Unit 10
Substances of Abuse
Adolescents frequently abuse substances. Substance Use Disorders are diagnosed when the use of a substance interferes with life. The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) lists 11 criteria: hazardous use, problems from use, neglect of significant roles, withdrawal when a substance is stopped, tolerance to the substance, increasing involvement, repeated attempts to quit, much time spent using, physical or psychological problems from use, activities that are given up for service, and craving.
To receive the diagnosis, they need to have met two of these in the last 12 months.
Neuroscientists believe that abused substances are reinforcing because they release or recycle neurotransmitters associated with pleasure and reward. However, for the adolescent, the reward system is rapidly changing.
If you or a loved one struggles with substance use or addiction, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.
These are the classes of the more common drugs that cause a substance Use Disorder in adolescents.
Stimulants are drugs that stimulate the brain, generally by enhancing the effectiveness of the neurotransmitter dopamine. Cocaine, crack (smokable cocaine,) and methamphetamine (“speed”) are examples. Prescription medications for ADHD like Ritalin and Adderall are also stimulants. However, they are much less active in the brain. Therefore, they are not the same as cocaine or speed, despite what some people on the internet say. Other stimulants include caffeine, which is perhaps the world’s most popular drug. Caffeine is usually safe in moderation. However, caffeine is also mildly addicting and causes tolerance.
Another stimulant is nicotine which recently has regained popularity in its vaped form(Phillips & Edwards, 2013). Previously, nicotine was most commonly ingested in cigarettes, cigars, and oral tobacco. Nicotine is highly addictive. There is also no safe way to ingest nicotine. Smoking of nicotine products is especially dangerous and causes cancer, heart disease, and many other disorders.
Depressants act by changing the action of neurons that respond to GABA or a closely related neurotransmitter. GABA is a very common neurotransmitter involved in putting the brakes on brain activity. It also slows down the transmission between the brain and other parts of the body. Barbiturates are an example of depressants. They are highly addictive drugs used primarily in hospital settings. Sometimes they are used on an outpatient basis for epilepsy and a few other reasons. They are usually taken orally. They can also be administered by veins. When taken with alcohol, they are very often fatal.
Valium, Klonopin, and Xanax are in the chemical family of drugs called benzodiazepines. These are milder depressants than barbiturates (Hopfer, 2011). They are used for prescription purposes, including for the treatment of anxiety. However, prolonged usage can easily be highly addictive for many people. Consequently, they are not prescribed as frequently as in previous times. Physicians are now more aware of their addiction potential. They are also cross-addictive with alcohol, another depressant. This means that if a person drinks a lot of alcohol, they will require a higher dose of benzodiazepine to get a similar effect. They also have an interactive and sometimes unpredictable effect with alcohol, including the possibility of blackouts, mood swings, or violent behavior. When mixed with alcohol, they can occasionally be fatal.
Alcohol may seem like a stimulant because people who drink it may often become livelier and more carefree. It relaxes some, though not all people. This is because it depresses areas of the brain related to inhibition and anxiety. In moderate amounts, alcohol increases sociability for many people. However, it also increases clumsiness and decreases memory (Jung, 2001). This is evident even in small doses.
For everyone, alcohol is neurotoxic in excessive doses. This means it kills brain cells. It is also toxic to a variety of bodily systems. The amount of alcohol that adolescents can safely drink is well known, and it is generally recognized as none. In fact, there is medical evidence that people who choose to drink alcohol should not start at least until their mid-20s (Hannigan, Spear, Spear, & Goodlett, 1999).
There may be health benefits to moderate drinking of alcohol in later years for heart and memory. However, there are absolutely no health benefits for adolescents. There are numerous risks. Whether individuals choose to do so later in life is an informed decision. Still, it should not be made based on supposed health advantages by people in the teenage years.
Binge drinking is particularly problematic for adolescents. Binge drinking is defined as consuming five or more drinks for males and four or more drinks on one occurrence for females. Binge drinking, even if occasional, is strongly associated with a variety of behavioral problems. There is evidence that it makes memory less efficient. It is associated with executive functioning (Lees et al., 2019). It is also related to accidents, overdosing, and violent behavior.
Death from alcohol overdosing or “alcohol poisoning” in young people is usually from two ways. First, a person drinks so much alcohol that their heart stops or they cease breathing. Or they asphyxiate (choke on vomit). Both possibilities are dire, and persons in danger of passing out from intoxication should be medically evaluated. Second, occasionally, a person with epilepsy or another seizure disorder may experience convulsions while under the influence of alcohol. This can be fatal.
While most adults can drink responsibly, about 7% to 13% of the population will have a diagnosable alcohol problem (Gómez, Nunes, & Ragnauth, 2012). For adults, the safe amount is two drinks for males per day maximum of 14 per week. For women, the amount is one drink per day, a maximum of seven per week. (You cannot save them up for weekends!) Above this is considered a health risk. The danger rises sharply with any extra amount. Some research suggests that this amount is not safe.
The adolescent brain is still in development. Therefore, the effects of alcohol can be particularly hazardous. Therefore, the American Academy of Pediatrics strongly recommends against any alcohol drinking by adolescents, a recommendation based on the best available science to date.
Another depressant is GHB (gamma-Hydroxybutyric acid, gamma hydroxybutyrate) and similar “clone” drugs. This drug is a drug popular in clubs. It causes very rapid releases of GABA, dopamine, and other neurochemicals only to cause a sudden crash. The effects usually last a few minutes. When overdosed or combined with alcohol, the drug can cause a person to blackout or even stop breathing. This can be fatal without medical intervention. GHB is usually odorless and tasteless and can be mixed quietly with alcohol. It is metabolized quickly into the body and can leave little trace unless medical personnel explicitly look for it. GHB’s use as a “rape drug” is based on this attribute.
Vignette 10.1 Sophie: ALCOHOL DEPENDENCE
“I don’t think of myself as an alcoholic, especially not that I was a teenage alcoholic,” said Sophie, who is now 23.
“I started drinking right before my freshman year in high school. There wasn’t any reason, like a broken home or anything. I just liked to drink. I loved it. Someone gave me a drink at their parents’ house, then a few days later at a party. I felt great, like I had found part of myself that was missing.
“In high school, it was hard to drink. I mean, it was difficult to make sure you could find something. But I hung out with a group of women who were a bit older, more trouble, I guess. So finding something wasn’t a problem on weekends, and I was drunk a lot. My philosophy is that when you get a supply, drink as much as you can. You never knew when you would get more.
“I went to college close to where I live. The reason was I knew that I could keep drinking, and no one would really care. There were some bars I could get into with a fake ID, even as a high school junior.
“I never blacked out or did something crazy. I pretty much remember everything I did. Believe it or not, I was never assaulted, though I ‘m sure I could have been. . I never drove drunk. I never got into fights. I was a happy drunk, at least that’s what people tell me.
“Sometimes I would take some other drug, but mostly this was to deal with my hangovers. I had some awful hangovers. I’d take whatever I could find to feel better. But I didn’t quit.
“I had moved out and was drinking with friends just about every night. My parents were concerned that I drank too much. So I stopped talking to them. Needless to say, I didn’t last long in school, only a semester. I had a series of jobs, but I wound up getting fired because I’d call in hungover.
“A place that I really wanted to work made me take a physical before they hired me. The person examining me, I think she was a nurse, said that my liver looked slightly swollen. I don’t know about that, but I’m sure I was hungover for the appointment. I probably smelled drunk. But she arranged for me to get some bloodwork. Results came back and surprise! I wasn’t healthy. They didn’t hire me, but the nurse told me that I needed to see a doctor and that something wasn’t right. I worried a little, but mostly, I was in denial.
“I was only 19, not quite 20, and I was drinking maybe six, maybe 12 drinks a day. Funny, I absolutely denied that I had a problem. Later I would learn that is typical of people with addictions.
“One day, not too much later, it snowed, and I couldn’t get out of the house. We’d had a party the night before. There was nothing to drink. I panicked. I actually got the shakes like in the movies. That’s when I realized I had a problem. It hit me, ‘You’ve been an alcoholic since your high school years.”
“It took me about a year more, but I got treatment. I didn’t do really well at first, but eventually, things turned around. I’ve been sober for 711 days, almost two years. Maybe it’s because I have a wonderful counselor. I’ve made new friends. I connected again with my family. I still go to counseling and will for a long time. I realize I need to learn how to live.”
Opioids, also classified legally as narcotics, are drugs that affect the body’s own opiate system. The opiate system exists in part to manage our own internal sensations of pain. They include the prescription drug morphine, used for extreme pain by physicians, and heroin, which is highly pleasurable and highly addictive (Olsen & Sharfstein, 2014). They also include methadone, used for severe pain and for the treatment of addiction. Until recently, heroin accounted for most overdose deaths. Heroin is injected with needles. It can also be smoked. Recently, attention has focused on hydrocodone and oxycodone. These are prescription opioid drugs that are highly abusable if misused. Unfortunately, these drugs have been at the forefront of an epidemic of recent opiate abuse, which has caused hundreds of thousands of lives (McAnally, 2018).
Fentanyl is an opioid produced in laboratories. It is extraordinarily addictive and much more potent than heroin. Although fentanyl has therapeutic use for extreme forms of pain, it is very abusable. It has resulted in many overdoses and deaths (Seth, 2018). Small amounts ingested by accident may cause respiratory arrest. Varieties of fentanyl are being produced in laboratories and constantly changed. This makes detection by law enforcement and medical research difficult (Peacock et al., 2019).
Hallucinogens are drugs that cause people to see and hear things that are not present. They work through a variety of mechanisms, mainly through the serotonin system. LSD (Lysergic Acid ) is the most famous though there are many similar drugs. Peyote and mescaline are natural hallucinogenic substances. They are used by American Indians for religious purposes. These substances induce intense hallucinations.
Phencyclidine (PCP) is a hallucinogen known for unpredictable, occasionally extremely violent effects. It is usually smoked, and it is often sprinkled on different street drugs to enhance their effect. It has no medical use in humans and has been outlawed as an animal tranquilizer since 1978. It can cause psychosis, paranoia, and seizures.
MDMA (ecstasy or various other names) was originally a prescription drug for psychotherapy and depression. It is now abused for its stimulant and hallucinating effects. However, researchers are investigating it again for medical use in some situations, including psychotherapy in very controlled conditions. It should not be used in uncontrolled settings.
Ketamine is a short-acting anesthetic. It is abused for its hallucinogenic properties. It can produce unpredictable hallucinations. It is also being investigated for therapeutic potential under highly controlled conditions.
Marijuana is a well-known substance that is classified as a cannabinoid. Cannabinoids are notable because they appear to mimic many natural substances in our system responsible for regulatory functioning. Examples of cannabinoids include marijuana, hashish, and many types of synthetic weed. In addition, marijuana is hallucinogenic in high doses. This means that when people take too much, they sometimes hallucinate.
Evidence suggests marijuana decreases motivation and may make some people more predisposed to psychological problems. These can include psychosis which resembles schizophrenia. In addition, marijuana reduces memory functioning in the short term. The effects on the developing adolescent brain are not clear. Research from animal studies suggests that this drug should be avoided during developmental years.
Marijuana may have several medical uses but is also very abusable in adolescents who lack cognitive judgment, motivation, and social support. In addition, when smoked, it may contain cancer-causing substances.
Kratom is a drug that affects cannabinoids and other systems. According to the National Center for Complementary Medicine, use by adolescents in the US is rising, leading to dependence and several medical complications. Kratom has been linked to liver damage, anxiety, and life-threatening seizures. This drug is available on the internet, in some convenience stores, and is not well-regulated.
Inhalants are drugs that are inhaled or sniffed. They give the user a buzz or a sense of euphoria. However, they may also cause a loss of control and hallucinations. They are generally toxic to the brain. Examples are gasoline, paint thinner, freon, and aerosol sprays. They can also produce liver and kidney damage. Short-term effects can include seizures and cardiac arrest (heart-stopping). They are sometimes popular with adolescents because they are easy to use and are inexpensive.
Laughing gas, or nitrous oxide, is an inhalant familiar to many people who have had minor surgery. It is not usually neurotoxic but may cause respiratory arrest if used without medical supervision. Sometimes people sniff the whipped cream aerosols to get a few seconds of this substance. Chloroform and ether are also inhalants with medical uses that are abused. This drug is more commonly abused by older adolescents who have access to it.
“Poppers” or nitrites are commercial products marketed as deodorizers, cleaners, or solvents that are actually—usually illegally- sold to be inhaled. People use these cancer-causing products to enhance sexual enjoyment and for laughs. They are vasodilators, meaning that they cause blood vessels to swell. The effects generally last seconds to a few minutes and produce side effects of headache, flushing, and a drop in blood pressure. In addition, they can cause strokes or other cardiovascular problems. If a person drinks them, they can be poisonous and often fatal. They should never be mixed with erectile enhancers because they can cause a potentially fatal drop in blood pressure.
Nonpharmacological Addictions
Adolescents are also susceptible to nonpharmacological addictions. This means dependence on behavior without a co-dependent substance. These include addiction to video games, social media, and gambling.
Excessive video gaming has been recognized by the World Health Organization as a potential addiction.
Gambling problems in adolescents used to be rare (Horvath, 2004). Today these problems are not uncommon. Even though there is no particular substance involved, there is often a tolerance and a withdrawal indistinguishable from many other addiction types.
Gambling addiction in adolescence was comparatively rare in part because adolescents lacked gambling opportunities. Today adolescents can use the internet to wager on a variety of activities. They can do so anonymously, just as adults do. If they have a source of income or can steal or forge, they can accrue gambling debts, again like adults.
“Gamble” by nicubunu. photo is licensed under CC BY-SA 2.0
Addictive Substances: A Multifactor Theory
Mental health experts now realize that an addictive substance or experience is addicting for a variety of reasons. Yet, the similarity is that all addictions have motivating properties.
Addictive substances and experiences also have the property of increasing tolerance and causing withdrawal. These factors for addiction may overlap but are not necessarily the same. This is called the multifactor theory. It is essential in adolescent development. Different aspects of addiction may be more critical at varying points in adolescents’ developmental histories.
First, addictive drugs and experiences are rewarding. They generally feel good. At least, this is true initially. Otherwise, they would be avoided.
Secondly, addictive drugs and experiences motivate us to seek out the experience associated with their use somewhat independently of their rewarding properties. This is what makes them so dangerous.
Third, though not all, many addictive drugs and experiences cause a tolerance, which means more is required to get to a specific effect.
Finally, many, though again, not all addictive drugs and experiences cause withdrawal when use stops.
Psychological properties are fundamental in substance abuse and dependence. Expectancy or expectation can be essential. People who are given a placebo, basically a sugar pill, often experience the same effect as being given an active drug. This is true even if they have knowledge that they have been given a dummy version.
Furthermore, prior experience is essential if a person uses a drug in a setting where they have used it before. They are more likely to get an enhanced effect, probably due to learning.
Social attitudes and peer influences are also necessary. For example, suppose a person believes drug usage is permissible and their friends encourage it. In that case, they are much more likely to engage.
There is much discussion regarding when casual drug usage crosses the line and becomes problematic. Evidence strongly suggests that the earlier people begin using potentially addictive substances, they are more likely to develop addictive behaviors. This is likely to be true for social and neurological reasons. Furthermore, the teenager who types abusive substance problems loses the opportunity to develop necessary social skills. For example, they do not know how to become assertive in the presence of peers or adults and may fluctuate between being passive and inappropriately aggressive. They may feel that they need substances to assist them in making decisions. Repercussions can well last a lifetime, especially unless there is an appropriate treatment.
Treatment
In general, the outcome of adolescent treatment for substance abuse and other addictions is good(Gonzales, Brecht, & Rawson, 2013). Treatment providers have several strategies to draw from.
Many treatment providers combine methods based on current evidence of what works best for whom. As previously noted, this is called Evidence-Based Treatment. Still, the relapse rate for addictions is exceptionally high. This is true for many reasons.
One reason is that many people in treatment are addicted to several drugs at the same time. Another is that many people with addictions also have complex behavioral or other psychological problems. Many also have histories of trauma, few social supports, and insufficient economic resources (Franklin & Frances, 2007).
Data shows that, as in adults, treatment in adolescents results in changes in brain functions (Hammond, Allick, Rahman, & Nanavati, 2019). These changes are observable and are predictable, correlating with clinical outcomes. Since adolescent brains are still developing, clinical changes may be much more permanent. Therefore, addiction interventions may be longer lasting and have a more successful outcome than with adults. While the younger brain is very susceptible to the effects of substances, it may also be vulnerable to treatment.
Diets
Being obese during adolescence is a health risk. It can help cause many long-term problems. These included depression, hypertension, and early-onset type 2 diabetes. Obese adolescents are more likely to be discriminated against, teased, bullied, and suffer from low self-esteem. They are at risk of growing up and becoming obese adults (Davies, Fitzgerald, & Silk, 2019). Obesity is now at epidemic proportions.
One reason obesity is common is that young people’s diets often include excessive sugars and processed carbohydrates. These foods are fattening and often have little nutritional value. In addition, they cause a spike in blood glucose resulting in a process that increases fat storage. When combined with sedentary behavior, the combination can increase weight.
For many people, including many less well-off people who lack economic resources or food options, cheap “junk foods “ may be the only alternative. When parents or caregivers are constantly working, ready-made snacks or convenience food may seem a good alternative. When these foods become a large portion of an adolescent’s diet, they result in undesired weight gain.
Sodas and sugar-laced snacks have likely had a significant impact on the health of adolescents. The average weight of adolescents has been increasing since the late 1970s. One reason has been the increase in fast-foods, available seemingly everywhere and in communities regardless of their economic status.
High sugar soft drinks are a known cause of weight gain. They are increasingly consumed by adolescents. Research shows that they are harmful to multiple areas of the body.
Energy drinks and even diet soft drinks are often used immoderately. They can cause caffeine overdose as well as headaches. They may also contribute to hypertension (high blood pressure), especially when combined with other factors. As is the case with so many different dietary choices, moderation is needed. Still, it may be difficult for young people who are constantly stressed, feel that they have no time, have social pressures, and have fewer choices.
“Duck Donuts” by Alexander C. Kafka is licensed with CC BY-ND 2.0. To view a copy of this license, visit https://creativecommons.org/licenses/by-nd/2.0/
Most people realize that there are advantages to eating fresh foods. However, in many locations, adolescents and people of all ages simply do not have access to these choices. These people dwell in food deserts.
Adolescent obesity can be successfully treated. However, its treatment is often more complex than with adults because adolescents have several environmental cues associated with eating. Furthermore, the decision abilities of adolescents are not as fully developed as adults. As a result, it is harder for them to make reasonable choices. Adolescents also have fewer options available to them. Yet data suggest that adolescents can maintain healthy body weight.
People concerned about their weight should be urged to discuss their situation with a qualified health care provider.
Steroids
Steroids are human-made versions of hormones. They are prescribed by health care professionals for many medical purposes. These include treating infection, handling the side effects of cancer and burns, and blocking the body’s immune response following transplants and other medical conditions.
Many adolescents know about steroids for bodybuilding or strength enhancement. However, when used for these purposes, they have many long-term side effects. Steroids do not appear to actually increase bulk or strength. Instead, they seem to decrease the time needed for rest and recovery after physical workouts. This allows people to train harder.
At best, steroids leave the participant vulnerable to physical injury. These injuries may seem unlikely to adolescents, but they can be severe and even catastrophic when they occur.
Steroids can also influence moods and result in rage or psychosis. This is even more likely if mixed with other drugs.
Other side effects are often severe. They can be harmful or fatal. The mechanism of death is often through heart disease, strokes, or later through various cancers. The use of steroids for strength enhancement or training is banned by major athletic groups and closely monitored. The short-term benefits of these drugs for non-medical reasons are usually far outweighed by the long-term dangers that they impose.
According to the National Institute of Mental Health (NIMH, 2021), unapproved muscle-building drugs are sold over the counter and on the internet. These drugs, called SARMS or selective androgen receptor modulators, are popular due to their perceived safety compared to anabolic steroids. The NIMH notes that these drugs are popularly used with human growth hormones and various weight loss drugs. Their safety is questionable.
Injection of steroids has been associated with HIV disease in addition to a variety of other disorders.
“Test C” by leostroid is licensed under CC BY-SA 2.0
Eating Disorders
Eating disorders are a problem for many adolescents in North American and Europe. Restricted eating is a term that is used to describe several conditions. For example, anorexia involves restricting where a person limits food to the point where they experience a health problem (Keel, 2018). Unfortunately, this restriction can frequently be fatal because the person who shares the state can resist all efforts to force food.
Bulimia is a restricted eating condition where people eat to excess and then purge through vomiting, enemas, or laxative use. This pattern may cause serious health problems from damage to the esophagus, stomach lining, teeth, digestive system, and intestines.
Some people alternate between periods of anorexia and bulimia. They may have periods when they do not eat. Then they will eat large amounts followed by purging.
Restricted eating in adolescents can be especially dangerous because it can interfere with critical growth periods, puberty timing, and long-term health consequences (Neale, Pais, Nicholls, Chapman, & Hudson, 2020). However, there is evidence that the results are often reversible. Effective treatments for more severe cases may involve various therapies administered to the patient and the family over a prolonged period.
Regardless, eating disorders are potentially severe and should be discussed with a health care or mental health professional. As in many conditions, adolescents often fear that the professional will shame them or be stigmatized. However, they need to realize that caring and concerned professionals receive training to communicate effectively and therapeutically with adolescents over sensitive topics.