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Psychoactive Drugs

• Natural or synthesized substances that alter our central nervous system, including our thoughts, emotions, and behaviour

• Can also affect our autonomic nervous system, thus having the potential to either balance our systems or disrupt core biological functions,

  • Cardiovascular, endocrine, respiratory, immune, sexual arousal, fight-or-flight, and digestive systems

• May be used for the intended or unintended purpose of altering one’s mind and bodily functions

Categories of Psychoactive Drugs

• Medical or non-medical

• Licit or illicit

Drug Misuse

• Occasional improper or inappropriate use of either a social or prescription drug leading to adverse effects

  • Medical complications

  • Behavioural alterations

  • Social, medical, legal, vocational problems

• May lead to addiction/dependence
  

Early conceptualizations of Addiction

• Importance of morality and workplace productivity

• Focused on behaviour

  • Compulsive drug seeking

  • Loss of personal control

  • Breakdown in lifestyle

• Only solution is complete abstinence

• 1950s-1960s: Associated with unpleasant physical withdrawal symptoms

• 1964: WHO broadened focus to “dependence” with distinct physical and psychological components

Problems with ASAM definition of Addiction

• Narrow focus on medical aspects of addiction

• Doesn’t include holistic nature of addiction

Perspectives on addiction beyond a medical condition

• Peele: Not chemical but social experience that in and of itself can bring about dependency to particular state of body and mind

• Anthropologists: Drinking alcohol is generally a social act that occurs in a socially recognized setting

• Human geographers: Drinking alcohol takes place at specific times in specific places

Social Context of Addiction Requirements

• Peele and Brodsky (1992)

• Readily available substance

• Stress is severe form including misery, danger, and discomfort

• Alienation

• Emotional and/or vocational deprivation

• Lack of control over one’s life

Addiction - Importance of social/environmental factors

• Example

• U.S. soldiers in Vietnam

  • 75% of returnees who tested positive for heroin said they became addicted in Vietnam

  • One-third continued using on return to the U.S.

  • Only 10% showed dependency

Addiction viewed holistically

• Addiction needs to be seen holistically as social, economic, and situational factors play key roles

• Addiction is a bio-psycho-social phenomenon

Physical dependency

• Physiological state of cellular adaptation where body can only function normally when drug is present

• Relieved by administering drug or substitute

• Can occur with chronic use of most drugs

Psychological dependency

• Drug is so important to person’s thoughts and actions they believe they can’t manage without it

• In many instances, considerably more important than physical dependency which can be managed
  

Drug dependence & the DSM-V

• Drug abuse and drug dependence is now called substance use disorder

  • Mild (2-3 symptoms)

  • Moderate (4-5 symptoms)

  • Severe (6 or more symptoms)

• Lists alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedative-hypnotics, stimulants, tobacco, other/unknown, and gambling

What happened with addiction toward the end of 20th century?

• Medicalization of behaviour → non-medical problems become medical

• Explanation: U.S. health insurance companies require diagnoses

Compulsive conditions

• Not an addiction

• Definition: Repetitive behaviours performed in effort to minimize anxiety or control or prevent obsessive thought which may be related to behaviours

• But: No distinct biological dimension, no chemically induced change to nervous system, no change in brain as in psychoactive drugs, no fight/flight response

Food Disorders

• Not an addiction

• Eating disorders are complex mental conditions

• Release of dopamine when eating (or other compulsive activities) isn’t enough to produce adequate reinforcement (especially compared to drugs like cocaine)

• Neither tolerance nor withdrawal have been satisfactorily shown with compulsive eating

Gambling issues

• Not an addiction

• DSM-V defines gambling as a substance-related disorder

• WHO ICD-11 classifies it as impulse control disorder

• Similarity to OCD with impulsivity, decision-making, and reward system response key

• No direct biological trigger

• No direct health risks

• No risk of physical harm from withdrawal

Sexual compulsions

• Not an addiction

• Sex addiction” used in popular culture but not in evidence-informed research

• DSM-V: No mention of sex

• WHO ICD-11: Classified as compulsive behaviour

• Academic literature: Compulsive or impulsive sexual behaviour

  • Difficulty controlling inappropriate or excessive sexual fantasies

  • Urgings, cravings, or behaviours that generate subjective distress or impairment in daily functioning

  • Some see it as variant on OCD

• Focus is solely on psychological and behavioural factors

Depressants

• Reduction of arousal and activity in CNS

• Used as anaesthetics, sleep aids, anti anxiety agents, sedatives

• Opioids: Depressants that mask pain

Stimulants

• Increase activity in cerebral cortex

• Elevate mood, increase vigilance, postpone fatigue

• Some used as appetite suppressants, decongestants, and to treat ADHD

Hallucinogens

• Generalized disruption in brain involving perception, cognition, and mood

• Cannabis is a hallucinogen but acts more like a depressant

Psychotherapeutic agents

• Primarily used to treat mental health issues like depression, bipolar disorder, and psychosis

• Can produce unpleasant side effects:

  • Proper compliance is a greater problem than misuse

• Aren’t rapidly acting so generally aren’t used non-medically
  

Neurons

• Neurons or nerve cells process information

• Neurons have no direct contact to each other

• Information is communicated chemically between them

Neurotransmitters

• Chemicals in brain that relay, amplify, and modulate signals between neurons that produce physical actions, feelings, and behaviours

• Found in the “synaptic cleft” between cells

• Over 40 known examples

• Most drugs of misuse directly or indirectly increase dopamine activity

Neurophysiology in adolescence and young adulthood

• Neurons and synapses are altered

• Greater vulnerability to effects of drugs compared to adults

Dopamine

• Stimulates nerves in brain

• Creates sensation of power, energy, and euphoria

• Stimulants act on dopamine

Endocannabinoids

• THC binds with receptors in parts of brain that can cause euphoria, time distortion, and minor hallucinogenic effects

• Also thought to release dopamine in synaptic cleft

Endorphins

• Bind to opioid receptors to block feelings of pain

• Can also modulate dopamine transmission leading to euphoria

Gamma-Aminobutyric Acid (GABA)

• Occupies receptor sites and blocks their stimulation

• General quieting influence on brain

• Acts as depressant transmitter to counter feelings of anxiety

Glutamate

• Excitatory neurotransmitter

• Balances out depressant effect of GABA

• Linked to memory and learning

• Association with ADHD

Norepinephrine

• Active in flight-or-fight responses

• Repeated or ongoing bursts leads to anxiety, hyperactivity, and loss of hunger

• Inhibiting it aids in alleviating depression

• Elevated levels can lead to mania

Serotonin

• Known as happiness transmitter

• Reduces depression, alleviates anxiety, elevates mood, increases feelings of self worth

• New class of drugs including Prozac, Paxil, Zoloft, Celexa affect serotonin

Pharmacodynamics

What drugs do to the body

Tolerance

Repeated use of drug causes resistance to its effects

• Dispositional: Liver can process drug more efficiently and excrete from body more easily

• Functional: Physical changes to receptors such as reduced sensitivity

Tachyphylaxis

Rapid, nearly complete tolerance

Cross tolerance

Use of one drug leads to tolerance of another with
similar effects

Reverse tolerance/Sensitization

Needing less to have desired effects

Withdrawal

• Physical disturbance or physical illness when drug use is suddenly discontinued

• Rebound effect present in physical dependence

Pharmacokinetics

How the drug gets into the body and bloodstream to produce effects

Routes of Administration: Oral

Through mouth to stomach and intestines

• Advantages

  • Convenient

• Disadvantages

  • Losing the drug through vomiting

  • Stomach discomfort

  • Inability to accurately calculate amount of drug absorbed

  • Slowness of process

Routes of Administration: Across mucous membrane

In nose, gums, rectum, or vagina

• Advantages

  • Convenient

• Disadvantages

  • Irregular and unpredictable

  • Tissue damage

    • Deviated septum, oral cancers
      

Routes of Administration: Injection

Directly into vein, muscle, or under skin

• Advantages

  • Quickness

  • Accuracy of dose

• Disadvantages

  • Overdose

  • Painfulness

  • Can’t recall drug

  • Sharing needles can lead to disease

Routes of Administration: Through the lungs

Inhalation

• Advantages

  • Quickness

• Disadvantages

  • Lung damage

Routes of Administration: Transdermal

Through the skin

• Advantages

  • Convenient

• Disadvantages

  • Limited application (not used recreationally)

Worldwide adult population drug usage

• 50% use psychoactive drugs regularly

• 5.5% used illegal drugs in previous year

• 1990-2016: Increase in drug use worldwide

Drug usage in North America

• Highest illicit opioid use

• Highest licit opioid use

• Dramatic increase in drug poisoning

• Highest rates of amphetamines

Cannabis & Global drug use

Most used illicit drug

Alcohol & Global drug use

• 1/3 of world population consumes

• 10 times greater use than illicit drugs

• Highest use: Europe

• Lowest use: North African and Middle Eastern countries

• Global premature death from alcohol use decreased 1990-2017

  • Exceptions: Russia and the U.S.

• High percentage of road accident deaths are because of alcohol use

Tobacco & Global drug use

• 1.1 billion people use tobacco

• 80% of users in developing countries

• Of all drugs, contributes most to disease burden

• 8 million people die from tobacco use annually

• 1.2 million deaths from second-hand smoke

Alcohol use in Canada

• 78% of 15+ population used in last year

• 21% of drinkers exceed low risk drinking guidelines

Tobacco use in Canada

• 15% of population smoke cigarettes

• Dramatic decrease from 1965 when 50% smoked

E-cigarettes use in Canada

• 23% of youth 15-19

• 29% of young adults 20-24

Illicit drug use in Canada

• 1990s: 1% of population

• 2017: 3% of population

• Dramatic rise of opioid-related toxicity events

• Greatest increase was cocaine

• Increased crime associated with methamphetamines

Prescription psychoactive drugs use in Canada

• 22% of people 15 years and up

• Women use more than men

Cannabis use in Canada

• Regular recreational use: 5.5% in 1985, 15% in 2014

• Lifetime use: 41.5%

• Increased medical use

• Legalization has not increased use (?): “2019: 16.8% 15+ years use in last 3 months, increase of just 2% since legalization

Results of 2018-2019 Canadian Student Tobacco, Alcohol, and Drugs Survey

Grades 7-12

• 19% ever smoked

• 3-8% regular smokers

• 20% used e-cigarettes

• 44% alcohol at least once in last year

Foundations of the Moral Model

• Drug use is unacceptable, wrong, even sinful

• People are singularly responsible for their own behaviour

  • Addiction is consequence of personal choice and desire

  • People with addiction can decide not to use

• Has led to rejection of people who use drugs

  • Deep character flaws

  • Blame and shame

  • No recognition of complex biological, psychological, or social factors

  • Negative language makes it easier to ignore and discard people who use drugs

• Certain substances have been connected to race

• People who are addicted to drugs are treated poorly in health care system

War on drugs

• Started in 1970s in U.S. under Nixon

  • Increased incarceration

    • No decrease in illicit or licit drug use

• Ramped up by Reagan in 1980s

  • Used military to enforce drug laws in U.S. and abroad

  • Drug testing of federal employees

  • Mandatory minimum sentences

  • Death penalty for “drug kingpins”

  • Fought on race and class lines

  • Has led to mass incarceration in U.S.

War on drugs in Canada

• Not as pronounced

• Previous Conservative government tried to introduce mandatory minimum sentences, struck down by courts

• Current backlash to harm reduction efforts

War on drugs: The Philippines

• 2016: President Rodrigo Duterte came to power

• Permitted military personnel to shoot suspected drug dealers on sight

• Paramilitary operations targeting not just dealers but also users

• 22,983 deaths directly and indirectly linked to sanctioned anti-drug operations

Addiction in central Asian countries

• Vietnam, Cambodia, China have forced work camps to “treat” people who are assumed to be addicted

War on drugs: Global Views

• Some countries have death penalty for drug use or drug trafficking

• Users and traffickers are perceived as purveyors of death, whose crimes produce significant national harm

• Users and traffickers are seen as corrupting youth and disrupting traditional values

• Drug trade believed to be financed by and profitable to foreigners

• Drug trade seen as connected to organized crime and terrorism

• 66% of countries with death penalty have legislation applying it for drug-related offences (increase from 1985 to 2020)

Moral Model: How can we treat addiction?

• No room for treatment

• Problem of addiction can be solved by

  • Personal willpower and determination

  • Removing self from temptation

  • Building character

Moral Model: Limitations

• Lack of support empirically

• Lack of consistency

  • E.g. Alcohol in Western countries

Disease/Medical Model

• Counters moral model

• Substance dependency is a chronic, fatal disease process

• Involuntary biological trait to which some people are susceptible

• People with dependence viewed as requiring medical care

• Mechanism: Change in brain function

  • Experience and anticipation of reward

  • Perception and memory

  • Executive systems underlying cognitive control

Course of the Disease/Medical Model

U-shaped course of disease with rock bottom

Example:

• Social or integrated drinking

• Blackout stage with increasing preoccupation with alcohol

• Loss of control over consumption

• Chronic phase of prolonged intoxication where drinking is obsessive

• Rock bottom with choices of death or recovery (usually AA)

• Upswing: Rehabilitation and abstinence

Criticisms of Disease Model

• Little empirical support

• Has never been able to fully explain substance dependence

• Substance use is not a dichotomy (diseased/not diseased)

• Not a scientific fact; substance use and dependence are socially constructed

• The 12-steps don’t address the complexities of substance dependence

• Fails to fully remove feelings of shame and stigma

Why is the Medical Model Popular?

• Simple solution to complex problem

• First theory to challenge moral model

• Provides rationale and means for treatment

• Medical community benefits economically and socially

• Foundation for Alcoholics Anonymous

• No need for social reforms

• Money to be made treating patients

Neurobiology Model

• Focuses on how repeated exposure to substances affects brain structures and functioning, leading to dependence

• Brain mechanisms altered include those that control rewards, motivation, and learning and memory

• Research shows that brain functioning and structure change over time due to psychoactive drugs, with a threshold after which stopping drug use becomes difficult

Mechanisms of the Neurobiology Model

• Intracellular signaling: Signaling between neurons is increased

• Synaptic plasticity (neuroplasticity):

  • Adaptive response within neuron as well
    as between neurons

• Dopamine and reward system: Critical neurotransmitter involved in directing and rewarding goal-related behaviour

Problems with Neurobiological Theories

• Another name for the disease model

• These mechanisms occur for all human biological adaption to stimuli or environmental stressors

• Reductionist view that can’t account for complexity of human behaviour

Genetic Theory

• Addiction as an inherited disorder

• Evidence that some genes can influence processing and metabolism of alcohol

• Alcoholism is strongly familial, running through generations

• Supported by adoption and twin studies

  • Adopted sons dependent when biological father or brother are also dependent

  • Effect of genetics on substance use ranges between 30% and 70% depending on substance, gender, age, and cultural characteristics

• Genetic variation of dopamine release

Problems with Genetic Theories

• Genetics aren’t invariably and fully determinative

• Doesn’t explain all cases

• No “addiction gene” has been discovered

• Offers no treatment options

• Ignores other biological, psychological, sociological, and environmental factors

Allergy Theory

• Exposure to substance cause allergic reactions, leading to loss of control over consumption

• Influential in early AA

• No specific mechanism, pathway, or system has ever been proposed or shown
  

Why aren’t biological explanations deterministic explanations?

They are predispositions that complement psychological and sociological explanations

Learning Theory

• Operant conditioning: Positive and negative reinforcements influence behaviour

  • Positive reinforcement (reward): Stimulus increases likelihood of behaviour

  • Negative reinforcement (punishment): Stimulus decreases likelihood of behaviour:

• Positive reinforcement decreases over time

  • Habituation: Reduced response to drug

  • Extinction: Positive reinforcement for drug use gradually diminishes

• Withdrawal: Negative reinforcement

Personality Theory

• Widely used and studied: Five-factor model of personality

  • No consistent pattern found

  • Some evidence that extraversion, impulsivity, and narcissism are linked to dependence

• Alternatively, dependence as collection of “abnormal” personality traits

  • Highly emotional with low frustration tolerance; Nonconformity, impulsivity, and reward seeking; Negative affect and low self-esteem; Immature in personal relationships; Inability to express anger adequately; Ambivalence to authority; Excessive anxiety; Perfectionism and compulsiveness; Rigidity; Feelings of isolation; Gender-role “confusion”

• No “addictive personality” has been identified

Problems with Personality Theories

• No consistent patterns found

• Not clear if personality issues or dependence come first

• After decades of research, personality still only accounts for a small proportion of alcohol dependency

• Human behaviour is not 100% attributable to personality characteristics

Humanistic Theory

• Maslow’s Hierarchy of Needs

• Primary causes of drug dependency are boredom, frustration, or inability to reach potential because of blockage in hierarchy of needs

• Compulsive use of drugs to avoid pain, blame, shame and loss

• Dependency seen as a rationale response to unmet needs

Maslow’s Hierarchy of Needs

• Physiological: air, drink, food, sleep

• Safety: health, personal and financial security, familiarity; safe, ordered, secure world

• Belongingness: social and love needs; ability to relate to each other and develop close personal relationships; receiving and giving love

• Self-esteem: self-respect, respect for others; feelings of confidence and self worth

• Cognitive needs: seeking knowledge; discover, explore, learn about,

• Aesthetic needs: search for beauty in nature and in personal artistic expressions

• Self-actualization: realizing one’s personal potential and obtaining state of self-fulfillment

• Transcendence: striving to aid others in reaching their potential; social progress, altruism

Attachment Theory

• Universal need for intimate relationships begins in infancy

• Quality of relationships and lasting emotional bonds arise from ongoing interactions

• Addiction as an attachment disorder, insecure attachment leads to dependence later in life

• Unresolved attachment in adulthood can cause poor ability to consider child’s behaviours and feelings, leading to intergenerational phenomenon

• Dependence is an attempt to deal with

  • Alienated sense of self

  • Fearful and anxious mental states of self and others

  • Unregulated emotions and discomfort

• Substances are used as alternative to attachment in interpersonal relationships
  
  

Three types of attachment

• Secure attachment: primary caregiver provides comfort and reassurance; children are distressed when caregiver leaves and joy upon return

  • Healthy emotional regulation

  • Positive responses to situations

• Ambivalent-insecure attachment: caregiver not regularly available and children can’t depend on them when they need them; children are extremely and uncontrollably upset when caregivers leave

• Avoidant-insecure attachment: result of neglect, unpredictability, rejection, non responsiveness; children avoid caregiver

• Disorganized-insecure attachment: result of inconsistent parenting; children appear disoriented or confused

Rational Theory

• Rational human being strive for health and longevity

• When people learn about long-term harm, use reduces

• Some evidence this is important

• Doesn’t always work

Background in sociological theories

• General lack of specificity in sociological theories concerning individual substances and frequency of use

  • Use vs. misuse vs. dependence

  • Legal vs. illegal substances

  • Substance itself, e.g. alcohol vs. cannabis

• Explanations vary by

  • Person

  • Time

  • Situation

Cultural Theory

• Culture: Set of thoughts shared by members of a social unit including common understandings, patterns of beliefs, and expectations

• Cultural Guidelines: Generally unwritten rules of conduct and direction for acceptable behaviour and action

• Common cultural patterns of drug use

  • Healing and medical care

  • Customary regular use

  • Intermittent special occasion use

  • Excessive use

• Cultural norms encourage or discourage use and misuse and responses to them

Beliefs of Cultural Theory

• Culture influences use and dependence

  • Extent to which culture leads to inner tensions

  • Attitudes toward drinking

  • Availability of ways to cope apart from substance use

• Four cultural patterns

  • Abstinent: e.g. Middle Eastern nations

  • Ambivalent: attitude positive in social situations, negative in others, e.g. Morocco

  • Permissive: use of alcohol and other drugs is permitted, but public impairment is discouraged, e.g. Canada

  • Ultra-Permissive: most likely to occur in nation with rapid change, e.g. Russia

Cultures have lower rates of alcohol problems when…

• Rules governing use are clear and uniform

• Prohibitive social sanctioning occurs

• Early exposure to moderate alcohol use

• Excessive use, including drunkenness, is uniformly discouraged and proscribed

Subcultural Theories

• Importance of social environment

• Different subcultures, e.g.:

  • University students

  • Youth subcultures associated with particular music genre

  • Gender

• Or, feelings of alienation from society and no sense of belonging

Deviant Behaviour Theories

• Failure to obey society’s rules of what is deviant and what is accepted

• What is deviant varies (e.g. cannabis in Jamaica, khat in Canada, coca leaves in South America)

• Unusual or rebellious acts casts people away from society

• Media plays key role, e.g. crack cocaine, meth, OxyContin

• People begin seeing themselves as the negative labels ascribed to them

• Long associated with specific environments like neighbourhoods

• Lower social capital is associated with more drug misuse

Marxist Theories

• Central focus is

  • Relationship between human labour and capital

  • Means of production

• Class struggle

• People with money have the power

• Human problems are direct result of economic and sociological structure of a culture

• Powerful groups dominate less powerful groups and deny equal opportunities

• Laws are created to maintain status quo

• Directs us to examine how poverty, social exclusion, and lack of meaning in one’s work leads to dependence

Availability-Control Theory

• AKA consumption models

• Formal control exercised over use

  • Higher price discourages use

  • More availability encourages use

• Levers of control

  • Taxation

  • Raising drinking age

  • Controlling number of outlets

  • Reducing hours of sales

  • Limiting advertising

Environmental Stress Theory

• Not just individual stress, but stressful environments are associated with dependence

  • Soldiers returning from Vietnam

  • Rat Park

• Also, stress related to SES or belonging to a disadvantaged group

Colonialism

Policy or practice of acquiring full or partial control over another country, occupying it with settlers, and exploiting it economically

Ongoing system of power that perpetuates the genocide and repression of Indigenous peoples and cultures

Land Use - Pre-contact Indigenous communities

• Land was sacred

• Mother Earth was given by Creator to cherish and protect

• People’s responsibility was to cherish and protect nature

• Land ownership was unknown

• Taking of resources (birds, animals, trees, and rocks) required thought and ceremony

Land Use - Settlers

• Land was power

• Rigid class system was based on land ownership

• Natural resources could be quickly and completely exploited

• Contact with New World was a way to provide more wealth and power to ruling classes in Europe

• Could not understand ceremonies, or giving thanks, every time a tree is cut down, berries are harvested, or animals taken for food

Government Structures - Pre-contact Indigenous communities

Most governed through clan

• Plurality of knowledge

• Each clan with responsibility of certain aspect of life

Decision making

• Clans with expertise consulted

• Every voice heard (old to young)

• Discussions lasting days

• Decisions reached by consensus

Government Structures - Settlers

• Absolute monarchies reigned

• Absolute authority carried out without questions

• Ships leaving Europe carried a King or Queen's representative

• Could not understand need for full community participation in decision making

• Understandably, they thought Indigenous people had no formal governance structure

Family Structures - Pre-contact Indigenous communities

• Diversity across nations but significantly different from European

• E.g. Anishnaabe’s 8 distinct periods of life, each playing role in health of entire community

• Having a gift = having a responsibility to use gift

Family Structures - Settlers

• Did not recognize contributions of anyone except adult male ruling class

• Decisions made by select few

• Women and children were never to be seen or heard, let alone asked their opinion

• Integrated approach to family and community would be unrecognizable

• Concluded that Indigenous people were completely without structure or civilization

Spirituality - Pre-contact Indigenous communities

• Engrained into every part of life: Told them where to live, who to marry, where and when to hunt

• Gave people peace and balance and understanding of their place in Creation

• All knowledge comes from Creator

• Eager to see another example of teachings from Creator

• Did not understand giving up current teachings