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Alcoholism treatment, drug treatment, teen drug treatment, gambling treatment All drugs of abuse alter feelings, thoughts, and behavior. They directly affect the brain or the central nervous system (CNS). The specific actions of these drugs are highly complex. Feelings are altered when the drugs affect neurotransmitters and intercellular communications that seek a balance between excitatory and inhibitory functions. Every organism is driven toward establishing a balance between these two systems that is called homeostasis. It is widely believed by many experts in the field that the level of drug use in the United States is the highest in the industrialized world. More than one-half of American youth try an illicit drug before they finish high school. An estimated 14.5 million Americans used a drug illegally in the month prior to being surveyed in the 1988 National Household Survey on Drug Abuse. The number of people admitted to emergency rooms following cocaine use increased four times over the five year period between 1985 and 1989 (Adams et al., 1990). Specific drug action depends on the route of administration, the dose, the presence or absence of other drugs, and the clinical state of the individual. Generally psychoactive drugs can be classified by their primary action on the central nervous system (Goodman and Gillman 1980). CNS DEPRESSANTS The central nervous systems depressants depress excitable nervous tissue at all levels of the brain and nervous system. The CNS depressants include all sleeping medications, anti-anxiety drugs (also called minor tranquilizers), opium derivatives, cannabis, and the inhalants (Schuckit 1984). CNS STIMULANTS The central nervous system stimulants achieve their effect by the stimulation of nervous tissue through blocking the actions of inhibitory cells or the release of transmitter substances from the cells, or by the direct action of the drugs themselves. These drugs include all of the amphetamines and cocaine. Nicotine and caffeine also stimulate nervous tissue but to a much less degree (Schuckit 1984). THE HALLUCINOGENS The effect of these drugs is the production of an altered perception, thought, or feeling that cannot be experienced otherwise except in dreams. The hallucinations are usually of a visual nature. These drugs have no known medical usefulness. Lysergic acid diethylamide (LSD) is the most common hallucinogen currently found on the street (Jaffe 1980). THE REINFORCING PROPERTIES OF DRUGS Drugs of abuse are powerful reinforcers. Animals quickly learn to self-administer most of these drugs for their rewarding properties. Animals will press a lever over four thousand times to get a single injection of cocaine. They will continue to self-administer for weeks, alternating between self-imposed abstinence, and drug administration. These animals generally die of drug toxicity and lack of food; they would rather use drugs than eat. When given continuous access to drugs of abuse, animals show patterns of self-administration strikingly similar to human users of the same drug. These drugs are strongly reinforcing even in the absence of physical dependence (Woods et al., 1977; Thompson and Pickens 1970). TOLERANCE AND DEPENDENCE Tolerance and physical dependence develop after chronic administration of any one of a wide variety of mood-altering substances. With increasing tolerance, the individual needs more of the drug to get the same effect. Tolerance and dependency develop as the nerve cells chemically and structurally counteract the drug's psychoactive effects. Tolerance is a complex generalized phenomenon that involves many independent physiological and behavioral mechanisms. It leaves the chemically dependent individual physiologically and psychologically craving the drug. The individual becomes obsessed with obtaining the drug for a sense of well being. The chemically dependent person becomes inflexible in their behavior toward the drug despite adverse consequences. The intensity of this felt "need" or dependence, may vary from mild craving, to an intense overwhelming obsession. At severe levels, the individual becomes totally preoccupied with the drug (Kalant et al., 1978; Wilcox et al., 1994). Physical dependence is characterized by withdrawal symptoms. Withdrawal develops in an addicted individual when the drug is discontinued too quickly. Physical dependence occurs throughout the entire nervous system (Smith 1977). The withdrawal symptoms are a rebound effect in the physiological systems modified by the drug. For example, alcohol depresses the CNS, withdrawal stimulates the CNS. In studying the effects of withdrawal, look for the opposite effect that the drug was used for initially. Amphetamine is used to stimulate, to give energy, so amphetamine withdrawal causes depression and a lack of energy. The time required to produce physical dependence can vary. Withdrawal symptoms can develop in a day with large quantities of CNS depressants (Alexander 1951). For most drug users, development of physical dependence is gradual, occurring over weeks, months, or years of chronic administration. CROSS TOLERANCE The ability of one drug to suppress withdrawal symptoms created by another is referred to as cross-dependence or cross-tolerance. Cross-tolerance may partially or completely remove symptoms of withdrawal. All drugs of abuse cause intoxication and induce a psychological dependency. The individual is self-administering the drug to change their level of consciousness or to increase psychological comfort (Schuckit 1984). ALCOHOL No one knows when alcohol was first produced. If any watery mixture of vegetable sugars or starches is allowed to stand long enough in a warm temperature, alcohol will make itself. Nature alone cannot produce anything stronger than fourteen percent alcohol, but by distillation, the percentage can be increased to ninety-three percent (Kinney and Leaton 1987). Alcohol is the most used and abused psychoactive chemical in the United States (U.S. Department of Health and Human Services 1984). Approximately thirty percent of the general population abstains, ten percent are heavy drinkers, and five to ten percent are problem drinkers (Warheit 1985). Ninety two percent of children use before they leave high school and thirty six percent have consumed more than five drinks at one time in the last thirty days (Centers for Disease Control, 1991). It is estimated that two hundred thousand deaths per year are alcohol related (U.S. Department of Health and Human Services 1984). The early detection of alcohol abuse and dependency is complicated by denial that is found in the individual, the family, and in society. Long-term alcohol dependence has profound effects on personality, mood, cognitive functioning, and a variety of physiological problems involving virtually all organ systems. The interaction of alcohol and other drugs may lead to fatal overdoses (Frances and Franklin 1988). Alcoholism is the result of a complex interaction of biological vulnerability and environmental factors. Environment such as childhood experience, parental attitudes, social policies, and culture strongly affect the vulnerability to alcoholism. Genetic variables significantly influence the disease. There is probably no personality style that is predictive of alcoholism (Valiant 1984; Goodwin 1985). SEDATIVES, HYPNOTICS AND ANXIOLYTICS Benzodiazepines and barbiturates are useful medications with a potential for abuse and dependence. They are medically useful for a variety of symptoms such as insomnia and anxiety. Approximately fifteen percent of the population uses a benzodiazepine each year (Gottchalk et al., 1979). Sixteen percent of patients abuse the sedatives that are prescribed by their physician (Richels et al., 1983). In 1977, eighteen percent of young adults reported non-medical use of sedatives (Abelson et al., 1977). There is no sharp line that can be drawn between appropriate use, abuse, habituation, and addiction. Both the patient and the physician may not recognize symptoms of dependence. Both may assume that the anxiety, tremulousness, and insomnia that develop when the drug is discontinued is a return of the original anxiety (Jaffe 1980). Low dose benzodiazepine dependence is very common today. Some of these patients have been on a succession of various benzodiazepines for years. When the medication is withdrawn, anxiety symptoms may increase for months. Someone experienced in treating anxiety disorders must follow these patients. The therapist can work to reduce the anxiety symptoms while the patient is experiencing withdrawal (Burant 1990; Juergens 1994; Geller 1994). Diagnosis of sedative abuse may prove difficult. The abuse can start in the context of medical treatment for anxiety, medical disorders, or insomnia. Physical dependence can develop to low doses over several years or high doses over a few weeks (Dietch 1983). Intoxication, withdrawal, withdrawal delirium, and amnestic disorder are similar to those found with alcohol. Benzodiazepines have a much longer half-life, therefore withdrawal may not be evident until seven to ten days after cessation of use. These patients can have a protracted withdrawal that can last for months (Geller 1994). Alcohol and opioid CNS depression may interact with sedative hypnotics and potentate the depression. Adding small amounts of alcohol or opioids to the sedatives can quickly lead to overdose (Frances and Franklin 1988). Treatment of sedative, hypnotic, or anxiolytic withdrawal is similar to alcohol. A cross-tolerant sedative is administered to prevent severe withdrawal symptoms. This medication is gradually decreased until the patient is clear of the drug. OPIOIDS In the late 1960s the use of heroin increased in the United States. Once centered in large urban areas, use of heroin infiltrated smaller communities. Members of lower socioeconomic groups continue to be over-represented in this patient population, but the use of heroin is now observed with greater frequency in affluent members of society. A survey in 1977 indicated that two to three percent of young adults had tried heroin at some time in their lives. During the peak period of heroin use (1970-1973) there were more than five hundred thousand heroin addicts in the United States. The existence of opioid addiction among physicians, nurses, and health care professionals is many times higher than any group with a comparable educational background (Goodman and Gilman 1980). Rapid intravenous injection of opioids produces a warm flushing of the skin and sensations in the lower abdomen described by addicts as similar to orgasm. This lasts for about forty five seconds and is known as the "kick" or "rush" (Jaffe 1980). Tolerance to this high develops with repeated use. Physical signs of intoxication include constricted pupils, marked sedation, slurred speech, and impairment in attention and memory. Daily use over days or weeks will produce opioid withdrawal symptoms on cessation of use. The withdrawal symptoms are intense but generally not life threatening. Withdrawal starts approximately ten hours after the last dose (Frances and Franklin 1988). Mild opioid withdrawal presents as a flu-like syndrome with symptoms of anxiety, yawning, dysphoria, sweating, runny nose, tearing, pupillary dilation, goose bumps, and autonomic nervous system arousal. Severe symptoms include hot and cold flashes, deep muscle and joint pain, nausea, vomiting, diarrhea, abdominal pain, and fever. Protracted withdrawal may extend for months (Kosten et al., 1985; Gold 1994). The treatment of opioid addiction can be grouped into opioid maintenance with methadone versus abstinence approaches. Choice of the proper treatment depends upon the patient's characteristics. The course of heroin addiction typically involves a two to six year interval between the start of regular heroin use and the seeking of treatment. The need to participate in criminal activity to procure the drug predisposes the addict to further social problems. Treatment takes total psychosocial rehabilitation. Many heroin addicts can not or will not give up using opioids. Methadone maintenance programs substitute a long acting methadone for short acting heroin. Methadone has a half-life of 24 hours and can be take once a day, where heroin has a half-life of 4-6 hours and must be taken several times a day. Longer acting synthetic opioids are available, like LAAM (levo-alpha-acetyl-methadol) that have a half-life of 72 hours. These medications can be taken several times a week. Worldwide, methadone maintenance remains the major modality for the treatment of opioid dependency (Lowinson et al., 1992). Methadone has been found to be medically save even when used continuously for 10 years or more (Leshner, 1998). Methadone is administered to the patient orally at established methadone clinics. Although a mainstay of treatment, these programs reach only twenty to twenty-five percent of addicts with program retention rates between fifty-nine to eighty-five percent (Stimmel et al., 1977). Opioid detoxification should be slow to avoid relapse. The drug should be removed by as little as ten percent per week. Total abstinence may be the only alternative for many patients. COCAINE AND THE AMPHETAMINES Moderate doses of the psychoactive stimulants produce an elevation in mood, a sense of increased energy and alertness, and decreased appetite. Task performance that has been impaired by boredom or fatigue improves. Some individuals may become anxious or irritable. Cocaine addicts describe the euphoric effects of cocaine in a way that is indistinguishable from that of amphetamine addicts. In the laboratory, subjects familiar with cocaine cannot distinguish between the two drugs when both are given intravenously (Fischman et al., 1976). Animals use the drugs in a similar fashion, and the toxic and withdrawal syndrome of the drugs is indistinguishable. There is a difference in the half life of the drugs effects. Cocaine's effects tend to be brief, lasting a matter of minutes, while amphetamine effects last for hours (Griffith et al., 1972; Wesson et al., 1977). The user of a psychoactive stimulant at first feels increased physical strength, mental capacity, and euphoria. They feel a decreased need for sleep or food. A sensation of "flash" or "rush" immediately follows intravenous administration. It is described as an intensely pleasurable experience similar to an orgasm. With time, tolerance develops, and more of the drug is necessary to produce the same effects. With continued use, toxic symptoms appear. These include gritting the teeth, undue suspiciousness, and a feeling of being watched. The user becomes fascinated with their thinking and the deeper meaning of things. Stereotypical, repetitious behavior is common. Individuals may become preoccupied with taking things apart and putting them back together. The mixture of another CNS depressant drug such as an opioid (speedball), or alcohol can be used to decrease irritable side effects. The patient often becomes addicted to both drugs (Wesson and Smith, 1977). PATTERNS OF USE Stimulants may be injected or taken intranasally every few minutes to every few hours around the clock for several days. Such a "speed run" usually lasts until the individual has exhausted the drug supply or is too paranoid or disorganized to continue. Stopping administration is followed within a few hours by deep sleep. Upon arising, the individual feels hungry and lethargic. Some are depressed. Cocaine is inhaled, smoked, or injected intravenously. Cocaine users, who try to maintain the euphoric state, will ingest the drug every thirty to forty minutes (Wesson et al., 1977). Animals given free access to stimulants develop weight loss, self-mutilation, and death within two weeks (Jaffe 1980). Given a choice between food and cocaine, monkeys consistently choose cocaine (Aigner and Balster 1978). A toxic psychosis may develop after weeks or months of continued stimulant use. A fully developed toxic syndrome is characterized by vivid visual, auditory, and tactile hallucinations. There are paranoid delusions with a clear sensorium (Griffith et al., 1972). Unless the individual continues to use the drug, these psychotic symptoms usually clear within a week. The hallucinations are the first symptom to disappear (Jaffe 1980). Craving for the drug, prolonged sleep, general fatigue, lassitude, and depression commonly follow abrupt cessation of chronic use (Post et al., 1974). The National Institute of Drug Abuse estimated that over twenty five to forty million Americans tried cocaine by 1986 (National Institute of Drug Abuse 1986). Adolescent cocaine abuse leads to more rapid and severe consequences than in adults. The time from first use to addiction is reduced from four years in adults, to one and a half years in adolescents (Washton et al., 1984). Cocaine's price has decreased to the point that it costs as little as five dollars to get high. In the mid 1980s, the distribution of the ready to smoke freebase cocaine known as "crack" spread nationwide (Featherly and Hill 1989). With the potent free-based form there is an almost instantaneous euphoric high that is extremely desirable (Frances and Franklin 1988). Cocaine's half-life is less than ninety minutes, but the euphoric effect lasts for only fifteen to thirty minutes (Jaffe 1980). THE COCAINE ABSTINENT SYNDROME The cocaine abstinent syndrome has three phases. Phase one is the crash, where the subjects report depression, anhedonia, insomnia, anxiety, irritability and intense cocaine craving. These symptoms can last up to three days. In phase two, low level cocaine craving continues, with irritability, anxiety, and decreased capacity to experience pleasure. Over several days the negative consequences of cocaine use fade, the person feels more normal, and the craving for cocaine increases, especially in the context of environmental cues. The third phase consists of several weeks of milder episodic craving triggered by environmental stimuli. Many patients will appear to have a major depression shortly after cessation of cocaine or amphetamine use. These patients may become suicidal. Most of these symptoms will clear, but some symptoms, such as sadness and lethargy, can last for months (Schuckit 1984; Gawin and Kleber 1986). The treatments for stimulant rehabilitation are similar to the treatment of alcoholism. The euphoria that stimulants offer needs to be replaced by more adaptive achievements. Stimulant intoxication can be managed with the benzodiazepines or propranolol. Amphetamine or cocaine psychosis may have to be treated with antipsychotic medication. Patients in psychosis need to be kept in a quiet place, supported, and reassured. Antidepressants such as desipramine may ease the withdrawal syndrome (Gawin and Kleber 1986). PHENCYCLIDINE (PCP) Phencyclidine (PCP) is an anesthetic initially manufactured for animal surgery. For a short time it was used as a general anesthetic for humans. Street use of PCP became widespread in the 1970s, when it was introduced as a drug to be smoked or snorted (Jaffe 1980). Phencyclidine is still epidemic in certain eastern American cities (Caracci et al., 1983). In humans, small doses of PCP produce a subjective sense of intoxication, with staggering gait, slurred speech, and numbness of the extremities. The user may experience changes in body image and disorganized thought, drowsiness, and apathy. There may be hostile or bizarre behavior. Amnesia for the episode may occur. With increasing doses, stupor, or coma may occur, although the eyes may remain open (Domino 1978). Animals will self-administer PCP for its reinforcing properties (Balster and Chait 1978). Psychoactive effects of PCP generally begin within five minutes and plateau in thirty minutes. In contrast to the use of hallucinogens, use of PCP may lead to long term neurological damage (Davis 1982). Few drugs are able to produce a more wide a range of subjective effects than PCP. Among the effects that users like are increased sensitivity to external stimuli, stimulation, mood elevation, and a sense of intoxication (Carroll and Comer 1994). Other effects, seen as unwanted, are perceptual disturbances, restlessness, disorientation, and anxiety. Smoking marijuana cigarettes laced with PCP is the most common form of administration (Frances and Franklin 1988). Phencyclidine produces several organic mental disorders including intoxication, delirium, delusional mood, and flashback disorders (Spitzer 1987). Acute adverse reactions to this drug generally require medication to control symptoms. Benzodiazepines are usually the drug of choice but antipsychotics may become necessary. HALLUCINOGENS There is no sharp line that divides the psychedelics from other psychoactive drugs that cause hallucinations. Anticholinergics, bromides, antimalarials, opioid antagonists, cocaine, amphetamines, and corticosteroids can produce illusions and hallucinations, delusions, paranoid ideation, and other alterations in mood and thought similar to psychosis. What seems to distinguish the psychedelic drugs from the others is the unique characteristic to produce states of altered perception that cannot be experienced except in dreams (Jaffe 1980; Carroll and Comer 1994). The psychedelic most available in the United States is lysergic acid diethylamide (LSD). Southwest American Indians have long used the psychedelic psilocybin in religious ceremonies. In 1982 twenty one percent of eighteen to twenty five year olds had tried a psychedelic at least once (Miller 1983). The use of this drug is gratefully on the decline. Hallucinogens are not reinforcing to animals, and in humans, use is infrequent. Using more than twenty times is considered chronic abuse. Hallucinogens produce a variety of organic brain syndromes including hallucinogen hallucinosis, delusional disorder, mood disorder, and flashback disorder (Spitzer 1987). Flashbacks may occur in as many as twenty five percent of users (Naditch and Fenwick 1977). Chronic delusional and psychotic reactions, and rarely schizophrenoform states, have been reported in some psychedelic users (Vardy and Kay 1983). THE PSYCHEDELIC STATE During the psychedelic state, there is an increased awareness of sensory input often accompanied by a sense of clarity. There is a diminished ability to control what is experienced. The user experiences unusual and vivid sensory sensations. Hallucinations are primarily visual. Colors may be heard or sounds seen. Frank auditory hallucinations are rare. Time seems to be altered. Frequently the user feels like a casual observer of the self. The environment may be experienced as novel, often beautiful, and harmonious. The attention of the user is turned inward. The slightest sensation may take on profound meaning. Commonly there is a diminished ability to differentiate the boundaries of objects and the self. There may be a sense of union with the universe. The state begins to clear after about twelve hours (Freedman 1968). Generally intoxicated patients can be talked down without sedation. They need to be placed in a quiet environment free of excess stimulation. Occasionally a sedative may be necessary to calm the patient (Frances and Franklin 1988). CANNABIS Cannabis is an India hemp plant that has been used for medicinal purposes for centuries. Marijuana is a varying mixture of the plant's leaves, seeds, stems, and flowing tops. The psychoactive ingredient in cannabis is Delta-9-tetrahydrocannabinol (THC). Hashish consists of the plant's dried resin and it contains a higher percentage of THC (Turner 1980). Marijuana remains the most commonly used illegal drug in the United States. According to the 1988 National Household Survey, an estimated 66 million Americans had tried marijuana at least once in their lifetime (Adams et al., 1990). Surveys reveal that thirty-one percent of teenagers, forty percent of young adults, and ten percent of older adults have tried Marijuana. It is generally acknowledged that marijuana use among adolescents peaked in the 1970s. Daily users of marijuana dropped from 10.2 percent in 1978 to 5 percent in 1984 (Centers for Disease Control 1991; Frances and Franklin 1988). Cannabis produces effects on mood, memory, motor coordination, cognitive ability, sensorium, time sense, and self-perception. Peak intoxication with smoking generally occurs within ten to thirty minutes. Most commonly there is an increased sense of well being or euphoria, accompanied by feelings of relaxation and sleepiness. Where subjects can interact, there is less sleepiness and there is often spontaneous laughter (Hollister 1971; Jones 1971). Physical signs of use include red eyes, strong odor, dilated pupils, and increased pulse rate. With higher doses, short-term memory is impaired, and there develops a difficulty in carrying out actions that require multiple mental tasks. This leads to a tendency to confuse past, present, and future. Depersonalization develops with a strange sense of unreality about the self (Melges et al., 1970). Balance and stability of stance are affected even at low doses (Evens et al., 1973). Performance of simple motor skills and reaction times are relatively unimpaired until high doses are reached (Hollister 1971; Jones 1971). Marijuana smokers frequently report an increase in hunger, dry mouth and throat, increased vivid visual imagery, and a keener sense of hearing. Subtle visual and auditory stimuli may take on new meaning (Clopton et al., 1979). Higher doses can produce frank hallucinations, delusions, and paranoid feelings. Thinking becomes confused and disorganized, depersonalization and altered time sense increase. Anxiety to the point of panic may replace euphoria. With high enough doses, the patient presents with a toxic psychosis with hallucinations, depersonalization, and loss of insight. This syndrome can occur acutely or after months of use (Nahas 1973; Chopra and Smith 1974; Thacore and Shukla 1976). Chronic smoking of Marijuana and hashish has long been associated with bronchitis and asthma. Smoking effects pulmonary functioning even in young people. The tar produced by Marijuana is more carcinogenic than that produced by tobacco (Secretary 1977). Subjects using Marijuana chronically exhibit apathy, dullness, and impairment of judgment, concentration, and memory. They lose interest in personal appearance, hygiene, and diet. These effects have been observed in young users who regularly smoke a few Marijuana cigarettes a day. These chronic effects take months to clear after cessation of use (Tennant and Grossbeck 1972; Jaffe 1980). The pharmacological effects of Marijuana begin within minutes after smoking. Effects may persist for three to five hours. THC and its metabolites can be found in the urine for several days or weeks after a single administration. THC is highly lipid soluble and its metabolites tend to accumulate in the fat cells. They have a half-life of approximately fifty hours (Hollister 1971; Secretary 1977). Tolerance and dependence develops to Marijuana, and abrupt cessation after chronic use is followed by headache, mild irritability, restlessness, nervousness, decreased appetite, weight loss, and insomnia. Tremor and increased body temperature may occur (Jones et al., 1976; Wikler 1976; Gold 1994). As the withdrawal symptoms tend to be mild, detoxification is usually not necessary (Francis and Franklin 1988). INHALANTS Inhalants include substances with diverse chemical structures used to produce a state of intoxication. Gasoline, airplane glue, aerosol (spray paints), lighter fluid, fingernail polish, typewriter correction fluid, a variety of cleaning solvents, amyl and butyl nitrate, and nitrous oxide. Hydrocarbons are the most active ingredients in these substances. In 1980 ten percent of twelve to seventeen year olds reported using inhalants at least once (Francis and Franklin 1988). Several methods are used to inhale the intoxicating vapors. Most commonly, a rag soaked with the substance is applied to the mouth and nose and the vapors are breathed. The individual may place the substance in a paper or a plastic bag and the gases inhaled. The substance can also be inhaled directly from containers or sprayed into the mouth or nose (Spitzer 1987). Dependent individuals may use inhalants several times per week, often on weekends and after school. Young children sometimes use them, nine to thirteen years of age. These children usually use with a group of friends who are likely to use alcohol and marijuana as well as the inhalant. Older adolescents and young adults who have inhalant dependence are likely to have used a wide variety of substances (Spitzer 1987). While high doses of these agents produce CNS depression, low doses produce an increase CNS activity and a brief period of intoxication. Intoxication can last from a few minutes to two hours. Impaired judgment, poor insight, violence, and psychosis may occur during the intoxicated period. Inhalants are easily and cheaply acquired and they can be attractive to children who cannot drink legally. Animals will self-administer inhalants for a reinforcement. There is a strong cross-tolerance with inhalants and the CNS depressants. Studies of inhalers have found indications of long lasting brain damage (Sharp and Brehm 1977; Sharp and Carroll 1978; Cohen 1979). Long term damage to the bone marrow, kidneys, liver, and brain have also been reported (Francis and Franklin 1988). There have been a number of deaths among inhalant abusers, the deaths are attributable to respiratory depression or cardiac arrhythmia. These deaths often appear to be accidental (King et al., 1985). NICOTINE Crew who accompanied Columbus to the New World was the first Europeans to observe the smoking of tobacco. They brought the leaves and the practice of smoking back to Europe. Tobacco addiction is the number one preventable health problem in the United States. Approximately fifty million Americans currently smoke tobacco (Centers for Disease Control 1991). Cigarettes are responsible for more than four hundred and thirty four thousand deaths each year in the United States (Centers for Disease Control 1988). The burning of tobacco generates about four thousand different compounds, but tobacco's main psychoactive ingredient is nicotine. Nicotine produces a euphoric effect and has reinforcing properties similar to cocaine and the opioids (Henningfield 1984). Tolerance to some of the effects of nicotine quickly develops, but even the chronic smoker continues to exhibit an increase in pulse and blood pressure after smoking as little as two cigarettes. Nicotine has a distinct withdrawal syndrome characterized by craving for tobacco, irritability, anxiety, difficulty concentrating, restlessness, increased appetite, and increased sleep disturbance (Hughes and Hatsukami 1986; Surgeon General 1979). Tobacco addiction has many similar properties to opioid addiction. The use of tobacco is usually an addictive form of behavior (Frances and Franklin 1988). Tobacco produces a calming euphoric effect, particularly on chronic users. Nicotine in cigarette smoke is suspended on minute particles of tar and it is quickly absorbed from the lung with the efficiency of intravenous administration. The compound reaches the brain within eight seconds after inhalation. The half-life for elimination of nicotine is thirty to sixty minutes (Surgeon General 1979). Chronic use of tobacco is causally linked to a variety of serious diseases ranging from coronary artery disease to lung cancer. The likelihood of developing one of these diseases increases with the degree of exposure that is measured by the number of cigarettes per day. Cigarette smoking men have seventy-percent higher death rates than non smokers. Smoking in women is increasing along with smoking related diseases. Smoking is responsible for an estimated three hundred and fifty thousand premature deaths each year in the United States (Braunwald 1987). It is estimated that forty two million Americans have stopped smoking. Approximately thirty percent of smokers make an attempt to quit smoking each year. Eight percent of these attempts succeed. More than ninety percent of successful quitters do so on their own without participating in an organized cessation program. Smokers who quit "cold turkey" are more likely to remain abstinent than those who gradually decrease their daily consumption of cigarettes, switch to cigarettes with lower tar or nicotine, or use special filters or holders. Quit attempts are nearly twice as likely to occur among smokers who receive nonsmoking advice from a physician. Heavily addicted smokers (more than twenty-five cigarettes per day) are more likely to participate in an organized cessation program (Pierce et al 1989). As an addiction specialist, all counselors need to advise their patients against smoking and help them quit. Smokers can and do quit. All smokers should consult with the staff physician for non-smoking advice. Self help material can be presented to the patient's who request more information and a pharmacological alternative, such as gum containing nicotine or a nicotine patch can be substituted to ease withdrawal. Formal smoking cessation programs, such as the American Lung Association's "Freedom from Smoking" clinic may be beneficial for heavier smokers (Glynn 1990). The twelve steps can be useful in giving a smoker support in their attempt to quit. Some patients will want to quit smoking while in treatment. This should be encouraged and supported. POLYSUBSTANCE ABUSE Few drug abusers abuse only one drug. There is a strong correlation between misuse of heroin and alcohol problems, abusers of stimulants frequently use depressants to cut irritable side effects, and alcoholics are at a higher risk to abuse other depressants and stimulants (Schuckit 1984). In Western society, youths begin drug use with caffeine, nicotine, and alcohol. If they go on to use other drugs, the next drug of choice will most likely be marijuana, followed by one of the hallucinogens, depressants, or stimulants. These drugs are taken at first on an experimental basis, they are reinforcing, and lead to few serious consequences. Marijuana is seen as a step on the road to the use of other substances. Once the illegal barrier is crossed, it becomes easier to take a second and a third drug (Gould and Keeber 1974; Kandel 1978). The effects of a drug may be either increased or decreased by adding an additional drug. Depressants taken together may potentiate the effect of either drug taken alone. Depressants and stimulants taken together may decrease the level of side effects encountered when one of the drugs is used alone. Marijuana has been shown to potentiate the effects of alcohol, it may increase the likelihood of a flashback from hallucinogen use (Schuckit 1984). Over half of the patients presenting to a poly-drug clinic report the use of three or more substances (Cook et al., 1975; Fisher et al., 1975). The most common multiple drug withdrawal syndromes are those seen following concomitant use of multiple depressants or depressants and stimulants. Depressants produce the most severe and life threatening withdrawal symptoms. When depressants and stimulants are used together, the withdrawal syndrome more closely follows the clinical picture of depressant withdrawal, but it probably includes greater levels of sadness, paranoia, and lethargy (Shuckit 1984). 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