Drug Addiction

By Mayo Clinic staff

Definition ^back to top

You may be hooked emotionally and psychologically. You may have a physical dependence, too. If you have a drug addiction, you have intense cravings for the drug. You want to use it again and again. When you stop taking it, you may have unpleasant physical reactions.

While not everyone who uses drugs becomes addicted, many people do. Drug addiction involves compulsively seeking to use a substance, regardless of the potentially negative social, psychological and physical consequences. Certain drugs are more likely to cause physical dependence than are others.

Breaking a drug addiction is difficult, but not impossible. Support from your doctor, family, friends and others who have a drug addiction, as well as inpatient or outpatient drug addiction treatment, may help you beat your drug dependence.

Symptoms ^back to top

General signs and symptoms ^back to top

Addiction to any drug may include these general characteristics:

• Feeling that you need the drug regularly and, in some cases, many times a day
• Making certain that you maintain a supply of the drug
• Failing repeatedly in your attempts to stop using the drug
• Doing things to obtain the drug that you normally wouldn't do, such as stealing
• Feeling that you need the drug to deal with your problems
• Driving or doing other activities that place you and others at risk of physical harm when you're under the influence of the drug

The particular signs and symptoms of drug use and dependence vary depending on the type of drug.

Cannabis compounds: Signs and symptoms ^back to top

Cannabis compounds are found in marijuana and hashish. Signs and symptoms of use and dependence on these drugs include:

• A heightened sense of visual, auditory and taste perception
• Poor memory
• Increased blood pressure and heart rate
• Red eyes
• Decreased coordination
• Difficulty concentrating
• Increased appetite
• Slowed reaction time
• Paranoid thinking

Central nervous system depressants: Signs and symptoms ^back to top

Barbiturates and benzodiazepines are examples of central nervous system depressants. Phenobarbital, amobarbital (Amytal) and secobarbital (Seconal) are examples of barbiturates. Benzodiazepines include tranquilizers such as diazepam (Valium), alprazolam (Xanax), oxazepam (Serax), lorazepam (Ativan), clonazepam (Klonopin) and chlordiazepoxide (Librium).

Signs and symptoms of use and dependence on these drugs include:

• Drowsiness
• Slurred speech
• Lack of coordination
• Memory impairment
• Confusion
• Slowed breathing and decreased blood pressure
• Dizziness
• Depression

Central nervous system stimulants: Signs and symptoms ^back to top

This class of drugs includes amphetamines, methamphetamine, cocaine and methylphenidate (Ritalin). Signs and symptoms of use and dependence on these drugs include:

• Euphoria
• Decreased appetite
• Rapid speech
• Irritability
• Restlessness
• Depression as the drug wears off
• Nasal congestion and damage to the mucous membrane of the nose in users who snort drugs
• Insomnia
• Weight loss
• Increased heart rate, blood pressure and temperature
• Paranoia

Designer drugs: Signs and symptoms ^back to top

Synthetic compounds, such as Ecstasy, which has both amphetamine-like and hallucinogenic effects, are included in this category.

Signs and symptoms of using designer drugs vary depending on the drug. You might be able to tell that a family member or a friend is using or abusing a drug based on the physical and behavioral signs and symptoms associated with the drug.

For example, Ecstasy produces a mild hallucinogenic effect and a feeling of euphoria. It also causes an increased heart rate, overheating, high blood pressure, kidney and liver toxicity, and memory problems.

Hallucinogens: Signs and symptoms ^back to top

Use of hallucinogens produces different signs and symptoms depending on the drug. The most common hallucinogens are LSD, phencyclidine (PCP) and ketamine (special K), a so-called "club drug."

Signs and symptoms of LSD use include:

• Hallucinations
• Greatly impaired perception of reality, for example, interpreting input from one of your senses as another, such as hearing colors
• Permanent mental changes in perception
• Rapid heart rate
• High blood pressure
• Tremors
• Flashbacks, a re-experience of the hallucinations – even years later

Signs and symptoms of PCP use include:

• Hallucinations
• Euphoria
• Delusions
• Panic
• Loss of appetite
• Depression
• Aggressive, possibly violent behavior

Signs and symptoms of ketamine use include:

• Increased heart rate
• Nausea and vomiting
• Numbness
• Impaired motor function
• Loss of memory

Inhalants: Signs and symptoms ^back to top

The signs and symptoms of inhalant use vary depending on what substance is inhaled. Some commonly inhaled substances include glue, paint thinners, correction fluid, felt tip marker fluid, gasoline, cleaning fluids and household aerosol products.

When inhaled, these products can cause brief intoxication and a decreased feeling of inhibition. Long-term use may cause seizures and damage to the brain, liver and kidneys. Inhalant use can also cause death.

Opioids: Signs and symptoms ^back to top

Opioids are narcotic, painkilling drugs produced naturally from opium or made synthetically. This class of drugs includes heroin, morphine, codeine, methadone and oxycodone (OxyContin).

Signs and symptoms of use and dependence on these drugs include:

• Reduced sense of pain
• Sedation
• Depression
• Confusion
• Constipation
• Slowed breathing
• Needle marks (if injecting drugs)

Recognizing drug abuse in teenagers ^back to top

Possible indications that your teenager is using drugs include:

• School performance. Your child suddenly shows an active dislike of school and looks for excuses to stay home. Contact your school officials to see if your child's attendance record matches what you know about his or her absent days. A student who experiences a drop in performance, possibly failing courses or receiving only minimally passing grades, may be using drugs.
• Physical health. Listlessness and apathy may indicate your child is using certain drugs.
• Appearance. How they look is extremely important to adolescents. A sudden lack of interest in clothing, grooming or looks may be a warning sign of drug use.
• Personal behavior. Teenagers enjoy privacy, but exaggerated efforts to bar family members from entering their rooms or knowing where they go with their friends might indicate drug use. Also, drastic changes in behavior and in relationships with family and friends may signal drug use.
• Money. Sudden requests for money without a reasonable explanation for its use may be a sign of drug use. You may also discover money stolen from previously safe places at home. Items may disappear from your home because they're being sold to support a drug habit.

Causes ^back to top

The range of drugs to which you can become addicted is wide, and includes both legal and illegal drugs.

Drug dependence is characterized by impaired control over the drug, preoccupation with use, continued use despite negative consequence, and sometimes evidence of physical dependence on the drug. Various factors, such as your personality, your genetic makeup and peer pressure, affect your likelihood of becoming addicted to a drug. In addition, some drugs, such as heroin and cocaine, more quickly produce a physical addiction than other drugs do for many people.

Changing brain pathways ^back to top

Physical addiction appears to occur when repeated use of a drug alters reward pathways in your brain. The addicting drug causes physical changes to some nerve cells (neurons) in your brain. Neurons use chemicals called neurotransmitters to communicate. Neurons release neurotransmitters into the gaps (synapses) between nerve cells; neurotransmitters are received by receptors on other neurons and on their own cell bodies.

The changes that occur in this communication process vary with the type of drug to which you're addicted, though researchers have discovered that addictive drugs, such as cocaine and morphine, affect some areas of the brain in the same manner. If further research confirms findings such as this, it would be possible to develop more effective medications to combat addiction to more than one drug.

Risk factors ^back to top

These factors increase the likelihood of your having an addiction to a legal or an illegal drug:

• Personality. If you have another psychological problem, such as depression, attention-deficit/hyperactivity disorder or post-traumatic stress disorder, you're more likely to become dependent on drugs. Children who exhibit aggression, a lack of self-control and a difficult temperament may be at greater risk of drug addiction.
• Social environment. Particularly for young people, peer pressure is a strong factor in starting to use and abuse drugs. A lack of attachment with your parents may increase the risk of addiction, as can a lack of parental supervision.
• Anxiety, depression and loneliness. Using drugs can become a way of coping with these painful psychological feelings.
• Genetics. Drug addiction is more common in some families and likely involves the effects of many genes. If you have family members with alcohol or drug problems, you're at greater risk of developing a drug addiction.
• Type of drug. Some drugs, such as heroin and cocaine, more quickly result in physical addiction than do others.

When to seek medical advice ^back to top

Addiction is a chronic relapsing disorder, meaning you tend to fall back into old addictive behaviors, including drug use, even after treatment. The sooner you seek help, the greater your chances are for a long-term recovery. If you're initially reluctant to approach a doctor, help lines or hot lines may be a good place to start to learn about treatment. You can find these lines listed in the phone book or on the Internet.

Because denial is often a characteristic of addiction, many people who are addicted to or who abuse drugs won't seek medical treatment on their own. Family members, friends or co-workers may need to persuade the user to undergo screening for drug addiction. Breaking a drug addiction may involve counseling, an outpatient treatment program or residential treatment.

Tests and diagnosis ^back to top

Diagnosing a drug addiction often starts at the family doctor level, often after one family member has raised concerns about another family member's behavior. Your doctor may ask questions about the frequency of drug use, whether any family member has criticized your drug use or whether you've ever felt you might have a problem.

A definitive diagnosis of drug addiction usually occurs after an evaluation by a psychiatrist, psychologist or a specialized addiction counselor. Blood tests often aren't able to result in a diagnosis of a drug addiction, but these tests can help a doctor detect the presence of a drug when its use has been denied.

Complications ^back to top

Dependence on drugs can create a number of life-changing complications, including:

• Health. Drug use and addiction has many physical consequences that vary depending on which drug you use but may include delirium, seizures, coma, heart attack, respiratory failure, kidney damage, unconsciousness and sudden death. Recent research suggests that marijuana, which many consider to be a fairly harmless substance, may increase your risk of developing a psychotic illness, such as schizophrenia, later in life.

Using drugs may make you more likely to participate in other unsafe behaviors, such as sharing needles or having unprotected sex, which can increase your chances of contracting HIV or hepatitis. People who are addicted to drugs are also at a higher risk of overdosing because addicts need more and more of the drug to achieve the same feeling.

• Family. Behavioral changes may cause marital or family strife.
• Work. Work performance may decline, and you may be absent from work more often.
• Social. You may lose or alienate longtime friends.
• School. Academic performance and motivation to excel in school may suffer.
• Legal. Stealing to support your drug addiction and driving while impaired are just two of the possible legal problems drug addiction can cause.
• Financial. Spending money to support your habit takes away money from your other needs, could put you into debt and could lead you into behaviors that are contrary to your values.

Treatments and drugs ^back to top

Drug addiction treatment typically involves steps to help you withdraw from using the drug, followed by counseling and attending self-help groups to help you resist using the addictive drug again.

Withdrawal therapy ^back to top

The goal of withdrawal therapy (detoxification) is for you to stop taking the addicting drug as quickly and safely as possible. Detoxification may involve gradually reducing the dose of the drug or temporarily substituting other substances, such as methadone, that have less severe side effects. For some people, it may be safe to undergo withdrawal therapy on an outpatient basis; others may require admission to a hospital or a residential treatment center.

Withdrawal from different categories of drugs produces different side effects and requires different approaches.

• Central nervous system depressants. Minor side effects of withdrawal may include restlessness, anxiety, sleep problems and sweating. More serious signs and symptoms also could include hallucinations, whole-body tremors, seizures, and increased blood pressure, heart rate and body temperature. The most serious stage of withdrawal may include delirium, which is potentially life-threatening. Withdrawal therapy may involve gradually scaling back the amount of the drug.
• Central nervous system stimulants. Side effects of withdrawal typically include depression, fatigue, anxiety and intense cravings. In some cases, signs and symptoms may include suicidal thoughts and suicide attempts, paranoia and impaired contact with reality (acute psychosis). Treatment during withdrawal is usually limited to emotional support from your family, friends and doctor. Your doctor may recommend medications to treat paranoid psychosis or depression.

• Opioids. Side effects of withdrawal of opioids, such as heroin, morphine, oxycodone or codeine, can range from relatively minor to severe. On the minor end, they may include runny nose, sweating, yawning, feeling anxiety and craving the drug. Severe reactions can include sleeplessness, depression, dilated pupils, rapid pulse, rapid breathing, high blood pressure, abdominal cramps, tremors, bone and muscle pain, vomiting, and diarrhea. Doctors may substitute a synthetic opiate, such as methadone, to reduce the craving for heroin and to gently ease people away from heroin.

  The most recently approved medication to ease withdrawal from opiates is buprenorphine (Subutex). Buprenorphine is a milder opioid that was approved in the United States to manage cravings in individuals who decide to stop using stronger opiates. This drug is the first narcotic medication used for the treatment of addiction that may be prescribed in a doctor's office rather than a treatment center.

Continuing treatment ^back to top

After detoxification, therapies such as counseling, addiction treatment programs and self-help group meetings can help you stay sober.

• Counseling. Individual or family counseling with a psychologist, psychiatrist or addiction counselor may help you resist the temptation to resume using addicting drugs. Behavior therapies can help you develop ways to cope with your drug cravings, suggest strategies to avoid drugs and prevent relapse, and offer suggestions on how to deal with a relapse if it occurs.

Counseling also can involve talking about your job, legal problems and relationships with family and friends. Counseling with family members can help them to develop better communication skills and to be more supportive.

• Treatment programs. Treatment programs generally include educational and therapy sessions focused on establishing sobriety and preventing relapse. This may be accomplished in individual, group or family sessions. These programs are available in various settings from outpatient to residential and inpatient programs.
• Self-help groups. Many, though not all, of these groups tend to use the 12-step model first developed by Alcoholics Anonymous. Self-help groups, such as Narcotics Anonymous, exist for people addicted to drugs, such as cocaine, sedatives and narcotics. The message is that addiction is a chronic disorder with a danger of relapse and that ongoing maintenance treatment – which may include medications, counseling and attending self-help group meetings – is necessary to prevent a relapse. Your doctor or counselor can help you locate a self-help group. You also can find listings for self-help groups in the phone book, at the library and on the Internet.

Prevention ^back to top

The best way to prevent an addiction to an illegal drug is not to take the drug at all. Your doctor may prescribe narcotics to relieve pain, benzodiazepines to relieve anxiety or insomnia, or barbiturates to relieve nervousness or irritation. Doctors prescribe these medications at safe doses and monitor their use so that you're not given too great a dose or for too long a time. If you feel you need to take more than the prescribed dose of a medication, talk to your doctor.

Parents can take the following steps to help prevent drug dependency in their children:

• Communicate. Talk to your children about the risks of drug use and abuse.
• Listen. Be a good listener when your children talk about peer pressure, and be supportive of their efforts to resist it.
• Set a good example. Don't abuse alcohol or addictive drugs. Children of parents who abuse drugs are at greater risk of drug addiction.
• Strengthen the bond. Work on your relationship with your children. A strong, stable bond between you and your child will reduce your child's risk of using or abusing drugs.

Coping and support ^back to top

Along with counseling and attending self-help groups, talk with your doctor or counselor about other ways you can boost your chances of staying drug-free. Following are some suggestions:

• Give yourself time. For most people, it takes about three months before significant improvement occurs, so don't give up on your treatment program too soon.
• Promptly seek treatment for other mental health disorders. Because people with other mental health problems, such as depression, are more likely to become addicted to drugs, seek immediate treatment from a qualified mental health professional if you have any signs or symptoms of mental illness.
• Avoid high-risk situations. Don't go back to the neighborhood where you used to get your drugs. And, stay away from your old drug crowd.

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What are dual diagnosis services? ^back to top

Dual diagnosis services are treatments for people who suffer from co-occurring disorders — mental illness and substance abuse. Research has strongly indicated that to recover fully, a consumer with co-occurring disorder needs treatment for both problems — focusing on one does not ensure the other will go away. Dual diagnosis services integrate assistance for each condition, helping people recover from both in one setting, at the same time.

Dual diagnosis services include different types of assistance that go beyond standard therapy or medication: assertive outreach, job and housing assistance, family counseling, even money and relationship management. The personalized treatment is viewed as long-term and can be begun at whatever stage of recovery the consumer is in. Positivity, hope and optimism are at the foundation of integrated treatment.

How often do people with severe mental illnesses also experience a co-occurring substance abuse problem? ^back to top

There is a lack of information on the numbers of people with co-occurring disorders, but research has shown the disorders are very common. According to reports published in the Journal of the American Medical Association (JAMA):

• Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse.
• Thirty-seven percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness.
• Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs.

The best data available on the prevalence of co-occurring disorders are derived from two major surveys: the Epidemiologic Catchment Area (ECA) Survey (administered 1980-1984), and the National Comorbidity Survey (NCS), administered between 1990 and 1992. Results of the NCS and the ECA Survey indicate high prevalence rates for co-occurring substance abuse disorders and mental disorders, as well as the increased risk for people with either a substance abuse disorder or mental disorder for developing a co-occurring disorder. For example, the NCS found that:

• 42.7 percent of individuals with a 12-month addictive disorder had at least one 12-month mental disorder.
• 14.7 percent of individuals with a 12-month mental disorder had at least one 12-month addictive disorder.

The ECA Survey found that individuals with severe mental disorders were at significant risk for developing a substance use disorder during their lifetime. Specifically:

• 47 percent of individuals with schizophrenia also had a substance abuse disorder (more than four times as likely as the general population).
• 61 percent of individuals with bipolar disorder also had a substance abuse disorder (more than five times as likely as the general population).

Continuing studies support these findings, that these disorders do appear to occur much more frequently then previously realized, and that appropriate integrated treatments must be developed.

What are the consequences of co-occurring severe mental illness and substance abuse?^back to top

For the consumer, the consequences are numerous and harsh. Persons with a co-occurring disorder have a statistically greater propensity for violence, medication noncompliance, and failure to respond to treatment than consumers with just substance abuse or a mental illness. These problems also extend out to these consumers' families, friends and co-workers.

Purely healthwise, having a simultaneous mental illness and a substance abuse disorder frequently leads to overall poorer functioning and a greater chance of relapse. These consumers are in and out of hospitals and treatment programs without lasting success. People with dual diagnoses also tend to have tardive dyskinesia (TD) and physical illnesses more often than those with a single disorder, and they experience more episodes of psychosis. In addition, physicians often don't recognize the presence of substance abuse disorders and mental disorders, especially in older adults.

Socially, people with mental illnesses often are susceptible to co-occurring disorders due to "downward drift." In other words, as a consequence of their mental illness they may find themselves living in marginal neighborhoods where drug use prevails. Having great difficulty developing social relationships, some people find themselves more easily accepted by groups whose social activity is based on drug use. Some may believe that an identity based on drug addiction is more acceptable than one based on mental illness.

Consumers with co-occurring disorders are also much more likely to be homeless or jailed. An estimated 50 percent of homeless adults with serious mental illnesses have a co-occurring substance abuse disorder. Meanwhile, 16% of jail and prison inmates are estimated to have severe mental and substance abuse disorders. Among detainees with mental disorders, 72 percent also have a co-occurring substance abuse disorder.

Consequences for society directly stem from the above. Just the back-and-forth treatment alone currently given to non-violent persons with dual diagnosis is costly. Moreover, violent or criminal consumers, no matter how unfairly afflicted, are dangerous and also costly. Those with co-occurring disorders are at high risk to contract AIDS, a disease that can affect society at large. Costs rise even higher when these persons, as those with co-occurring disorders have been shown to do, recycle through healthcare and criminal justice systems again and again. Without the establishment of more integrated treatment programs, the cycle will continue.

Why is an integrated approach to treating severe mental illnesses and substance abuse problems so important? ^back to top

Despite much research that supports its success, integrated treatment is still not made widely available to consumers. Those who struggle both with serious mental illness and substance abuse face problems of enormous proportions. Mental health services tend not to be well prepared to deal with patients having both afflictions. Often only one of the two problems is identified. If both are recognized, the individual may bounce back and forth between services for mental illness and those for substance abuse, or they may be refused treatment by each of them. Fragmented and uncoordinated services create a service gap for persons with co-occurring disorders.

Providing appropriate, integrated services for these consumers will not only allow for their recovery and improved overall health, but can ameliorate the effects their disorders have on their family, friends and society at large. By helping these consumers stay in treatment, find housing and jobs, and develop better social skills and judgment, we can potentially begin to substantially diminish some of the most sinister and costly societal problems: crime, HIV/AIDS, domestic violence and more.

There is much evidence that integrated treatment can be effective. For example:

• Individuals with a substance abuse disorder are more likely to receive treatment if they have a co-occurring mental disorder.
• Research shows that when consumers with dual diagnosis successfully overcome alcohol abuse, their response to treatment improves remarkably.

With continued education on co-occurring disorders, hopefully, more treatments and better understanding are on the way.

What does effective integrated treatment entail? ^back to top

Effective integrated treatment consists of the same health professionals, working in one setting, providing appropriate treatment for both mental health and substance abuse in a coordinated fashion. The caregivers see to it that interventions are bundled together; the consumers, therefore, receive consistent treatment, with no division between mental health or substance abuse assistance. The approach, philosophy and recommendations are seamless, and the need to consult with separate teams and programs is eliminated.

Integrated treatment also requires the recognition that substance abuse counseling and traditional mental health counseling are different approaches that must be reconciled to treat co-occurring disorders. It is not enough merely to teach relationship skills to a person with bipolar disorder. They must also learn to explore how to avoid the relationships that are intertwined with their substance abuse.

Providers should recognize that denial is an inherent part of the problem. Patients often do not have insight as to the seriousness and scope of the problem. Abstinence may be a goal of the program but should not be a precondition for entering treatment. If dually diagnosed clients do not fit into local Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) groups, special peer groups based on AA principles might be developed.

Clients with a dual diagnosis have to proceed at their own pace in treatment. An illness model of the problem should be used rather than a moralistic one. Providers need to convey understanding of how hard it is to end an addiction problem and give credit for any accomplishments. Attention should be given to social networks that can serve as important reinforcers. Clients should be given opportunities to socialize, have access to recreational activities, and develop peer relationships. Their families should be offered support and education, while learning not to react with guilt or blame but to learn to cope with two interacting illnesses.

What are the key factors in effective integrated treatment? ^back to top

There are a number of key factors in an integrated treatment program.

Treatment must be approached in stages. First, a trust is established between the consumer and the caregiver. This helps motivate the consumer to learn the skills for actively controlling their illnesses and focus on goals. This helps keep the consumer on track, preventing relapse. Treatment can begin at any one of these stages; the program is tailored to the individual.

Assertive outreach has been shown to engage and retain clients at a high rate, while those that fail to include outreach lose clients. Therefore, effective programs, through intensive case management, meeting at the consumer's residence, and other methods of developing a dependable relationship with the client, ensure that more consumers are consistently monitored and counseled.

Effective treatment includes motivational interventions, which, through education, support and counseling, help empower deeply demoralized clients to recognize the importance of their goals and illness self-management.

Of course, counseling is a fundamental component of dual diagnosis services. Counseling helps develop positive coping patterns, as well as promotes cognitive and behavioral skills. Counseling can be in the form of individual, group, or family therapy or a combination of these.

A consumer's social support is critical. Their immediate environment has a direct impact on their choices and moods; therefore consumers need help strengthening positive relationships and jettisoning those that encourage negative behavior.

Effective integrated treatment programs view recovery as a long-term, community-based process, one that can take months or, more likely, years to undergo. Improvement is slow even with a consistent treatment program. However, such an approach prevents relapses and enhances a consumer's gains.

To be effective, a dual diagnosis program must be comprehensive, taking into account a number of life's aspects: stress management, social networks, jobs, housing and activities. These programs view substance abuse as intertwined with mental illness, not a separate issue, and therefore provide solutions to both illnesses together at the same time.

Finally, effective integrated treatment programs must contain elements of cultural sensitivity and competence to even lure consumers, much less retain them. Various groups such as African-Americans, homeless, women with children, Hispanics and others can benefit from services tailored to their particular racial and cultural needs.

Reviewed by Robert Drake, MD September 2003