Major Paper – FINAL

DUE: May 19, 2019 11:55 PM

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Apr   1, 2019 12:05 AM



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Assignment Instructions

Major Paper Assignment Instructions and Grading Rubric

This assignment meets the following Course Learning Objectives:

– Articulate basic drug terminology and drug taking behavior
– Identify the various addictive substances – legal and illegal – and their classifications
– Analyze the reasons people commonly abuse substances
– Analyze how substances affect the mind and body and society

In 2010, The American Academy of Pediatrics (AAP) released a policy statement addressing the complex relationships among children, adolescents, substance abuse, and the media. This assignment requires a critical examination of the AAP publication and a critique of a media portrayal of substance use, with links made to the AAP statement and course material. Conclusions about the implications of the media portrayals and the policies recommended by the AAP also should be made. Successful completion of this paper will require work over multiple weeks.  A two paragraph summary of the proposed example of substance use portrayal in the media was due by the end of Week 3. The full paper is due at the end of Week 7.

This is part one of the assignment that you did

This assignment proceeds in four steps: 


 Step One: Read the AAP Policy Statement located below. Make some notes for yourself about points of agreement or disagreement you have with the statement and specific findings regarding media depictions of substance use that you want to assess when you write the paper. 

 Step Two: Find a current example of substance use portrayal seen in the media; for example, scenes from a movie, a television show, or a commercial; print ads; or portrayals found in “new media” as discussed in the AAP article. The Internet is a good tool for finding film or television portrayals of substance use as well as examples of print ads if ready access to first-hand media is not available. A two paragraph summary of the proposed example of substance use portrayal in the media that will be used for the paper is due by the end of Week 3. This proposal is a separate assignment and is worth 10 points.


 Step Three: Write the paper. Begin the paper with an introduction that summarizes the main findings of the AAP article and previews what will be covered in the coming pages. Next, compare and contrast the portrayal of substance use found in the media with the information learned about that substance in the class and course readings. What messages about the substance are being portrayed? How accurate are those messages relative to the actual data on substance use? Be sure to cite the course readings as needed.

 Continue by comparing and contrasting the portrayal of substance use found in the media with the criticism of media portrayals found in the AAP paper. Does the media example match their arguments or contradict them? What links and connections can be made? Be sure to cite the article as needed. 

 Next, draw some conclusions about the portrayal of substance use found in the media, addressing the following: What are the implications of this type of portrayal? What messages are being sent and to whom? Are those messages an accurate representation of the use of this substance? Should media portrayals be required to be accurate in their depictions of use, showing both positive and negative consequences? 

 Finally, review the guidelines suggested by the AAP at the end of their policy statement and address the following: Although directed specifically at pediatricians, which of those recommendations is most important? Why? Are these recommendations necessary? If followed, will they be effective in addressing the concerns raised earlier in the article? Be sure to cite sources as needed.

 Step Four: 

The required length of this paper is 11 pages, plus a required a cover page and a reference list. Papers must comply with APA formatting rules, including font size and margins, and must have a scholarly focus and tone.  Quoting of published material and use of the first-person “I” are not permitted and will result in point loss. All source material must be paraphrased into your own words and cited appropriately. 

 On submission your work will auto-run through’s plagiarism checker software.    

 The grading rubric below details specific grading criteria.

The Final Major Paper document should be attached in the appropriate Assignment tab and will be evaluated using the rubric below: 




Needs Improvement 


Points Earned


15 Points Possible

Student provides a clear   introduction which summarizes the AAP article and previews the major points   to be covered in the paper.   

Student provides a mostly accurate   introduction which summarizes the AAP article and previews the major points   to be covered in the paper. At times description lacks coherence. 

Student provides a marginal   introduction which summarizes the AAP article and previews the major points   to be covered in the paper. Sufficient details and supporting evidence are   lacking.

Student does not provide an   introduction which summarizes the AAP article or preview the major points to   be covered in the paper.

Choice of Media Example

15 Points Possible

Discussion of chosen media   portrayal is clear, accurate, and related to the assignment. Sources are   credited and cited appropriately.   

Discussion of chosen media   portrayal is mostly accurate, and related to the assignment. Sources are   credited and cited. At times description lacks coherence. 

Discussion of chosen media   portrayal is marginally accurate, and related to the assignment. Sources   are credited and cited but not using appropriate formatting. Sufficient   details and supporting evidence are lacking.

Student does not chose a media   portrayal that is accurate and/or related to the assignment. Sources not   credited and cited.

Comparison of Media Example to   Class Material

25 Points Possible

Student provides a comparison of   media with information from class material that is clear and   thoughtful. Questions outlined in the assignment are   answered. Sources are credited and cited appropriately.   

Student provides a mostly accurate   comparison of media with information from class material that is largely   clear and thoughtful. Questions outlined in the assignment are mostly   answered. Sources are credited and cited appropriately. At times   description lacks coherence. 

Student provides a marginal   comparison of media with information from class material that is partial   clear and thoughtful. Questions outlined in the assignment are   marginally answered. Sources are credited and cited appropriately.   Sufficient details and supporting evidence are lacking.

Student does not provide a   comparison of media with information from class material. Questions   outlined in the assignment were not answered.

Comparison of Media Example to AAP   article

25 Points Possible

Comparison of media presented by   the student with information from the AAP article is clear and   thoughtful. Questions outlined in the assignment are   answered. Sources are credited and cited   appropriately.   

Comparison of media mostly presented   by the student with information from the AAP article is mostly clear and   thoughtful. Questions outlined in the assignment are mostly   answered. Sources are credited and cited appropriately. At times   description lacks coherence. 

Comparison of media marginally   presented by the student with information from the AAP article is mostly   clear and thoughtful. Questions outlined in the assignment are   marginally answered. Sources are credited and cited   appropriately. Sufficient details and supporting evidence are lacking.

Student did not compare media   presented with information from the AAP article. Questions outlined in   the assignment were not answered.  

Strength of Conclusion

40 Points Possible

Student provides an insightful and   creative conclusion, logically summarizing the main elements of the case   and the scholarly literature findings, articulating a personal reflection on   the case study analysis process

Student provides a mostly   cogent conclusion, logically summarizing the main elements of the case   and the scholarly literature findings, articulating a personal reflection on   the case study analysis process

At times description lacks   coherence. 

Student provides a   marginal conclusion, loosely summarizing the main elements of the case   and the scholarly literature findings, articulating a personal reflection on   the case study analysis process

Sufficient details and supporting   evidence are lacking.

Student does not provide a   clear conclusion or logically summarizing the main elements of the case   or reference scholarly literature findings; lacks a personal reflection on   the case study analysis process

Paper Format and Mechanics;   Spelling, Grammar and Punctuation

30 Points Possible

Work is presented in a logical and   coherent way. Writing is clear, articulate, and error free. Citations are   composed in proper format with few or no errors. Paper is the required   length, is double-spaced with 1-inch top, bottom, left and right margins, and   in Calibri or Times New Roman styles, size 12 font. Cover   page, paper body, citations and References are in the correct APA   format. There are few to no spelling, grammar, or punctuation   errors.

Work is grammatically sound with a   few minor errors. Citations are composed in the proper format with some   errors. 

Work contains frequent grammatical   errors. Citations are inaccurate or improperly formatted. 

Work does not demonstrate   appropriate graduate level writing. 

Summary Comments: 

Total Points:   (150   points total)

Supporting Materials




One of the most problematic, licit drugs in our society is alcohol. The simple process of fermenting sugar from a variety of naturally occurring fruits and grains has been ubiquitous across cultures and societies since the beginning of civilization. It is so pervasive within our society as to also seem to be a seamless part of it. One cannot easily characterize a particular type of person or group that is likely to be alcohol dependent; the affliction cuts across all imaginable demographics of society. Some people are able to drink on occasion for pleasure, whether alone or with friends. Others drink on a daily basis; others periodically binge. 

Here’s a quick, 9-minute history of the science, creation and use of alcohol across cultures, courtesy of

At present, it has been estimated that approximately 18 million Americans have a serious problem related to the use of alcohol. These 30% of all consumers of alcohol account for about 80% of all alcohol consumed. Men outnumber women in heavy alcohol use by a ratio of around three to one.

The heaviest users of alcohol, in turn, directly or indirectly impact an even larger percentage of the population with their subsequent behaviors while intoxicated. The costs of alcohol abuse and dependence are significant: this drug is the third leading cause of death and is implicated in over half of all deaths and injuries in car accidents and half of all physical assaults and homicides. Further, it has been estimated that at least four family members are directly affected from the maladaptive behaviors that follow from the alcohol-abusing individual; you can quickly begin to see extensive the social, familial, occupational, and emotional impact of this disorder. 

What’s the difference between alcohol abuse and alcohol dependence?

The initial psychiatric diagnosis that could be made for an individual that habitually uses alcohol to excess would be alcohol abuse. This diagnosis is characterized by the continued use of alcohol for at least a period of one month, despite having a recurrent physical problem or some serious personal problem in one’s social or occupational functioning because of the excessive drinking or the repeated use of alcohol in situations (e.g., driving) when consumption is physically hazardous.

The diagnosis of alcohol dependence reflects an even greater degree of impairment in individuals compared to alcohol abuse. Alcohol dependence typically involves at least three of the following serious circumstances: (1) drinking alcohol in greater amounts and over a longer period of time than intended by the individual; (2) a strong desire by the individual to reduce consumption and several unsuccessful attempts to do so; (3) spending a great deal of time drinking or recovering from the negative effects of excessive drinking; (4) continued drinking even though physical and/or psychological problems are apparent and problematic in the individual’s life; (5) social, work, or recreational activities have been significantly reduced or abandoned because of excessive drinking; (6) the development of marked tolerance for alcohol; and (7) consumption of alcohol specifically to avoid the symptoms of withdrawal. About 15 percent of men and 10 percent of women in the United States have met the diagnostic criteria for alcohol dependence during their lifetime.

How does alcohol affect the brain?

Alcohol, as a drug, acts as a depressant on the individual’s central nervous system. It is a small molecule and is quickly absorbed in the bloodstream. Alcohol is linked to inhibiting receptors for the neurotransmitter GABA. In low doses, alcohol depresses the inhibitory functions of the brain, including those areas of the brain that typically adhere to the social controls and inhibitory rules that people typically follow in society. As the alcohol concentration increases in the bloodstream, the depressive function of alcohol extends from the cerebral cortex to areas of functioning that are further (and deeper) into the brain’s primitive and reflexive areas of functioning. In extreme dosing, inhibition of respiratory and motor centers can occur with other symptoms that include stupor or unconsciousness, cool or damp skin, a weak rapid pulse, and shallow breathing. It should be noted that alcohol can only be metabolized and leave the body at a specific rate, regardless of how quickly (or how much) alcohol has been taken in by the individual, so attempts to quickly “sober up” an individual will be unsuccessful.

For more illustration of the science and physical problems associated with habitual alcohol consumption, check out this 4-minute video:

What are the behavioral effects of using alcohol?

Individuals experiencing alcohol intoxication will exhibit a variety of maladaptive changes in their behavior and psychological functioning. Examples include inappropriate sexual or aggressive behaviors, impaired judgment, quickly changing moods, incoordination, impaired gait, slurred speech, impaired attention and memory (sometimes to the point of blackout), stupor, and unconsciousness. The degree of symptoms is dose dependent with more pronounced symptoms occurring as the alcohol blood-level increases.

Withdrawing from alcohol intoxication (i.e., a hangover) is also dependent on recent dosing, history of chronic abuse, and involves a variety of symptoms which can include autonomic hyperactivity in the form of profuse sweating and rapid heartbeat, hand tremors, nausea or vomiting, fleeting illusions or hallucinations, psychomotor agitation, anxiety. At worst, grand mal seizures can occur following periods of prolonged and heavy use. Another significant withdrawal phenomenon that chronic, prolonged abusers of alcohol can experience is delirium tremens that is characterized by disturbances in cognitive functions (especially consciousness), autonomic hyperactivity, vivid hallucinations, delusions, and agitation.

Chronic alcohol dependence can lead to a medical condition known as Alcohol-Induced Persisting Amnestic Disorder (also known as Wernicke-Korsakoff’s Syndrome). This disorder is believed to be caused by deficiencies in thiamine and Vitamin B because their absorption in blocked with habitual alcohol consumption. Individuals afflicted with this disorders experience retrograde (the past) and anterograde (new knowledge) amnesia as well as confabulation, which is the tendency to attempt to compensate for memory loss by fabricating memories.

What are some of the life problems associated with heavy alcohol use?

The pervasive impact of chronic alcohol abuse can be seen across several important areas of in life that generally impair one’s ability to function adaptively (i.e., take care of oneself in a manner appropriate for one’s age) and experience a good quality of life. It is a complex problem in living with psychological, physical, and behavioral components. These include (1) demonstrating a preoccupation with alcohol and drinking; (2) demonstrating emotional problems (e.g., depression); (3) having overt problems at work, within one’s family, and other important social relationships because of alcoholism; and (4) associated physical problems that result from habitual alcohol consumption.

Given that alcohol is a central nervous system depressant, it shouldn’t be a surprise that depression can become a comorbid (or co-occurring) condition for some individuals. In general, the incidence of depression in substance abusers is quite high. People who drink alcohol heavily to the point of intoxication can experience very strong emotions and are frequently disinhibited (i.e., impulsive). Feelings of hopelessness, helplessness, and suicidal thoughts often accompany bouts of heavy drinking.

To review the relationship among amount (dosing) of alcohol consumed, blood alcohol levels, and effects on the central nervous system and behavioral performance, check out this five-minute Healthy McGill video here:

Who is at greatest risk for abuse or dependence?

Research has demonstrated that two risk factors can contribute significantly to the manifestation of alcohol abuse and dependence in the individual. The first risk factor is a family history of chronic alcohol abuse. Children of alcoholic parents have a higher statistical risk of becoming alcoholics themselves when compared to children of nonalcoholic parents. Whether this represents an increase genetic or environmental risk, however, is difficult to determine since both are intertwined in such instances. A second and independent risk factor that has been identified is those cases where an individual has a genetic predisposition to have low response to the psychoactive effects of alcohol (and, as a result, requires higher amounts of alcohol to become intoxicated). Individuals with this lower response to alcohol are more likely to abuse alcohol, as they require considerably more drinking to obtain the level of intoxication experienced by others who drink less to get the same effect.

When taken together, an adult child of an alcoholic who also possesses a low response to the effects of alcohol has an even higher statistical chance of developing a pattern of alcoholism. Keep in mind that all of these examples are just risk factors and statistically probabilities – none of these outcomes are written in stone. Further, research demonstrates that there are also protective factors (variables) in the environment that can also help promote resiliency in some individuals and lead them not to drink alcohol in an excessive or maladaptive fashion when they are present. Clearly, again, the path to alcoholism (and responsible drinking and abstinence) is multi-factorial.

What are some of the treatment options for Alcohol Dependence?

        Unfortunately, flaws in methodology jeopardize much of the research on the effectiveness of alcohol treatment programs. That is, the studies aren’t well controlled in terms of error variance and it cannot be clearly determined whether the observed changes in the studies are due to the employed treatment or other, uncontrolled, factors during the study. For example, many studies do not use untreated comparison groups. One generalization that can be made from the available research is that formal treatments are not always adequate or even necessary. A positive outcome to treatment appears to be related more to the presence of certain psychosocial factors like specific threats to one’s physical or social well-being (i.e., hitting “rock bottom”) than any particular intervention. 

        There are, however, some treatments that have had some success. These treatments have several components in common, including covert sensitization and other forms of aversive counterconditioning. Antabuse, for example, is a medication that, when taken, will result in an individual becoming violently ill should they consume alcohol. Other treatments that put together broad-spectrum interventions such as social skills training, learning to drink in moderation, stress management techniques, and teaching coping skills and other self-control techniques help to teach the individual better, healthier alternatives methods when faced with environmental triggers to consuming alcohol.

        Many modern programs incorporate aspects of Alcoholics Anonymous and/or the drug Antabuse. However, the effectiveness of these treatments has not been empirically demonstrated. One criticism that has been levied on these treatments is that they do not take into account individual differences and the wide variety of psychosocial problems and/or lack of resources that can make successfully managing alcohol consumption. In general, individuals with severe problems with alcohol require more intensive treatments (e.g., inpatient hospitalization), while those who experience less pathological problems require more periodic, milder interventions.

        Another criticism that has been raised about some current treatment programs for alcohol abuse and dependence is that they tend to be based on the belief that failures in treatment are largely due to the individual’s denial of having a problem or otherwise not having an adequate level of motivation. Many therapists have not supported this line of thinking, however. Research on treatment outcome, alternatively, points to the importance of therapist factors such as their level of empathy toward clients and their attitudes about what constitutes healthy recovery as being more related to positive outcomes than client’s own motivation or personality characteristics. 

        Some experts in the field of alcohol research have emphasized the importance of the clients’ reaction to instances of relapse, especially from a cognitive (how they think) and emotional (how they feel) perspectives.  Researchers stress the need to get away from the idea that a relapse represents a “violation of abstinence” which can lead to anxiety, depression, self-blame and an increased likelihood of further alcohol consumption. Alternatively, relapses should be characterized as a mistake that came about from external, controllable factors and not the result of internal factors (e.g., personality characteristics) that are essentially thought to be out of one’s control.

Dually diagnosed individuals (those with a mental illness or personality disorder in addition to a substance abuse disorder) usually have a hard time finding treatment in one place. In many jurisdictions, they have to see a therapist at a mental health center and a separate therapist at a substance abuse center, or they are forced to make a choice of one over the other. You will find that there is often a lack of cross-training between mental health and substance abuse professionals, and that makes it harder for clients to get the treatment they need. Furthermore, in some places, you may find that the treatment support groups for substance abuse have an interpretation of sobriety that prohibits the use of psychotropic medication.

Legal Drugs in Our Society – Part II

        Hopefully, you have found the historical account to date of which drugs have largely been considered illicit, those that have typically been licit and readily available, and those that have switched from one designation to the other, to be an interesting review. Such distinctions among different groups of people and across different periods of time often speak to the changing cultural, social, religious, and scientific beliefs and morays of the time. This week, you will be studying two very popular and legally sanctioned drugs, tobacco and caffeine, that have been readily consumed by people since the beginnings of structured societies. 


From its use in religious ceremonies and purported medicinal herb thousands of years ago to the image of sophistication and modernism it has held in industrialized societies over the last few hundred years, tobacco has occupied a role of prominence among individuals and groups alike.  Think about it: what other drug has been so popularized in society as to be physically accommodated with lighters and ashtrays in automobiles and airplanes? What about spittoons in the restaurants and bars of the late 1800s and early 1900s? How about the smoking cars in trains and smoking sections at airports and restaurants? All these examples serve to demonstrate just how indoctrinated tobacco use has been in modern culture. 

How did tobacco, the plant, get to be such a big deal? Check out this 8-minute history and science video from DNews Plus:

How have patterns of tobacco use changed over the decades in the United States and the world? What are some of the reasons for these changes?

Tobacco is interesting and noteworthy in that it is one of the only drugs that has been commercially available, openly accessible, and integrated within the culture of many societies for hundreds and hundreds of years. Further, it has been monetized as a commodity with economic value for the purposes of trade and payment of debts. In some circles, over time and across cultures, tobacco was even used as its own form of currency. In fact, one could certainly argue that the colonization, formation, and military defense of the United States of America occurred largely in part through the economic power generated through tobacco cultivation, sale, and distribution to other European countries.

It is interesting to note the relationship between the amount of government regulation that exists with the tobacco industry and the resultant use by population. There is a clear relationship between the growing regulation in the United States that began in the early 1970s and the eventual decline of tobacco use among large segments of the U.S. population. This can be especially seen in new generational cohorts; that is, the adoption of chronic smoking habits by younger people. Many other European and South American countries do not employ such heavy restrictions on the advertisement, marketing, and accessibility of cigarettes and other tobacco products upon their population. As a result, the decreases in use and dependence that have been realized in the United States have not been generalized to other countries across the world. The zenith of tobacco use in the United States has come and gone. The preponderance of research has clearly demonstrated its pathological effect on the body and that information, plus rigorous regulation, has helped contribute to the decline in its use.

There are a variety of ways to consume tobacco products as a vehicle by which to introduce the drug nicotine into the bloodstream and the brain. Smoking (via cigars, pipes, and cigarettes), chewing, and snuffing are all legitimized drug-using behaviors whose differing favorability has waxed and waned over the years. Over the years, most individuals were shaped into eventually preferring the use of tobacco cigarettes, which could be mass-produced in very high volumes inexpensively.

The intense and intentional role of marketing has been very significant in shaping the appeal to certain demographic groups of the population. The aggressiveness of early mass marketing campaigns also extended themselves, ultimately, to the denial and cover up by corporate America with regards to the deleterious effects of tobacco use. It wasn’t until 1964 that the federal government began to formally investigate the health effects and cost of tobacco use and to institute policies that would eventually lead to the restriction of marketing and sales in the United States. 

What are some of the adverse consequences of smoking?

The deleterious effects, both physically and psychologically, that result from chronic tobacco use have been well documented. The three-fold combination of carbon monoxide, tar, and nicotine can produce a wide variety of lifelong physical ailments, including a higher risk for cardiovascular disease, respiratory disease, and lung cancer than for nonsmokers. As is widely popularized, there are literally thousands of chemical found in cigarette smoke, including ones commonly used in pesticides. Additionally, other forms of cancer have also been implicated with chronic tobacco use. In fact, the vast majority of deaths each year that can be attributed to drug use and dependence are the result of tobacco use and nicotine dependence.

The primary psychoactive drug in tobacco, nicotine, has been determined by research trials to be a dependence-producing substance. As you recall from previous lectures, drug dependence is defined by continued use of a drug even in the face of obvious occupational, physical, familial, and social problems that one experiences in direct relation to its use. This also includes the psychological experience of craving and high drug-seeking behaviors. The rate at which nicotine is absorbed into the blood stream and penetrates the blood-brain barrier certainly speaks to its strong psychoactive properties. Withdrawal symptoms begin as early as six hours after the last dose. Within 24 hours, common complaints can include headache, irritability, problems concentrating, and sleep disturbance. Finally, in the late 1990s, the tobacco industry finally conceded publically that the products they were producing were not only physically harmful to individuals but also that the nicotine contained within then was a dependence-inducing substance.

What are some of the best strategies to employ when attempting to stop using tobacco products?

    You know just how difficult it is to treat nicotine addiction in terms of a smoking cessation program. The research has demonstrated, much like successful treatment programs for other types of drugs, that have a high degree of dependence, that a multimodal approach is best. This type of additive treatment program incrementally increases the probability of success by systematically addressing addiction from a biological, social, operant conditioning, and environmental cue framework. Individuals are encouraged to think deeply about, and even write down, their personal reasons to stop smoking. This cognitive-behavioral approach helps an individual really contemplate the meaning and reasons behind their decision to stop smoking – beyond the simplistic reasons often given by others or conveyed through warning labels or public service announcements. 

Much like treatment for opiate dependence, a gradual reduction of the addictive drug nicotine helps lessen the severity of the withdrawal symptoms that can often make smoking cessation very difficult. In other words, the strategy of simply going ”cold turkey” often does not result in a successful outcome. The research has shown that a gradual reduction in smoking, often coupled with the intermittent use of medications that can regulate nicotine such as transdermal patches, tends to have better and more long-lasting effects.

    Other strategies that have been shown to be useful in an individual’s armamentarium of treatment strategies include attempting to stop smoking within the context of a social support group. Research has demonstrated that when you confide your goals to others who have your best interests at heart, this can be a powerful social reinforcer to maintain attempts at smoking cessation. The support of other individuals can often also help assuage feelings of stress that one has in their life. Certainly, any attempts one can make at stress reduction in terms of their daily life challenges, the fewer external cues there will be to return to smoking which, for many people, has been used as the primary means for stress reduction in their life.

    From a behavioral perspective, it is important for individuals who want to stop smoking to remove from their environment the physical cues that are associated with the behavioral habits of smoking. This strategy is similarly employed with other types of illicit substance abuse where the act of taking the drug carries significant import. Cigarette butts, packets of tobacco products, ashtrays and even behavioral habits such as alcohol or coffee consumption that often accompany tobacco use need to be removed or significantly changed in the individual’s life to minimize the effects of the operant conditioning history. 

Like with treatment for other types of serious drug addiction, it is important to realize that relapse is a real possibility and that an individual should be rewarded and reinforced for attempts at cessation. Additionally, one should not be overly self-critical or invalidate the process of recovery when instances of backsliding or relapse occur. The research is shown that, in fact, quitting tobacco use is a process that often takes, on average, seven or eight failed attempts before finding a long-lasting successful outcome.

    Another important treatment modality is that of physical exercise. It primarily can serve as a substitution for many of the stress-relieving properties that tobacco use once served. In addition, the conditioning of an individual’s cardiovascular system can help rehabilitate bodily functions that have long suffered under the excessive burden that tobacco use, typically smoking, has brought on these organ systems. As with the other forms of drug treatment, the consultation of a physician during the process can aid in the chances of success. Physicians have as their disposal a variety of medications, including some in the antidepressant class, which have shown good efficacy in helping to curb cravings and the resultant irritability associated with withdrawal. However, they are certainly not without some risk factors and frequent monitoring by primary care professional is important.


What can one say about the drug caffeine? To state that it may be one of the most pervasively and ubiquitously consumed drugs throughout the world might just be an understatement. Next to the naturally occurring and arguably nutritious substance of sugar, it may be one of the substances that is most readily infused into the diet of most Americans in modern society. Put another way, caffeine use is one of the most popular forms of drug use in the world. One only needs to look at the recent proliferation of coffeehouses and coffee culture, and the subsequent indoctrination of younger generations of individuals to soft drinks and coffee use, to see a pattern of life-long use. In addition, a whole new line of product development and targeted marketing has occurred over the last 15 years: that of the ”energy” drinks and individual doses of caffeine in a one-shot delivery system. In other words, society has moved from caffeine being a desired byproduct of a consumable beverage to being its own means to a desired end.

Here’s a quick and humorous four-minute overview from on the world’s most popular psychoactive drug:

Tea is the world’s oldest caffeine containing beverage. Like tobacco, tea has historically been a commodity that has political power in terms of economics in trade. Typically, tea contains less caffeine than a cup of coffee, although particularly strong brews of tea can approximate the same caffeine level as found in coffee. There is some medical literature that suggests that consumption of tea in moderation does have specific health benefits. For example the bronchodilating effect of tea has been found to be helpful in the treatment of asthma symptoms and other respiratory problems. The flavonoids found in chocolate have been implicated in cardiovascular health by functioning as antioxidants within the bloodstream. There is a positive association or correlation found between the consumption of dark chocolate and reduced risk for cardiovascular disease and stroke. Coffee consumption has been present for several thousands of years and, at least in industrialized societies, has offered an alternative to excessive alcohol consumption in some circles of society. However, it should be noted that consumption of coffee and the caffeine therein can in no way abate the effects of alcohol intoxication or somehow “sober up” an individual faster; this is a common myth. Fortunately, most doses of caffeine taken in individual servings of substances such as a cup of coffee, a bar of chocolate, or a cup of tea are relatively low and benign in terms of their overall affect on individuals.

The most commonly ingested source of caffeine in our society is that of soft drinks or sodas. The largest segment of our population in terms of demographics uses these products. Approximately 95% of the caffeine that is found in soft drinks is artificially added through the manufacturing process; that is, unlike the coffee bean or the tealeaf, the caffeine is not naturally occurring as a part of the substance being consumed. The United States leads the world in per capita consumption of soft drink products. In addition, as has been previously stated, the United States is at the forefront of development of new energy drinks that are marketed for the express purpose of high dose caffeine ingestion. These energy drinks typically can contain anywhere from two to three times the levels of caffeine that would typically be found in a soft drink or single cup of coffee.

Caffeine can also be ingested from over-the-counter products typically sold in pharmacies. Products can range from pain relievers and cold remedies to weight control supplements. Caffeine acts a vascular dilator tour that can be helpful in treating asthmatic conditions as well as headache pain. Still other drugs are expressly designed to keep the individual awake and alert for a sustained period of time. When ingested, caffeine is absorbed into the body in 30 to 60 minutes with peak levels of caffeine seen in the bloodstream about an hour after in just station. Sometimes individuals will describe an immediate boost of energy as a symptom following caffeine consumption; however this is either simply psychological in nature in terms of an expectancy effect or, more likely, related to ingesting the sugar that commonly is paired in drinks.

What are some of the symptoms and effects of caffeine use?

Caffeine is a psychoactive stimulant drug that, when taken in excessive amounts, can certainly cause difficulties for the individual using it. High levels of caffeine use lead to intoxication, sometimes known as caffeinism, which involves symptoms of restlessness, nervousness, insomnia, excitement, flushed face, gastrointestinal problems, and diuresis (excessive urination) in comparison to low doses. One of the most commonly affirmed symptoms of caffeine is the tendency to delay onset of sleep and the reduction of quality of sleep that comes following its use. Many individuals certainly report that, as they age, they are unable to continue to drink caffeinated beverages into the late afternoon or early evening because of the disruption in their sleep patterns that will result.

Typically, users report a feeling of mental alertness and lack of fatigue after ingesting caffeine. Most individuals will report that they feel they are able to work more effectively and for longer periods of time, for example, after their morning cup of coffee. However, research examining the behavioral performance of individuals taking caffeine is mixed with regard to human performance. Caffeine use seems to help when individuals are faced with mundane and boring tasks by keeping their attentiveness high and their response time fairly fast. However, for more complex tasks in which individuals need to make intricate discriminations or weigh the relative consequences of different choices, caffeine seems to have little positive, and can actually be disruptive to this mental process.

When individuals ingest large doses of caffeine, the individual will experience more prominent symptoms such as muscle twitching, cardiac arrhythmias, rambling thoughts or speech, and psychomotor agitation. While there have been some studies that suggest physical problems or disease can be associated with caffeine use, the vast majority of these studies suffered from significant methodological problems and the results, therefore, have been inconclusive.

Research has demonstrated that there is physiological evidence of tolerance and withdrawal as well as psychological cravings associated with chronic caffeine use. There is certainly concern about the rapid increase in the last decade of children who are consuming larger doses of caffeine than we have previously seen. It will take some time for research to bear out whether or not deleterious effects are associated with excessive caffeine consumption in children whose brains are still developing. Certainly, the excessive amount of sugar that is often paired with caffeinated drinks also raises concern with regards to childhood obesity. In addition, the symptoms of nervousness and anxiety that are often reported with higher-level doses of caffeine have yet to be fully understood with regards to childhood consumption.

Enhancers and Depressants

There are three disparate groups of widely used drugs in our society: performance-enhancing drugs, depressants, and inhalants. 

How did the use and development of performance-enhancing drugs evolve over time and societies? Start by checking out this entertaining and informative nine-minute overview video from

Performance-Enhancing Drugs

As you read the chapter on performance-enhancing drugs, it is likely that you may think this area of drug abuse represents a tangent from your previous week’s studies and is a relatively new and esoteric realm of drug abuse. However, quite to the contrary, the abuse of drugs for the explicit purpose to gain a physical performance advantage in competition and battle has been in existence and documented since at least 300 B.C. and the first Olympic games. By the end of the 19th-century, recorded accounts are archived of professional athletes consuming a wide variety of drugs for the purposes of enhancing their physical prowess, including caffeine, alcohol, cocaine, opioids, and amphetamines. However, over the centuries, not all attempts to enhance performance through the ingestion of chemicals and drugs were successful; strychnine and nitroglycerin were two examples of substances that ended up causing more harm than help to those that used them. Occasional deaths were reported as a direct result of overdosing on some of these powerful drugs; the first recorded death of a professional athlete in such a manner occurred in the late 1800s with the collapse of a cyclist who was discovered to have used a combination of cocaine and heroin, commonly known as a ”speedball,” in a race to deleterious effect.

The advent of modern-day performance-enhancing drug use began in the 1930s with the manufacture of anabolic steroids, patterned after the male sex hormone testosterone. This class of drugs was noticeably different from its predecessors in that this drug actually changed (often permanently) aspects of an individual’s physiology rather than simply their experience or behaviors for a period of time. These effects were long lasting and often generalizable across a wider range of activities. Anabolic steroids were originally designed to help address the affects of severe anemia, malnutrition, and starvation in soldiers, victims of war, and other patients whose bodies were severely degraded. However, it quickly became apparent that the gains seen when administering these drugs two waylaid individuals could also be used to magnify the prowess and abilities of healthy individuals as well. It wasn’t long before coaches and athletes began to experiment with these drugs as a way to enhance performance, or produce ergogenic effects, across a variety of sports and competitive events.

How do anabolic steroids work?

Testosterone serves two fundamental purposes in the body: promoting the development of male sex characteristics and the development of muscle tissue. In typically developing males, a higher level of testosterone found in the bloodstream helps explain, in part, the larger muscles and sheer mass of men compared to their female counterparts. Anabolic steroids, which are developed through a manipulation of the testosterone molecule, produce similar effects, but in a more rapid manner, when taken by any individual. 

For much of the modern Olympic games, it was quite common for many athletes to use performance-enhancing drugs, including anabolic steroids. Their use was most prominent and acknowledged from the 1960s to the 1980s. While some athletes were placed on protocols of anabolic steroids secretly under the supervision of their coach and a physician, others athletes were part of large, systematic programs of drug use and performance measurement within their country. It wasn’t until the 2000 Olympic games that stringent restrictions were placed on the use of performance-enhancing drugs and all athletes had to attest that they were not using drugs or otherwise “doping” to enhance their performance. 

While the increase in regulations, restrictions, and sanctions have lessened overt use of performance enhancing drugs, there continues to be a dynamic, and well financed, amount of covert use in professional competition. By 2004, the World Anti-Doping Code was created, which codified the specific rules and regulations regarding performance-enhancing drugs and their use in sporting events. Since that time, and with the advent of better testing to identify cases in which athletes have violated the Code, there have been many high profile cases in the media that highlight the ongoing concern with performance-enhancing drugs. It should be noted that the sanctions received for violations have increased quite significantly in the last 15 years. In addition, legislation was passed in 1990, designating anabolic steroids as a Schedule III controlled substance, which makes them subject to criminal penalties if inappropriately manufactured, distributed, or used.

Some individuals may argue that the stakes in modern sports are higher than they have ever been in human history as a means for justifying, excusing, or explaining the use of performance enhancing drugs. However, while the records in sports that exist today are higher than they have been in the past, individual athletes still have to struggle to make a living and support their families, much like their predecessors. In addition, there was less revenue from multiple sources (e.g., commercial endorsements) available to athletes in the past, so making a living as a full-time professional athlete was even more precarious during past generations. In other words, the life of a professional athlete has always been difficult and always required sacrifice. Temptations to cheat and “game the system” have existed in various forms since the beginning of organized competition.  What has changed is the manner of sophistication and subtlety in which drugs can be used to enhance one’s performance.

Certainly, what passes as a standard for masculinity in our society has changed over time and this, in part, could be one source of cultural influence in today’s current climate of performance-enhancing drug use. In our modern society, the images that are portrayed in terms of masculinity, femininity, athletic prowess, and endurance can potentially influence individuals in terms of behaviors that they might engage in to meet or exceed an imagined cultural standard. 

What are some of the physical and psychological symptoms and side effects of anabolic steroid use in men and women?

There are several well-documented hazards associated with the use of anabolic steroids. One confound in determining the effects of various dose– response relationships is the fact that many individuals illegally abusing anabolic steroids take anywhere from 5 to 500 times the recommended dose. Because of this high degree of variance, it can be hard to gauge the relative risk from individual to individual. However, some generalizations can be made.  As these synthetic hormones enter the bloodstream and systemically flood the body with testosterone, changes occur across a wide variety of organ systems, and not all with an efficacious outcome. Given that the liver’s function is to help clear toxins and unnatural substances from the body, it should come as no surprise that this organ can suffer greatly from prolonged anabolic steroid use in both men and women. This is typically seen through the increased risk for tumors, the increase in lifetime risk for liver failure and, when they rupture, the need for emergency liver surgery. An increased risk for cardiovascular disease has also been noted with chronic anabolic steroid use.

One notable change in men with prolonged use is that an individual’s own testes glands begin to produce less testosterone in the body becomes as the body becomes acclimated to having it artificially introduced into the system at higher-than-normal levels. This not only causes male function to decrease (shrinking testicles, lower sperm count, enlarged prostrate) but the low, natural production level also results in less inhibition of naturally occurring estrogen which can result in and increase in feminine, secondary sex characteristics (e.g., enlarged breasts or gynecomastia). Some of these effects are reversible when hormone supplementation is stopped, while others are not.

        For women, the sustained use of anabolic steroids, and the introduction of a large amount of testosterone into their bodily systems, has an overall tendency to accentuate stereotypically male characteristics in them, including a lower voice, increased facial hair, increased aggressiveness, decreased body fat, diminished or stopped menstruation, increased acne, and decreased breast size. Again, some of these symptoms are reversible with discontinuation of anabolic steroids, while others continue to persist.

        Anecdotally, psychological problems in men and women who abuse anabolic steroids have included severe mood swings and a lower threshold for aggressive behavior, commonly referred to a “’roid rage.” However, more systematic research needs to be conducted in this area to determine more clearly the propensity of these symptoms for different individuals. In short, a variety of other, possibly confounding variables, come into play that can moderate the resultant mood changes with anabolic steroid abuse, such as an individual’s temperament, personality, and the social context within which a person lives and trains.

        In term of dependence to anabolic steroids, there is evidence to support the phenomenon of psychological dependence to the drug and associated drug-taking behaviors. Many athletes engage in drug use in a cyclic fashion, incrementally increasing the doses (whether taken orally, intramuscularly, or both) and then tapering down for a period of time, usually at the point when they suspect they will be tested for the presence of illegal drugs in their system. Some muscle atrophy or shrinkage has been noted with the lessening or cessation of anabolic steroids and this, when coupled with an individual who is inordinately preoccupied with their physical appearance, leads to concerns about losing physical appearance and prowess and a higher likelihood to continue to use the drug. 

From a perceptual standpoint, some individuals who chronically abuse anabolic steroids development “muscle dysmorphia,” which is a disturbance in their perception of their bodies, much like what is seen with some people who have eating disorders, where the individual believes that their bodies are weak and insufficient (thereby requiring more anabolic steroids), even in the face of physical evidence to the contrary. Unfortunately, it does not appear that in our dominant culture in the United States, with its focus on youth, attractiveness, and physical prowess, will be helping to ameliorate this social problem anytime in the near future.


You will now shift your study from performance-enhancing drugs to the class of medications that are collectively known as depressants. As classified, these medications collectively bring one “down” and create symptoms in individuals that are the antithesis of the stimulant class of medications (e.g., amphetamines, cocaine, caffeine) that you have previously covered in this course. Keep in mind that these drugs are manufactured in the laboratory and don’t naturally occur in the environment as many classes of drugs that you have previously studied in this course.

What are the major distinctions between barbiturates and benzodiazepines?

One of the original and major classes of depressants is that of barbiturates. They are tasteless and odorless and historically were prescribed as a sleep aid. Compared to benzodiazepines, which will be discussed shortly, barbiturates pose a greater health risk because of their broader, systemic effect upon the body. Depending on the dose taken, the effects of the barbiturates can range from mild relaxation to coma and death. As such, the threat of a lethal overdose is a significant concern. 

In and of itself, the effects of barbiturates are positively reinforcing; animal studies have shown how consistency they will respond in an operant learning environment to receive a continuous infusion of barbiturates into their system. Barbiturates are also known to have a synergistic, or additive, affect when taken with alcohol; one can take a non-lethal dose of both but, when taken together, they can be a lethal combination to the unsuspecting user.

Individuals who take barbiturates at relatively low dose report feeling a sense of relaxation and euphoria. As the dose level of barbiturates increase, more primitive areas of the brain are subsequently affected, including those that control autonomic functions like consciousness and respiration. At these higher doses, people report feeling heavily sedated and drowsy. While initially used as a sleep aid, researchers demonstrated that this class of drugs is typically not well suited for that purpose. Specifically, it has been noted that Rapid Eye Movement (REM) sleep is inhibited during the periods when barbiturates have been taken. REM sleep is generally thought of as being one of the deepest stages of sleep and highly restorative to bodily functions. As such, individuals taking barbiturates often report feeling tired upon wakening and describe their sleep as not very restful. Further, upon discontinuation of barbiturates, many individuals experience a sleep “rebound” effect in terms of REM sleep in that they experience inordinately longer cycles of REM sleep than typical and these periods of sleep are characterized by highly vivid and often disturbing dreams.

Using barbiturates as a primary treatment for sleep problems can certainly lead to symptoms of dependence. Physiologically, the body builds up dependence to the drug with regards to effects on sleep, requiring progressively larger amounts of the drug to achieve sleep-inducing effects. Compared to other classes of drugs, the withdrawal from barbiturates can be very dangerous if attempted without medical supervision. Symptoms of withdrawal include tremors, vomiting, perspiration, nausea, convulsions, confusion and high fever. Individuals are negatively reinforced to continue taking the drug in an attempt to avoid these undesirable symptoms. As a result, the use of barbiturates as a sleep aid has largely been discontinued in the United States because of these risks. 

Another important and more modern class of depressant is benzodiazepines. Compared to barbiturates, these are the next generations of depressants – they focus more selectively on the concerning symptoms of anxiety without causing global sedation across all bodily systems as its predecessor, barbiturates, do. This is preferred because the risk of a lethal overdose by shutting down the respiratory center in the brain is greatly reduced. In addition, benzodiazepines are absorbed more slowly into the bloodstream, avoiding any reinforcing “rush” effect where the resultant symptoms of relaxation more slowly with a longer duration of effect. As a result, this drug is a poor reinforcer of drug-using behavior. Benzodiazepines work by increasing the activity of the neurotransmitter GABA, which produces an inhibitory effect upon the central nervous system. 

It is interesting to note that one of the primary uses for depressants in our society over the years has been to aid and sleep and to lesson symptoms of anxiety. While these drugs have been used with varying degrees of success in treating these ailments, it should be noted that there are a wide variety of cognitive-behavioral interventions that have been supported in research studies to address these problems without the use of drugs. For example, there is a whole body of research on sleep hygiene and the appropriate behavioral habits, routines, and nighttime rituals which can help promote and sustain healthy, natural sleeping patterns in individuals. Similarly, the available psychological literature on cognitive-behavioral treatments to address symptoms of anxiety has been well documented. 

For a quick overview of anxiety disorders and how they can disrupt aspects of daily functioning like sleep, check out this 11-minute video:

Unfortunately, many individuals in our society as well as healthcare professionals espousing the medical model often look to pharmaceutical interventions as a first-line solution for many problems in living. While it certainly takes fewer appointments and less effort on the part of the individual and care provider to simply prescribe a medication to an individual, as you have learned in reviewing the reading materials and this lesson for the week, it is not without its own risks in terms of health and symptoms of dependence. Other avenues of non-pharmaceutical intervention should be actively explored; often, those strategies can be generalized broadly and have longer-lasting effects for individuals without the risks associated with overreliance on drugs to ameliorate their symptoms.


Inhalants, like most of the other drugs you have studied in this course, have been used throughout societies and cultures for thousands of years in an attempt to obtain mind-altering effects.  These drugs also fall into the general category of depressants in that brain activity (as measured by EEG) is significantly slowed down with their use. The first readily documented accounts occurred in the late 1700’s with the use of nitrous oxide and ether as pain-reliving analgesics that also produced a mild sense of euphoria, a sense of wellbeing, and a period of sedation.  

The aftermath of their use, however, can include nausea, vomiting and sensory confusion. Another significant concern with inhalants in that they dilute the amount of available oxygen for respiration when individuals cover their mouths and inhale other, noxious substances. Ether also has the dubious distinction of also being highly flammable. Beginning in the 1950’s, other substances, including glue and aerosol solvent chemicals, began to be abused, heralding in the modern area of what we typically know as common inhalants. 

What makes the use of inhalants appealing to children and teenagers?

Most substances used as inhalants are inexpensive, readily available and because they are found in common household products, don’t need to be hidden covertly from others like other illicit drugs. Unfortunately, because these substances are absorbed rapidly through the lungs, inhaling these substances produce a quick “high” which can be very reinforcing to the user and lasts about an hour with withdrawal symptoms that are relatively mild when compared to other drugs such as alcohol. 

Because of the ease of purchase and accessibility, this form of drug abuse is most commonly found in children and teenagers and chronic abuse, when it does occur, is most likely to be found among poor and disadvantaged children who are experiencing significant psychosocial problems. Perhaps the best outcome research that we have to date on inhalants is that many individuals stop using them after a period of time and that there use appears to be developmental and peer-influenced in nature. The long-term physical effects are not readily understood.

Medicinal Drugs

This week, you will be studying the use of different classes of psychoactive drugs that are not typically abused – leading to the diagnosis of a mental disorder relating to substance abuse or dependence – but, alternatively, are actually used to treat specific mental disorders in individuals. The development of these drugs has literally revolutionized the modern treatment of many major psychiatric conditions and provided substantial relief for millions of people, helping to assuage some very significant, chronic, and endogenous mental health conditions. These medications have also given researchers an effective means by which to test various hypotheses relating to the relative presence or absence of specific neurotransmitters in the brain and their relationship with moods, thoughts, sensorium, and behaviors. 

This working research framework has been described as the biochemical model of mental illness. This perspective holds that abnormal thoughts and behaviors largely result from abnormal biochemical processes in the brain. While this certainly does not account for the significant role that environment, relationships, and other personal resources have in moderating or ameliorating problems in living, it certainly has been a very significant area of research in understanding physiological processes that relate to drug response and mental illness. What follows is a discussion of the use of drugs that is relevant to several major classes of mental health disorders; namely schizophrenia and variants of what are collectively known as mood disorders (e.g., major depressive disorder, bipolar disorder).

To begin, review this 10-minute video on Depressive and Bipolar Disorders to gain a greater understanding of some of these chronic conditions and the role that neurotransmitters play in their occurrence.


Modern psychopharmacology, at the turn of last century, was instrumental in the discovery of certain medications that could address specific psychiatric symptoms in major, chronic mental disorders. One of the most prominent discoveries at that time was that of the first generations of antipsychotic medications to treat psychotic thought disorders, such as schizophrenia. These mental disorders can be characterized by a variety of symptoms which reflect disordered thinking, including hallucinations, delusions, disorganized speech or thought processes, and disorganized or catatonic behavior. 

    The advent of antipsychotic medications during the 1950s is thought to be one of the most relevant milestones in the treatment of schizophrenia. The first generation of antipsychotic drugs have been implicated in reducing the rates of hospitalization as well as psychiatric relapse (or reoccurrence of symptoms severe enough to disable an individual from being able to care for themselves). Of the antipsychotic medications available, the phenothiazines and butyrophenones are the most commonly prescribed for schizophrenia. While the effects of these medications can vary across individuals, they are most noteworthy for addressing what are known as the positive symptoms of schizophrenia. 

Learn more about Schizophrenia with this 11-minute video:

What are the positive symptoms of schizophrenia that are best addressed by antipsychotic medications?

While the term schizophrenia literally means “split mind,” it is best thought to characterize the split that an individual with this disorder has with the perceptual reality around him or her. Positive symptoms are those irrational behaviors engaged in by individuals that are overt, observable, and considered to be classically associated with the diagnosis of schizophrenia. Examples include florid hallucinations, disorganized and apparently purposeless behaviors, disorganized speech, and delusions. These symptoms have to persist for a minimum of six months’ duration to meet the diagnostic threshold for this mental disorder.

A delusion is a false belief that is strongly held by an individual, despite evidence in the environment and beliefs held by all those around them to the contrary. For individuals who have been diagnosed with schizophrenia, delusions are often characterized by persecutory beliefs such as the individual thinks they are being tricked or spied upon, or referential beliefs such as the false belief that an individual is receiving special messages that are directed to them individually. Regardless, these beliefs are far outside the realm of ordinary human experience, illogical, and without direct evidence to support their belief.

Hallucinations are false sensory perceptions that can occur with any sensorimotor modality (e.g., sight, feeling), but are typically associated with hearing (auditory hallucinations). Hearing voices that are divisive or threatening in nature is often how these hallucinations are manifested. Disorganized speech can be characterized by expressive language that is often tangential or ”loose” in terms of the associations that an individual makes; the content of speech is often not tied to an obvious, immediate environmental context. Individuals who exhibit this type of language may talk in a manner where they seem to go from one topic to the next without appropriate social transitions and without making any sense to the listener. 

At the extreme, individuals can exhibit nonsensical “word salad” in their speech and use language that could be described as unintelligible gibberish. Unusual or disorganized behaviors can include being unable to care for oneself in an age-appropriate fashion, being unpredictably agitated, or engaging in repetitive and apparently purposeless behaviors.

         By contrast, negative symptoms as they relate to a diagnosis of schizophrenia are subtler in nature and typically involve the restriction or a limited range of intensity or expressiveness of emotions and behaviors seen in a typical individual. Examples include a lessening or ”flattening” of emotional responsiveness, which could include facial expressions as well as general, emotional expressiveness, alogia (poverty of thought and speech), and avolition (reduced goal-directed behavior). When compared to positive symptoms, antipsychotic medications have not demonstrated as much of an effect on these types of symptoms in the treatment of schizophrenia. 

Current research generally finds that while schizophrenia has a significant genetic component, it also typically requires the presence a certain psychosocial risk factors and a lack of resiliency factors in tandem for it manifest itself in an individual. That is, it does not manifest itself in adulthood with a one-to-one correspondence as might be expected if it were a dominant genetic trait. Rather, there needs to be a genetic propensity in place in the individual, coupled with the right mix of psychosocial stressors in their life, which will elicit the manifestation of the disorder.

What is the primary neurochemical theory behind the drug treatment of schizophrenia?

With regard to drug effectiveness, there are several neurochemical theories pertaining to the mental disorder of schizophrenia. The most well-known of these, and the one that has received the most empirical support, is the dopamine hypothesis. Simply stated, it contends that schizophrenia occurs because of excessive levels of the neurotransmitter dopamine at the receptor sites in the brain that produce random and overly rapid (and maladaptive) transmission of neural impulses. 

Evidence from drug research that supports the dopamine hypothesis includes the observation that when people with schizophrenia our prescribed phenothiazines, which are believed to block dopamine receptors, that positive symptoms of schizophrenia are significantly reduced. Conversely, when people with a low threshold for psychotic-like symptoms are given medications such as amphetamines that are known to increase dopamine at the receptor, under controlled situations, the severity and frequency of delusions, hallucinations, and other psychotic symptoms increase significantly.

Some individuals with the diagnosis of schizophrenia may exhibit motor disturbances, but these can, in fact, be due to the use of antipsychotic drugs as an unwanted side effect. In fact, other problems which can arise from taking antipsychotic medications (especially first generation ones) include an increase in some of the negative symptoms which have been previously mentioned as well as the development of rather severe motor side effects, most notably tardive dyskinesia, which is characterized by involuntary jerky motions of the face and lips, rocking, and an unsteadiness when walking. As is the case with the treatment of many chronic and severe mental disorders, noncompliance with ones prescribed medication regimen can also be problematic.

As you have studied from previous weeks, it is often the case that a multimodal treatment is best with regards to treatment outcome for a mental health disorder like substance dependence. This is certainly the case with regard to the treatment of schizophrenia as well. Some research has indicated that combining family therapy with antipsychotic medication management leads to better treatment outcomes for individuals when compared to pharmacologic treatment alone. 

In addition, the provision of family therapy has been shown to enable the prescribing physicians to utilize a lower dose of these strong antipsychotic medications without a greater chance of relapse when treating people as compared to a medication-only treatment plan that often requires a higher dose of the same drug. Finally, the effects of antipsychotic medication are heightened when patients whose symptoms are severe enough to merit hospitalization also receive concurrent social skills training that helps them improve their interpersonal communication skills through modeling experiences and practice role playing exercises.

Mood Disorders

Psychoactive drugs have also been important tools in the treatment of mood disorders such as Major Depressive Disorder and Bipolar Disorder as well. For a major depressive episode, the essential characteristics of such a mental disturbance include a depressed mood for more than two weeks’ duration in which there is a pronounced loss of interest or enjoyment in activities that a person once regularly found enjoyment and engaged in. In addition, it is quite common for people to experience feelings of worthlessness and hopelessness, a loss or increase in appetite with commensurate weight loss or excessive gain, fatigue or loss of energy, insomnia or bouts of excessive sleeping, problems concentrating and possible suicidal ideation. 

Given the reported incidents of sleep disturbance in this clinical population, when coupled with the increased risk for suicidal ideation, it is important that a prescribing physician not consider a barbiturate drug for the treatment of any reported sleep disturbance. As you have learned from previous week’s material, the risk of combining a barbiturate with alcohol into a lethal combination presents too significant of a risk and individual who may be suicidal.

What is the prevailing neurochemical theory of depression? How is it treated with drugs?

To begin, review this quick 4-minute video from for an overview of the physiological processes:

        When left untreated, major depressive disorders can last for six months’ duration or longer but, eventually, most individuals return to a premorbid state of functioning, regardless of treatment. The disorder appears to be more common in females than males with a ratio of approximately 2:1. The most prominent neurochemical theory that serves to explain the presence of depression in individuals is that of the catecholamine hypothesis. It views symptoms of depression as being due to a deficiency in the neurotransmitter norepinephrine and, possibly, serotonin. This hypothesis is supported, in part, by research which demonstrates that drugs which increase norepinephrine at the neural receptor sites also seem to concurrently help alleviate symptoms of depression. Conversely, when depressed individuals are given medications that decrease the amount of norepinephrine at the neural receptor sites, more severe symptoms of depression are elicited. Other neurotransmitters have also been implicated in the manifestation of depression, including acetylcholine, dopamine, and GABA.

Three classes of antidepressant drugs are available to treat mood disorders. This includes tricyclics (TCAs), heterocyclic antidepressants (HCAs) and monoamine oxidase inhibitors (MAOIs). It has been estimated that somewhere between 60 and 70% of individuals who are prescribed one of these classes of drugs respond positively in terms of a lessening of depressive symptomatology when compared to a course of placebo. Tricyclic antidepressants seem to be most effective for addressing what would be considered the most characteristic or “classic” symptoms of depression (e.g., sadness, loss of interest in activities), experience a worsening of symptoms in the morning, and self-reported symptoms of mild to moderate severity. 

In contrast, monoamine oxidase inhibitors seem to be most beneficial for individuals who have atypical symptoms associated with their depression, including phobias and anxieties and a mood that worsens late in the day. Regardless of medication that is chosen, it is quite typical for an individual to take these antidepressant drugs for several months until their symptoms have sufficiently resolved. It often requires several weeks of consistently taking one of these classes of medications before the individual reports a therapeutic effect.

How is depression different from bipolar disorder?  How does the drug treatment differ?

Bipolar Disorder

        Bipolar Disorder is a specific type of mood disorder that not only exhibits periods of major depressive episodes as you have reviewed, but also includes distinct periods of mania. A manic episode is a period of time lasting at least one week in which the overarching mood of the individual is characterized by a persistently grandiose, expansive, irritable, and/or elevated mood. Individuals experiencing mania often demonstrate inordinate enthusiasm for interpersonal and occupational activities as well as unsubstantiated and overblown sense of optimism and self-confidence. Given the high level of energy and impulsivity that is exhibited, it is not uncommon for the need for sleep to be significantly diminished. Speech at these times is often pressured and the content of what is discussed as often grandiose and seems to be characterized by a “flight of ideas.” 

Keep in mind that all of these symptoms have to be severe enough to significantly impair an individual’s familial, social, or occupational functioning. It is not uncommon for individuals in a manic episode to engage in extremely reckless and dangerous behavior they can have negative repercussions on their relationships, employment, and financial standing.

For cases of bipolar disorder, the primary drug that is prescribed to treat this condition is lithium carbonate, primarily because of its prominent effect on reducing symptoms of mania. This drug is effective in not only reducing manic symptoms but also helping to ameliorate repetitive mood swings. Unfortunately, this can be a difficult drug to take on a chronic basis; patients often stop taking the drug when they start “feeling better” and begin to feel like the medication is no longer necessary. It often takes concurrent individual psychotherapy to help individuals come to understand that they, in fact, have a chronic mental disorder that requires life-long maintenance to maintain a healthy quality of life.

        It is important for care professionals to think about ongoing suicide assessment for individuals who struggle with chronic and persistent mental health disorders like schizophrenia, major depression, and bipolar disorder. It should be noted that approximately 50% to 80% of individuals who report suicidal ideation have a history of severe depression. The second and third most common mental disorders for individuals who commit suicide are alcoholism and schizophrenia, respectively. Interestingly, and perhaps paradoxically, individuals are actually more at risk in the first three months following effective treatment of their depression; that is, once the heaviest symptoms of depression begin to abate, and individuals report having more energy and perhaps more clarity of their life circumstances, are they actually a more threat to themselves. This is important to consider as one begins drug treatment for this condition and continues to monitor an individual’s progress in treatment. 

Prevention and Treatment

You will be examining the role that substance-abuse prevention programs and substance-abuse treatment programs play in our society. Given the multitude of variables – biological, genetic, familial, social, socioeconomic status, peer influences, comorbid mental disorders (e.g., depression) – that contribute to whether a person decides to take that first drink, huff, hit or toke – you can begin to understand what a complex undertaking these types of programs face. The burden to families, the economy, the healthcare system, and society has been great. There have been some significant gains in helping to prevent and treat the serious problems of drug abuse and dependence as well as some serious missteps over the years. You can learn from both.

Substance-Abuse Prevention

What are the three major levels of intervention in substance-abuse prevention strategies?

        It can be helpful to think about substance-abuse prevention strategies along the lines of differing levels of intervention based on the population of individuals that an intervention program wants to reach and the specific goals of the program. It should make sense to you that more than one type of intervention strategy is needed because not everyone who abuses or is otherwise dependent on a drug will be at the same stage of use or confront the same challenges. 

Some individuals may be very early in the process and only contemplating whether or not they would like to experiment with taking a drug. In situations like these, the role of the family, the peer group, and having basic knowledge about the drug under consideration is very relevant. At other times, individuals may already be using a drug on a fairly regular basis and/or have experienced one or two instances where their drug-seeking or drug-taking behaviors have negatively impacted important aspects of their lives. In those instances, a more targeted approach, geared to their current degree of drug use, is needed.

        The first level of intervention is that of primary prevention programs. These are strategies that are targeted to individuals who have not yet had any direct experience or had only minimal exposure with the drug in question. As you would expect, these types of programs typically target children and young adolescents and the information that is imparted to them is often through school-based curriculum or media campaigns. It is common for these programs to demonstrate scenarios where a child or teen might be offered the opportunity to use an illicit drug, and then role-play different ways to respond to the social press from another peer. These programs also provide the individual with basic knowledge regarding the risks and unwanted side effects associated with the specific drug being targeted. Drugs that are typically targeted at this level are the ones that are most accessible to children: tobacco, alcohol, marijuana, and prescription medications.

        The next level of intervention to help prevent drug abuse and dependence is found in secondary prevention programs. Since, in this instance, individuals already have had some experience using the drug, the content of the intervention is geared toward limited the continued exposure the individual with the drug.  The goal of these programs is to limit (and possibly discontinue) the use of the drug and to prevent an increase in the frequency of drug use or escalation of drug use toward more dangerous and illegal substances. As you would expect, messages of this nature will be targeted toward older individuals, typically teenagers to young adults. At times, these programs also teach strategies for responsible drug use when used in legal circumstances (e.g., alcohol use for young adults).

        The final level of intervention in terms of substance-abuse prevention programs is that of tertiary prevention. These types of programs are targeted toward individuals who have been identified as having a substance abuse and/or dependence problem and are in treatment for the condition. As such, the goal is more in line with what you would think of in terms of conventional interventions – to help remove the remnants of drugs out of the individual’s bodily system and work toward a drug-free life and to not relapse upon discharge from a treatment program. If one can live independently at the completion of treatment without incidents of relapse, then the intervention can certainly be said to have been successful.

What are approaches to substance-abuse prevention that have been unsuccessful?

        There have certainly been examples in our country of substance-abuse prevention programs that have been unsuccessful. At times, they have oversimplified the problem or didn’t sufficiently grasp the complexities of the many variables which influence the decision an individual makes to try and drug or to maintain using one. Prevention programs that take into account both the accumulated research on the risk factors associated with use, in addition to the research on the resiliency factors that help it to not occur, tend to have the best outcomes. How one chooses to measure the success of prevention programs (e.g., student self-report, parent satisfaction, number of school suspensions) also comes into play in the evaluation of the efficacy of a program. The most robust outcome measure really should be: has the actual prevalence of use, abuse, and/or dependence decreased in relation to a control group (i.e., a group of same-age peers who did not receive the prevention program)?

        There have been several approaches to drug prevention in our society that have failed in their goals. Attempts at reducing the sheer availability of drugs through law enforcement and attempts to decrease international drug trafficking haven’t yielded significant results. These legislative and law enforcement strategies have, in effect, decreased the overall supply but, in addition, have also increased the demand or cost as a result. The vacuum created by decreasing the availability of one drug in an area has often resulted in an increase in the availability and/or use of another. Further, efforts at curtailing international drug smuggling have been limited at best. Similarly, increasing the amount of punishment that a society hands out to those who break the laws relating to illicit drug possession, distribution and use has not demonstrated a significant decrease in the rates of substance abuse or dependence. In short, the threat of being arrested or convicted of a drug crime has had limited impact in affecting change in drug abuse in our society.

        Finally, the use of scare tactics and other negative advertisement campaigns have been largely unsuccessful in decreasing instances of drug use and abuse. Appeals to fear are often delivered to the adolescent population who, developmentally speaking, are already “wired” to mistrust the credibility and authenticity of adults in their world. As such, these types of messages often do nothing but to reinforce their belief that adults tend to “blow things out of proportion,” expect the worse from teenagers, and are too simplistic, lacking an understanding about the reasons behind why a person might use drugs.

What elements help make school-based substance-abuse prevention programs successful?

Out of the ashes of several of the failed prevention programs of the past, and based more on evidence-based research in terms of effective outcomes, many of today’s school-based substance-abuse prevention programs have made some headway in reducing the prevalence of drug use in children. In particular, successful programs have focused on building those skills in children that have been positively correlated with resilience and factors that decrease the risk of experimenting with drugs. Examples include programs that train children to develop a repertoire of social and behavioral skills – and the self-esteem necessary to – refuse advances or social presses by their peers to try a drug when presented to them. Helping children develop skills and resources to reduce anxiety and perceptions of stress in their life – often a precursor to drug use – can also pay back big dividends toward continued abstinence.

What role can the family play in substance-abuse prevention?

The role of the family in substance-abuse prevention cannot be underscored enough; in effect, it is where the beginning of resilience and inoculation occur against many of societies’ ills, including drug abuse. On the other end of the spectrum, the family also plays a significant role in the outcome of treatment for drug abuse and dependence as well. However, gaining access to the parents or caregivers of those children who are considered to be the most at-risk for drug use can be difficult because they themselves may struggle with their own psychosocial challenges and problems in living. When they are available and engage in a prevention program, caregivers provide very powerfully persuasive factors to children, particularly as role models, conveyors of information about the risks associated with drug use, and as rule makers with regards to consequences for infractions as it relates to their children using drugs.

Substance-Abuse Treatment

As an adjunct to your study, review this 10-minute video that reviews the relationship between trauma and substance abuse:

You will now shift your focus from prevention strategies to that of treatment modalities. Despite the available (or lack of) resiliency factors in an individual’s environment, and the preponderance of risk variables, some individuals’ initial experimentation with drugs turns into a chronic and maladaptive pattern of abuse and dependence. For these individuals, a rigorous and highly structured program is needed to help change the highly reinforcing pattern of drug addiction. This can be quite challenging and the rate of relapse is often quite high. As you have seen previously, a multimodal approach that attempts to address as many intervening variables as possible, while also bolstering all available, naturally occurring supports, tends to work best. 

What are some of the challenges in creating an effective substance-abuse treatment program?

One of the primary challenges in the development of an effective treatment program for the individual who is substance abusing or dependent is that, in many cases, they are using, abusing, or dependent or an array of drugs, both licit and illicit. This complicates the approach of intervening in that the likelihood for drug substitution and the influence of the individual’s environment particularly habits and social relationships related to multiple drug use, is particularly ingrained and strong. In fact, the Diagnostic and Statistical Manual of Mental Disorders (DSM) uses the diagnosis of Polysubstance Abuse and Dependence to designate cases of such complexity where co-occurring drugs are abused in a concurrent fashion to the detriment of the individual’s life across a variety of contexts.

Another layer of complexity that exists in the treatment of substance-abusing individuals is that approximately 30% of the sample will also be actively experiencing problems with at least one chronic mental health disorder. These dually diagnosed individuals need to be receiving co-occurring mental health treatment which has evidence-based support for the particular disorder of concern. In some instances, drug abuse by individuals who are experiencing untreated mental disorders are, in effect, trying to ameliorate their own mental health symptoms, albeit in a pathological manner. It is often advantageous for a treatment team consisting of a physician and a psychologist or counselor, at a minimum, to work together to address the individual’s concerns.

The prevailing model that attempts to effectively address many of the aforementioned complexities is the biopsychosocial model of substance-abuse treatment. As the name implies, this model acknowledges that drug abuse and treatment is both multi-dimensional and multi-factorial and requires evidence-based understanding and interventions targeted across the realms of biologic, psychological and social factors. This model advocates taking an integrated approach in the design and implementation of a treatment program. This requires a variety of professionals from several disciplines (as a multidisciplinary treatment team) and an active degree of communication and collaboration among them.

What are the stages of change as they relate to substance-abuse treatment and recovery?

The psychological theorist, Prochaska, developed a theoretical framework to help people understand the cognitive and behavioral processes of change that individuals pass through over time when often struggling to make difficult changes in their lives. This five-stage model includes the following steps. (1) The Precontemplation Stage is what occurs first and it involves the intermittent wish or desire to change, but without any well-reasoned plan of action or even awareness that an individual, in the case of substance abuse, has a problem significant enough to merit full consideration of the need to change. In the case of substance abuse and dependence, an example might be an individual who has been placed in treatment immediately following a crisis, but has yet to make any self-directed decisions about his or her own future to address future occurrences.

The Contemplation (2) Stage is distinguished by the fact that an individual does indeed acknowledge that a problem in one’s life exists, and he or she is considering how to address this problem, but have yet to make a firm commitment to an action(s) to address the problem. The individual may report feeling overwhelmed by the challenges involved in making a firm commitment, including the discomfort with withdrawal and making significant relationship changes in their lives. It is at this point that a therapist can be helpful in helping to delineate reasons for committing to lifestyle changes and the cost of not doing so. 

The Preparation (3) Stage is defined as being committed to making a lifestyle change and planning to initiate action in the next 30 days after having been unsuccessful in making any substantive, positive changes over the last year. This may manifest itself as a proposed “quit date” or a date for the first day of sobriety. Again, therapists can be useful at this stage to discuss ways for the individual to inoculate himself or herself against postponing the intended change, as well as preparation for the short-term negative repercussions that will surface upon the first few steps of drug cessation and withdrawal.

The Action (4) Stage is defined by being proactive and taking actions to stop drug seeking and drug-use behaviors.  As you can imagine, this is the most difficult and fragile stage because the threat of relapse becomes more poignant at this stage. Individuals need ongoing support and reinforcement for all behaviors that are incompatible with former pathological actions that related to drug use. Support networks, whether family or treatment groups, are critical at this juncture. 

Finally, the Maintenance (5) Stage is entered after the individual has been drug-free for a minimum of six months. For this to occur, new changes in habits and lifestyle will have had to occur. However, treatment is far from over and continued mindfulness and proactive steps toward sobriety will need to be continued. These stages are certainly fluid and the possibility of relapse is real and moving among the various stages throughout life is quite common.

Once in treatment, what role(s) do the family play in outcome?

        As has been discussed throughout this course, the role of the family is extremely significant in the origin, continuation, maintenance and discontinuation of drug use in individuals. Families can be a great source of support and resilience and, conversely, can also be a source of continued risk and the enabling of self-destructive behavior. It is important for the recovering individual, hopeful in the company of a well-trained therapist, to carefully evaluate the role that the family has played to date and what, if any, role the family can have with regards to recovery. There may be some individuals within the family system that engage in destructive, enabling behaviors such as avoiding, denial, shielding others from consequences, and rationalizing, while others who are ready to extend themselves and their resources to help ensure success for the person needing assistance.

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