same if not greater abuse potential than marijuana, a Schedule I drug. However, the inclusion of a drug on a certain schedule is related to public policy, which will be discussed in Chapter 15. For example, the reclassification downward of a drug such as marijuana would be politically unpopular, and the reclassification of benzodiazepines upward would be resisted by the manufacturers of these drugs.

The Concept of Dangerousness

Related to the preceding discussion of schedules of drugs is the concept of the inherent dangers of certain drugs. Tobacco, alcohol, and other drugs are not safe to use. There are acute and chronic dangers, and these dangers vary by drug. For example, there is little acute danger from the ingestion of a glass of wine by an adult. The acute danger of shooting cocaine is far greater. Chronic use of any drug (including alcohol) has an increased risk, but the danger of smoking one pack of cigarettes a day for 40 years is greater than the dangers from drinking one beer a day for 40 years. Danger is also related to the method used to administer a drug. Smoking a drug or injecting it produces the most rapid and intense reaction, while ingesting a drug generally produces effects with longer duration, although less intensity. Snorting drugs is in between but has more similarities to smoking and injecting than ingesting. Although any method of administration may be dangerous both acutely and chronically, smoking or injecting drugs tends to result in the most acute problems since these routes of administration rapidly introduce the drug to the bloodstream and, subsequently, to the brain. Also, smoking drugs causes damage to the respiratory system, and the intravenous use of drugs may cause serious problems including abscesses, blood clots, allergic reactions to the substances used to “cut” the drug, and communicable diseases such as hepatitis and HIV.

It is certainly important that you understand the acute and chronic effects of different drugs and the addictive potential of tobacco, alcohol, and other drugs. However, it is essential that you understand that any of the psychoactive drugs we discuss in this chapter can be used in an addictive manner. You will learn that hallucinogens are not physically addicting in the sense that body tissues require these drugs for normal functioning. However, this does not imply that people are immune from serious problems resulting from the use of hallucinogens. Alcohol is clearly an extremely dangerous drug in spite of the fact that many people use the drug without problems. Marijuana is not as acutely or chronically dangerous as cocaine, but that does not mean it can be used safely. We have worked with clients who have serious life problems from marijuana use. This is not a sermon to “Just Say No.” It is a caution to avoid concluding that you can direct clients away from some drugs to other drugs, and a caution to avoid using your own experience with AOD as a basis for determining which drugs are safe and which are dangerous.

Definitions

Terminology in the AOD field can be confusing. One author may have a very specific meaning for a particular term while another may use the same term in a more general sense. An analogy might be the use of the term neurotic in the mental health field. While one professional may use this term when referring to some very specific disorders, another may use it to describe a wide variety of mental health problems. However, there is no universal agreement about how some of these terms should be used. Therefore, the following definitions should assist you in understanding this chapter and the rest of the book, but you may find differences in definitions as you read professional and popular literature in the AOD field.

Addiction: Compulsion to use alcohol or other drugs regardless of negative or adverse consequences. Addiction is characterized by psychological dependence (see below) and, often (depending on the drug or drugs) physical dependence (see below). As we will discuss in Chapter 14, the term addiction is sometimes applied to behaviors other than AOD (e.g., eating, gambling).

Alcoholism: Addiction to a specific drug: alcohol.

Chemical dependency: A term used to describe addiction to alcohol and/or other drugs and to differentiate this type of addiction from nonchemical addictions (e.g., gambling).

Dependence: A recurrent or ongoing need to use alcohol or other drugs. Psychological dependence is the need to use alcohol or other drugs to think, feel, or function normally. Physical dependence exists when tissues of the body require the presence of alcohol or other drugs to function normally. All psychoactive drugs can produce psychological dependence and many can produce physical dependence. Dependence will also be defined in Chapter 6, based on the criteria in theDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000), to diagnose AOD dependency disorders.

Intoxication: State of being under the influence of alcohol or other drugs so that thinking, feeling, and/or behavior are affected.

Psychoactive drugs: Natural or synthetic chemicals that affect thinking, feeling, and behavior.

Psychotropic drugs: Chemicals used to treat mental disorders.

Substance abuse: The continued use of alcohol and/or other drugs in spite of adverse consequences in one or more areas of an individual’s life (e.g., family, job, legal, financial). Abuse will also be defined in Chapter 6 according to the criteria in the DSM-IV-TR.

Tolerance: Requirement for increasing doses or quantities of alcohol or other drugs in order to create the same effect as was obtained from the original dose. Tolerance results from the physical or psychological adaptations of the individual.

Cross-tolerance: Refers to accompanying tolerance to other drugs from the same pharmacological group. For example, tolerance to alcohol results in tolerance to minor tranquilizers such as Xanax, even when the individual has never used Xanax.

Reverse tolerance: Refers to a condition in which smaller quantities of a drug produce the same effects as did previous larger doses.

Withdrawal: Physical and psychological effects that occur when a drug-dependent individual discontinues alcohol or other drug use.

The Neurobiology of Drugs1

1This information comes from the National Institute on Drug Abuse (NIDA) Drugs, Brains, and Behavior—The Science of Addiction (2010). Available athttp://www.nida.nih.gov/scienceofaddiction/index.html. All material, including illustrations, is in the public sector.

Drugs affect the brain by impacting the way nerve cells send, receive, and process information. Drugs such as heroin and marijuana activate neurons by mimicking natural neurotransmitters. Other drugs like methamphetamine and cocaine cause nerve cells to release extremely large amounts of neurotransmitters or prevent the normal reuptake of neurotransmitters into the nerve cells (see Figure 2.1).

Figure 2.1 Effect of drugs on neurotransmitters.

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Most drugs of abuse directly or indirectly target the brain’s reward system by releasing or blocking the re-uptake of the neurotransmitter dopamine. Dopamine is present in regions of the brain that regulate movement, emotion, cognition, motivation, and feelings of pleasure. When dopamine floods the neuron system in the brain’s reward center, euphoria results. Natural human behaviors (e.g., eating, sex) also release dopamine and the person experiences pleasure. Since our brains are designed for the survival of the species, we want to repeat these natural, pleasurable activities. However, when drugs stimulate the brain’s reward center, our brain is in effect “fooled” into believing that drug taking is also a survival behavior that should be repeated.

Many naturally pleasurable activities are not habitually repeated like drug taking can be. The neurobiological explanation is that 2 to 10 times more dopamine is released by drugs than by natural activities. Furthermore, depending on the method that drugs are administered, this dopamine release is almost immediate and is very intense. Therefore, the euphoric properties of drug taking can be very powerful and highly reinforcing.

Unfortunately, the brain adjusts to high levels of dopamine by producing less or reducing the number of dopamine receptors. When this occurs, the drug user has more difficulty experiencing pleasure and must increase the amount of drugs consumed to feel normal. This is referred to as “tolerance.” In Figure 2.2, the gray areas in the white ovals areas are dopamine transporters from PET scans of a normal brain and the brain of a methamphetamine abuser. You can clearly see the reduction of these gray areas in the methamphetamine abuser. When a drug abuser abstains from drugs for a period of time, the brain usually returns to normal. However, the length of time it takes depends on the type of drugs abused and the number of years that drugs were abused.

Figure 2.2 Effect of methamphetamine on the brain.

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Source: Am J Psychiatry 158:377–382, 2001.

The neurobiology of addiction is a very complex subject and this brief section is intended to give you only a conceptualized understanding of the topic. (See Table 2.1 for an overview of drug classifications.) There are additional readings at the end of the chapter for those who want to pursue this area in more detail.

Table 2.1 Summary Table of Drug Classifications

  Common Drugs Main Routes of Administration Major Acute Effects Major Chronic Effects Overdose Tolerance Withdrawal
CNS Depressants Alcohol, barbiturates, benzodiazepines, sleep aids Drinking, ingesting pills Relaxation, disinhibition, reduction of anxiety, impaired motor coordination Alcohol: Damage to every organ system Common with alcohol, can be dangerous, synergistic effect Develops rapidly, cross-tolerance occurs Can be medically dangerous
CNS Stimulants Cocaine, methamphetamine, caffeine, nicotine Snorting, smoking, injecting, drinking Alertness, mood elevation, increased heart rate and blood pressure Health damage from tobacco products, addiction, depression, suicidal ideation Tremors, sweating, tachycardia, anxiety, insomnia Rapid tolerance to pleasurable and stimulating effects Unpleasant and long-lasting but not medically dangerous
Opioids Heroin, morphine, methadone, pain pills Injecting, snorting, swallowing pills Sedation, pain relief Addiction, complications from lifestyle and method of administration Depressed central nervous system functioning, death can occur Rapid tolerance to pleasurable effects with repeated administration Very unpleasant but not usually medically dangerous
Hallucinogens LSD, magic mushrooms, PCP Ingesting or smoking Alters perception of sensory stimuli, panic attacks in some users Flashbacks Except for PCP, overdose does not occur with PCP, agitation, confusion, aggression Tolerance to hallucinogenic properties does occur No physical dependence
Cannabinols Marijuana Smoking or ingestion Enhanced taste, touch, and smell; relaxation; increased appetite; impaired immediate recall Adverse effect on lung function, decrease in testosterone, suppression of immune system; impact is controversial Overdose does not occur; adverse reactions are panic attacks Tolerance to normal effects occurs but it is probably not physiological Irritability, insomnia, restlessness
Inhalants and Volatile Hydrocarbons Solvents, aerosol sprays, amyl nitrate, isobutyl, nitrous oxide Inhaling (huffing) Reduced inhibition, dizziness, slurred speech, impaired motor coordination; unconsciousness and death can occur. Damage to liver, kidneys, brain, and lungs Hallucinations, muscle spasms, coma Tolerance to nitrous oxide No known withdrawal syndrome
Anabolic Steroids Depo-Testosterone, Danocrine, Halotestin Igested or njected Increased muscle strength, body mass, and aggressiveness Jaundice, liver tumors, mood swings Increased doses result in chronic problems No tolerance Depression, fatigue, restlessness, Insomnia

Central Nervous System Depressants

Central nervous system (CNS) depressants (also referred to as sedative-hypnotics) depress the overall functioning of the central nervous system to induce sedation, drowsiness, and coma. The drugs in this classification include the most commonly used and abused psychoactive drug, alcohol; prescription drugs used for anxiety, sleep disturbance, and seizure control; and over-the-counter medications for sleep disturbance, colds and allergies, and coughs. In general, CNS depressants are extremely dangerous. There are approximately 79,000 deaths annually caused by excessive alcohol use in the United States, the third leading lifestyle cause of death (Centers for Disease Control and Prevention, 2010a). Alcohol alone or in combination with other drugs accounted for nearly 36% of drug abuse-related emergency room episodes in 2007 (Substance Abuse and Mental Health Services Administration, 2010).

Drugs in This Classification

Alcohol is the most well-known CNS depressant because of its widespread use and legality. The alcohol content of common beverages is beer, 3% to 6%; wine, 11% to 20%; liqueurs, 25% to 35%; and liquor (whiskey, gin, vodka, etc.), 40% to 50%. The “proof” on alcohol beverages is computed by doubling the alcohol content. Therefore, a bourbon that is described as “90 proof” is 45% alcohol. It is important to remember that the amount of alcohol in one 12-ounce beer is the same as the amount of alcohol in 6 ounces of wine or in 1.5 ounces of liquor (all standard drinks). The alcohol in beer is simply contained in a larger amount of liquid.

Barbiturates are prescription drugs used to aid sleep for insomniacs and for the control of seizures. These drugs include Seconal (reds, red devils), Nembutal (yellows, yellow jackets), Tuinal (rainbows), Amytal (blues, blue heaven), and Phenobarbital. There are also nonbarbitu-rate sedative-hypnotics with similar effects but with different pharmacological properties. These include Doriden (goofballs), Quaalude (ludes), Miltown, and Equinil. Being a Schedule I drug, Quaalude cannot be legally prescribed in the United States.

The development of benzodiazepines or minor tranquilizers reduced the number of prescriptions for barbiturates written by physicians. These drugs were initially seen as safe and having little abuse potential. Although the minor tranquilizers cannot be easily used in suicide as can barbiturates, the potential for abuse is significant. The benzodiazepines are among the most widely prescribed drugs and include Valium, Librium, Dalmane, Halcion, Xanax, and Ativan. In addition, non-benzodiazepine hypnotics are being heavily marketed as sleep aids. These include Ambien, Lunesta, and Sonata. These drugs can be abused and do have addictive potential. Rozerem, another widely marketed sleep aid, is not pharmacologically similar to the other non-benzodiazepine hypnotics and is not addictive. It is like the herbal remedy melatonin.

Finally, certain over-the-counter medications contain depressant drugs. Sleep aids such as Nytol and Sominex, cold and allergy products, and cough medicines may contain scopolamine, antihistamines, or alcohol to produce the desired effects.

Routes of Administration

Obviously, alcohol is administered by drinking. Some over-the-counter medications are also in liquid form. The barbiturates, nonbarbiturate sedative-hypnotics, minor tranquilizers, and non-benzodiazepine hypnotics come in pill form. As with many psychoactive drugs, liquid forms of the drugs are produced and administered by injection.

Major Acute and Chronic Effects

The effects of CNS depressants are related to the dose, method of administration, and tolerance of the individual, factors that should be kept in mind as the effects are discussed. At low doses, these drugs produce a feeling of relaxation and calmness. They induce muscle relaxation, disinhibition, and a reduction in anxiety. Judgment and motor coordination are impaired, and there is a decrease in reflexes, pulse rate, and blood pressure. At high doses, the person demonstrates slurred speech, staggering, and, eventually, sleep. Phenobarbital and Valium have anticonvulsant properties and are used to control seizures. The benzodiazepines are also used to clinically control the effects from alcohol withdrawal.

In terms of damage to the human body and to society, alcohol is the most dangerous psychoactive drug (tobacco causes far more health damage). Alcohol has a damaging effect on every organ system. Chronic effects include permanent loss of memory, gastritis, esophagitis, ulcers, pancreatitis, cirrhosis of the liver, high blood pressure, weakened heart muscles, and damage to a fetus including fetal alcohol syndrome and fetal alcohol effect (see Chapter 12). Other chronic effects include family, social, occupational, and financial problems. Acutely, alcohol is the cause of many traffic and other accidents and is involved in many acts of violence and crime. Certainly, the other CNS depressants can cause the same acute problems that are the result of injury and accident and chronic effects on the individual and family due to addiction.

Overdose

Alcohol overdose is common. We refer to this syndrome as being “drunk.” The symptoms include staggering, slurred speech, extreme disinhibition, and blackouts (an inability to recall events that occurred when the individual was intoxicated). Generally, the stomach goes into spasm and the person will vomit, helping to eliminate alcohol from the body. However, the rapid ingestion of alcohol, particularly in a nontolerant individual, may result in coma and death. This happens most frequently with young people who participate in drinking contests.

As these drugs depress the central nervous system, overdose is extremely dangerous and can be fatal. Since the fatal dosage is only 10 to 15 times the therapeutic dosage, barbiturates are often used in suicides, which is one reason they are not frequently prescribed. It is far more difficult to overdose on the minor tranquilizers. However, CNS depressants have a synergistic or potentiation effect, meaning that the effect of a drug is enhanced as a result of the presence of another drug. For example, if a person has been drinking and then takes a minor tranquilizer such as Xanax, the effect of the Xanax may be dramatically enhanced. This combination has been the cause of many accidental deaths and emergency room visits.

Tolerance

There is a rapid development of tolerance to all CNS depressant drugs. Cross-tolerance also develops. This is one reason why overdose is such a problem. For example, Bob, a very heavy drinker, is quite anxious and is having difficulty sleeping. He goes to his physician with these symptoms. The physician does not ask about his alcohol use and gives him a prescription of Xanax. Bob follows the directions and takes one pill. However, because he is tolerant to alcohol, he is also cross-tolerant to Xanax and the pill has no effect. He can’t sleep so he takes three more pills and has a glass of brandy. The synergistic effect of these drugs results in a coma.

The tolerance that develops to the CNS depressants is also one reason that the use of the minor tranquilizers has become problematic. People are given prescriptions to alleviate symptoms such as anxiety and sleep disturbance that are the result of other problems such as marital discord. The minor tranquilizers temporarily relieve the symptoms but the real problem is never addressed. The person continues to use the drug to alleviate the symptoms, but tolerance develops and increasing dosages must be used to achieve the desired effect. This is a classic paradigm for the development of addiction and/or overdose.

Withdrawal

The withdrawal syndrome from CNS depressants can be medically dangerous. These symptoms may include anxiety, irritability, loss of appetite, tremors, insomnia, and seizures. In the severe form of alcohol withdrawal called delirium tremens (DTs), additional symptoms are fever, rapid heartbeat, and hallucinations. People can and do die from the withdrawal from these drugs. Therefore, the detoxification process for CNS depressants should include close supervision and the availability of medical personnel. Chronic, high-dosage users of these drugs should be discouraged from detoxifying without support and supervision. For detoxification in a medical setting, minor tranquilizers can be used, in decreasing dosages, to reduce the severity of the withdrawal symptoms.

The dangerousness of withdrawal from CNS depressants is one reason why supervised detoxification is needed. In addition, supervision and support are usually required because the withdrawal symptoms are unpleasant and rapidly alleviated by using CNS depressants. For example, a 47-year-old man decides that he has been drinking too much and wants to quit. He doesn’t tell anyone and is going to “tough it out.” Although he doesn’t have any medically dangerous symptoms, he is anxious, irritable, and has trouble sleeping. His family, friends, and coworkers remark about how unpleasant he is, and he is quite uncomfortable. He has a few drinks and finds that the symptoms are gone. Very rapidly, he is drinking heavily again.

Central Nervous System Stimulants

CNS stimulants affect the body in the opposite manner as do the CNS depressants. These drugs increase respiration, heart rate, motor activity, and alertness. This classification includes highly dangerous, illegal substances such as crack cocaine, medically useful stimulants such as Ritalin, drugs with relatively minor psychoactive effects such as caffeine, and the most deadly drug used, nicotine. The drugs in this classification were mentioned in 34% of the drug abuse-related emergency room episodes in 2007 (Substance Abuse and Mental Health Services Administration, 2010).

Drugs in This Classification

Cocaine (coke, blow, toot, snow) and the freebase or smokeable forms of cocaine (crack, rock, base) are the most infamous of the CNS stimulants. Cocaine is found in the leaves of the coca shrub that grows in South America. The leaves are processed and produce coca paste. The paste is, in turn, processed to form the white hydrochloride salt powder most of you know as cocaine. Of course, before it is sold on the street, it is adulterated or “cut” with substances such as powdered sugar, talc, arsenic, lidocaine, strychnine, or methamphetamine. Crack is produced by mixing the cocaine powder with baking soda and water and heating the solution. The paste that forms is hardened and cut into hard pieces, or rocks. The mixing and heating process removes most of the impurities from the cocaine. The vaporization point is lowered so the cocaine can be smoked, reaching the brain in one heartbeat less than if it is injected. Therefore, crack is a more pure form of cocaine than is cocaine hydrochloride salt powder.

Amphetamines are also CNS stimulants, and one form in particular, methamphetamine, is a major drug of addiction. The amphetamines include Benzedrine (crosstops, black beauties), Methedrine or methamphetamine (crank, meth, crystal), and Dexedrine (dexies). There are also nonamphetamine stimulants with similar properties such as Ritalin and Cylert (used in the treatment of attention deficit-hyperactivity disorder) and Preludin (used in the treatment of obesity). These drugs are synthetics (not naturally occurring), and the amphetamines were widely prescribed in the 1950s and 1960s for weight control.

Some forms of CNS stimulants are available without a prescription and are contained in many substances we use on a regular basis. Caffeine is found in coffee, teas, colas, and chocolate as well as in some over-the-counter products designed to help people stay awake (e.g., No Doz, Alert, Vivarin). Phenylpropanolamine is a stimulant found in diet-control products sold over-the-counter (e.g., Dexatrim). These products are abused by individuals who chronically diet (e.g., anorexics). Pseudoephedrine is a substance in many nasal decongestants. Since it is used in the manufacture of methamphetamine, federal and state laws have been passed to restrict the quantities of these over-the-counter medications that can be purchased.

Although it has mild euphoric properties, nicotine is the highly addictive stimulant drug found in tobacco products. According to the Centers for Disease Control and Prevention (2010b), an estimated 440,000 Americans die each year from smoking-related illnesses. This is more than five times as many deaths as result from alcohol. By a wide margin, nicotine is the most deadly drug we will discuss. Ironically, it is not only legal, it is marketed. We will mention this contradiction in public policy in Chapter 15.

Routes of Administration

With CNS stimulants, every method of administration is possible and utilized. Caffeine is consumed in beverage form, but it is also eaten (e.g., chocolate) or taken in pill form (e.g., No Doz). Nicotine is obviously smoked but can be chewed (chewing tobacco, nicotine gum) or administered through a skin patch. Cocaine and amphetamines can be snorted, smoked, injected, and ingested.

Major Acute and Chronic Effects

As with most of the psychoactive drugs, some of the CNS stimulants (cocaine and methamphetamine) have a recreational use. The purpose is to “get high,” or to experience a sense of euphoria. Methamphetamine and cocaine users report a feeling of self-confidence and self-assurance. There is a “rush” that is experienced, particularly when cocaine is smoked and when cocaine and methamphetamine are injected. The high from methamphetamine is generally less intense but longer acting than cocaine.

CNS stimulants result in psychomotor stimulation, alertness, and elevation of mood. There is an increase in heart rate and blood pressure. Performance may be enhanced with increased activity level, one reason why athletes use CNS stimulants. These drugs also suppress appetite and combat fatigue. That’s why people who want to lose weight and people who want to stay awake for long periods of time (e.g., truck drivers) will use amphetamines.

The acute effects of CNS stimulants can be dramatic and fatal. These include heart attacks, strokes, seizures, and respiratory depression. However, the results of chronic use cause the most problems. The addictive properties of these drugs are extremely high. Individuals with addictions to cocaine and methamphetamine spend a tremendous amount of money to obtain drugs, and they encounter serious life problems related to their addiction. Also, there is an increased risk of strokes and cardiovascular problems, depression, and suicide in chronic users. Symptoms of paranoid schizophrenia can occur. If cocaine or methamphetamine is snorted, perforation of the nasal septum can occur. Injection of CNS stimulants has the same risks as injecting other drugs (e.g., hepatitis, HIV). Since these drugs suppress appetite, chronic users are frequently malnourished.

If you are smugly saying to yourself that the only CNS stimulant you use is caffeine, see the caffeine-induced disorders that are described in the DSM-IV-TR (see Chapter 6). Also, caffeine may precipitate panic attacks in individuals predisposed to panic disorders, and the drug may be detrimental to some heart patients. A woman who is considering having a baby should reduce caffeine intake, and pregnant and breastfeeding women are advised to abstain.

Clearly, the chronic effects of nicotine addiction are damaging to health. The number of health-related problems, deaths, and days of work missed due to the chronic use of tobacco products is astounding.

Overdose

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