ICCE Study Guide for Addiction Professionals (PDF)

ICCE CREDENTIALING EXAMINATIONS Study Guide for Addiction Professionals Published by Colombo Plan International Centre for Credentialing and Education of Addiction Professionals Acknowledgments ICCE Study Guide for Examinations is developed to assist addiction practitioners to prepare themselves to write the ICCE examinations for International Certified Addiction Professional (ICAP) credentials. This Study Guide is written in the same format that covers the four domains and the outlines of the three levels of ICAP examination. It is a comprehensive and user friendly manual suitable for candidates preparing for ICAP I, II and III examinations and also for treatment practitioners who need a refresher course on all aspects of substance use disorder. Special thanks goes to Dr. Shanthi Ranganathan, Honorary-Secretary, TT Ranganathan Clinical Research Foundation (TTK Hospital), Chennai India and Dr. V. Thirumagal, Programme Consultant, TT Ranganathan Clinical Research Foundation (TTK Hospital), Chennai India for developing the manual; Mr. Tay Bian How, Director, ICCE for his guidance and leadership throughout the development of the Study Guide. We would like to thank the following persons for their contributions to the development of this publication: Ms. Winona Pandan, Curriculum Development Coordinator and Ms. Susmita Banerjee, Training Executive of ICCE for reviewing the Study Guide; and Ms. Nimalka De Silva, Graphic Designer of ICCE for designing the Study Guide. Disclaimer The substance use disorder treatment interventions described or referred to herein do not necessarily reflect the official position of ICCE or the Colombo Plan. The guidelines in this document should not be considered substitutes for individualised client care. 2nd Edition Published 2016 - Sri Lanka TABLE OF CONTENTS CHAPTER 1 5 Introduction CHAPTER 2 21 Pharmacology of Psychoactive Substance CHAPTER 3 77 Theoretical Base of Counselling CHAPTER 4 119 Special populations – issues for consideration and Co-occurring medical and mental disorders CHAPTER 5 183 Counselling Practice CHAPTER 6 289 Professional Issues CHAPTER 7 323 Sample Test Questions CHAPTER 1 Introduction INTRODUCTION 7 Colombo Plan Established in 1950 at the Commonwealth Conference on Foreign Affairs in Colombo, Sri Lanka, Colombo Plan remains one of the longest existing inter-governmental organisations in the region. Originally, it consisted of seven member countries, namely, Australia, Canada, India, Pakistan, New Zealand, Sri Lanka, and the United Kingdom. However, it has since expanded to include 27 member countries including non-Commonwealth countries. Colombo Plan is based on the partnership concept of self-help and mutual help, with the objective of improving the socioeconomic advancement of its member countries. Over the years, Colombo Plan has evolved to reflect the needs of member countries in a fast- changing global economic environment. The Colombo Plan Drug Advisory Programme (DAP) is the region’s oldest inter- governmental programme aimed at capacity-building for drug demand reduction in Asia and the Pacific Region. DAP’s key initiatives in combatting substance use in the region include the establishment of national drug focal points, formulation of national drug policies, implementation of several drug demand reduction initiatives, initiation of the Afghanistan drug demand reduction initiative, and the International Centre for Credentialing and Education of Addiction Professionals (ICCE). Credentialing of Addiction Professionals The Colombo Plan International Centre for Credentialing and Education of Addiction Professionals (ICCE), established in February 2009 as the training and credentialing arm of the Drug Advisory Programme plays a prominent role in the global initiative funded by the Bureau of International Narcotics and Law Enforcement Affairs (INL), US Department of State to develop, expand, and professionalise the drug demand reduction workforce. The ICCE has the status of an International Certified Education Provider of the National Association of Alcohol and Drug Abuse Counsellors (NAADAC) in the USA. In collaboration with NAADAC, ICCE has developed three levels of credentialing for treatment professionals, namely, the International Certified Addiction Professional (ICAP) ICAPI, ICAP ll and ICAP lll. The credentialing is an indication of the addiction practitioner’s current level of knowledge and practice in alcoholism and drug abuse counselling. Furthermore, the same credentials are offered in all the 47 participating countries where ICCE currently has training initiatives. This means that an addiction professional with an ICAP I credential in a Southeast Asian country will have the same level of knowledge, skills and competence as another addiction professional with the same credential in an African country. As NCC AP in USA as well as National Certification Boards of the participating A 8 CHAPTER 1 countries recognise ICCE credentials, this reciprocity facilitates addiction professionals to move and practise from one country to another. Benefits gained by credentialing Validation of the skills, knowledge and competencies of the drug demand reduction workforce. Declaration of the addiction practitioner’s competencies, thus enhancing his employability and career advancement. Ascertaining the quality of addiction prevention interventions, treatment and aftercare services. Setting a benchmark for prevention specialists and addiction professionals. Administration The credentialing programme is administered by the International Centre for Credentialing and Education of Addiction Professionals (ICCE) of the Colombo Plan in collaboration with the Professional Testing Corporation (PTC) in New York, USA. Eligibility criteria for the ICCE credentials i) International Certified Addiction Professional I (ICAP I): At least 1 year of full time or 1,500 hours of supervised working experience in drug and alcohol related field. Passed the first public examination (9th/10th/11th grade). Competency in reading and writing. Applicants with Substance Use Disorder would need to furnish proof of continuous and supervised sobriety for at least a period of one year. Written verification of competency in required counselling skills and functions as certified by addiction professional, supervisors or other health care professionals who have personally observed the candidate’s alcohol and/or drug abuse related counselling work. The Candidate should have conducted screening, intake, client education, group counselling, referral services for at least 50 clients. To endorse competency, the supervisor should observe counselling done to at least 5 clients and also gone through the case records of 5 clients. Supervisor should be a senior professional with an (self-attested) experience of at least 3 years of addiction counselling. A INTRODUCTION 9 Documentation of a total of 120 contact hours of education and training in alcoholism and drug abuse or related counselling subjects. Included in this total must be at least 6 contact hours of HIV/AIDS training 6 hours of Co-occurring disorders and at least 6 contact hours of ethics training. (Relevant topics should include all the areas covered in the UTC Basic level series) Submission of a signed and dated statement that the candidate has read the ICCE Commission’s Code of Ethics for addiction professional and has agreed to adhere to it. If the candidate is attached to a drug treatment organisation, the organisation should have a code of ethics in place. Completion of an application for the appropriate level of credential and submission of the same to ICCE. Payment of non-refundable application fee. Passing of the ICCE Level I examination for ICAP I credentialing. ii) International Certified Addiction Professional II (ICAP II): At least 2 years of full-time or 3,000 hours of supervised working experience as an alcoholism and/or drug abuse related professional. The 2 years need not be consecutive. Passed the first public examination (9th/10th/11th Grade). Competency in reading and writing. Applicants with Substance Use Disorder would need to furnish proof of continuous and supervised sobriety for at least a period of two years. Successful completion of ICAP I and practising as an addiction professional for at least 2 years following ICAP I credentialing or graduate/higher in relevant field (Psychology, Social Work, Behavioural Science courses and Nursing Courses) Written verification of competency in required counselling skills and functions as certified by counsellors or supervisors or other health care professionals who have personally observed the candidate’s alcohol and/or drug abuse counselling work. The candidate should have conducted assessment, treatment planning and counselling for at least 75 clients following ICAC I. To endorse competency, the supervisor should observe counselling done to at least 5 clients and gone through the case records. Supervisor should be a senior counsellor with an (self-attested) experience of at least 4 years of addiction counselling. Documentation of a total of 240 contact hours of education and training in alcoholism and drug abuse or related counselling subjects. Included in this total must be at least 6 contact hours of HIV/AIDS training 6 hours of Co-occurring disorders and at least 6 A 10 CHAPTER 1 contact hours of ethics training. (Relevant topics should include all the areas covered in the UTC Intermediate level series) Submission of a signed and dated statement that the candidate has read the ICCE Commission’s Code of Ethics for addiction professional and has agreed to adhere to it. If the candidate is attached to a drug treatment organisation, the organisation should have a code of ethics in place. Completion of an application for the appropriate level of credential and submission of the same to the ICCE. Payment of non-refundable application fee. Passing of the ICCE II examination for ICAP II credentialing. iii) International Certified Addiction Professional III (ICAP III) At Least 5 years of full-time or 7,500 hours of supervised working experience as an alcoholism and/or drug abuse related professional. The 5 years need not be consecutive. Passed the first public examination (9th/10th/11th grade). Competency in reading and writing. Applicants with Substance Use Disorder would need to furnish proof of continuous and supervised sobriety for at least a period of 5 years. Successful completion of ICAP II and practising as an addiction professional for at least 2 years following ICAP II or Masters/higher in relevant field. (Clinical Psychology, Psychiatric Social Work, Behavioural Science courses and Nursing Courses) Written verification of competency in required counselling skills and functions as certified by addiction professional or supervisors or other health care professionals who have personally observed the candidate’s alcohol and/or drug abuse counselling work. The candidate should have conducted assessment, treatment planning and counselling for at least 100 clients following ICAP II. To endorse competency, the supervisor should observe counselling done to at least 5 clients and gone through the case records. Supervisor should be a senior professional with an (self-attested) experience of at least 6 years of addiction counselling. Documentation total of 500 contact hours of education and training in alcoholism and drug abuse or related counselling subjects. Included in this total must be at least 20 hours on supervision, 6 contact hours of HIV/AIDS training, 6 hours of Co-occurring disorders and at least 6 contact hours of ethics training. (Related topics should include areas covered in UTC Curriculum) Submission of a signed and dated statement that the candidate has read the ICCE Credentialing Code of Ethics and agreed to adhere to it. A INTRODUCTION 11 Completion of an application for the appropriate level of credential and submission of the same to ICCE. Payment of non-refundable application fee. Passing of the ICCE III examination for ICAP III credentialing. Definitions: Supervision: Supervision is provided by the individual who oversees the work and/ or signs off on the candidate’s reporting/ client records. This individual is the candidate’s supervisor by position and his/her credentials need not to be presented as part of the application. Supervision for those in private practice may consist of oversight by a medical director or knowledgeable colleagues attesting that the candidate is indeed in the practice of alcoholism and drug abuse counselling. Education: Contact hours are defined as the actual number of classroom or workshop hours spent in the activity, exclusive breaks, or the actual supervised (director or indirect) hours spent in training practice, internships, or apprenticeship primarily involved in alcohol/ drug counselling activities. Instructions may receive credit for alcoholism/ drug abuse counselling related courses presented. The instructor receives the same number of hours as the student received. Credit will be given only once for a course regardless of the number of times it is completed. There are no hours available for preparation activities. No education hours is offered for writing a book or other articles for publication. Documentation of education: Documentation of all educational hours for the level of credential requested. It is important to show proof of attainment of educational hours required. Documentation may consist of copies of certificates of attendance at training, copy of college transcripts (student copies are acceptable), or a validate listing of appropriate trainings including name of provider, subject of training, dates attended and hours completed. Note: Send an official or student copy of bachelor’s degree transcript if applying for ICAP II. Calculation of Contact Hours on the basis of University Degrees on General and Relevant Subjects: A 12 CHAPTER 1 General Relevant Addiction Science University Degrees Subjects Subjects Studies Diploma 10 hours 40 hours 80 hrs Degree 20 hours 80 hours 100 hrs Post Graduate Diploma 30 hours 120 hours 200 hrs Masters 40 hours 180 hours 220 hrs PhD 50 hours 400 hours 450 hrs Relevant Subject for Bachelor’s Degree: Psychology, Social Work, Behavioural Sciences Science courses Nursing Courses and Addiction Science. Relevant Subjects for Master’s Degree: Clinical Psychology, Psychiatric Social Work, Behavioural Science courses and Nursing Courses. Continuing Education hours required for ICAP credentialing: Credentials Continuing educational hours ICAP I 120 hours ICAP II 240 hours ICAP III 500 hours Attainment of credentials The portfolios of addiction professionals who successfully complete the eligibility review and the appropriate written examination will be presented to the ICCE Commission for final approval. Candidates will be notified of their examination results approximately four weeks after the date of examination. Portfolios of passing candidates will be presented to the ICCE Commission for final review and approval which may consume an additional eight weeks. Upon approval from the ICCE Commission, addiction professionals are encouraged to use the appropriate designation, ICAP I, ICAP II or ICAP III, after their names in all their professional endeavours. Re-credentialing The ICCE credential is awarded for a period of two years, at which time the candidate must meet current eligibility requirements for the level at which he/she wishes to re-credential. Note: All training hours for Ethics and HIV/ AIDS must be within the past 5 years and payment of USD 100 to be paid to ICCE as re-credentialing fees. A INTRODUCTION 13 Revocation of credentialing As individual’s credential may be revoked for any of the following reasons: 1. Falsification of any information, including experience data, requested in the application. 2. Misrepresentation of credentialing status. 3. Revocation or suspension of state level credentialing. 4. Violation of the ICCE Code of Ethics (See page 312 and 313). Application procedure Once the dates for the examinations are confirmed, it will be advertised on the Colombo Plan website. For application and other necessary documents, kindly visit http://www. colombo-plan.org/icce/?page_id=29. Completion of application Complete or fill in as appropriate ALL information requested on the application form. Mark only one response unless otherwise indicated. NOTE: The name entered on the application form must match exactly the name shown on individual’s current government-issued photo ID such as driver’s license or passport. Nicknames or abbreviations are not allowed. Candidate information: Starting at the top of the application form, print the name, address, phone numbers, e-mail address and language in which the examination will be taken. Eligibility and background information: All questions must be answered. Mark only one response, unless otherwise indicated. Optional information: These questions are optional. The information requested is to assist in complying with equal opportunity guidelines and will be used only in statistical summaries. Such information will no way affect your test results. Candidate signature: Once all required information has been completed, sign and date the application form in the space provided. Verification of work experience: The accuracy of the candidates’ career history, as stated in the application form as well as competency in accepted counselling techniques and A 14 CHAPTER 1 practice, and adherence to ethical standards must be verified by the candidate’s supervisor of the immediate past 12 months. List of Documents to be submitted by the candidate: Detailed CV of the candidates (signed by the candidates with date) Narrative description of the most recent work experience in addiction treatment (verified and recommended by the supervisor on the organisation’s letter head) Certified true copies of the training certificates ( Attended in the last 5 years) Certified true copies of School / University certificates (As mentioned in the CV) An examination fee to be submitted upon approval of application. Bank Details for Payment. A/C Name: COLOMBO PLAN COUNCIL – ICCE – CSI A/C Number: 73655700 Bank: Bank of Ceylon (Super Grade) International Department,1st Floor, BOC Merchant Tower, 28, St. Michael’s Road, Colombo 03, Sri Lanka Swift Code: BCEYLKLX Cheques or money orders should be made payable to: International Centre for Credentialing and Education of Addiction Professionals (ICCE). Please Note: Fees are NOT refundable. DO NOT SEND CASH. Examination administration: The ICCE Examination I, II and III are computerised/ manual examinations administered on predetermined dates. Rules for the examination: 1. No signalling devices, including pagers, cellular phones, and alarms may be operative during the examination. 2. No books or other reference materials may be taken into the examination room. 3. No questions concerning content of the examination may be asked during the testing period. The candidates should carefully read the directions that are provided on screen at the beginning of the examination session. A INTRODUCTION 15 Reports of results: Candidates will be notified by ICCE within four weeks of the closing of the testing period irrespective of whether they have passed the examination. Scores on the major areas of the examination and on the total examination will be reported. Re-examination: Candidates wishing to retake the examination may do so upon filling a new application form and paying an examination fee. There is no limit to the number of times the examination may be repeated. Confidentiality: Test scores will be released in writing only to the individual candidate and the state or agency authorised by the candidate to receive the results. Any questions concerning test results or the credentialing process should be referred to the state or agency representative. Content of ICCE examinations: 1. The ICCE Examinations are online examination composed of: ICCE I: 125 multiple-choice, objective questions with a total testing time of three (3) hours. ICCE II: 175 multiple-choice, objective questions with a total testing time of three (3) hours. ICCE III: 225 multiple-choice, objective questions with a total testing time of four (4) hours. 2. The content for the examination is described in the Content Outline stated below. 3. The questions for the examination are obtained from individuals with expertise in alcoholism and drug abuse counselling and are reviewed for construction, accuracy, and appropriateness by the International Centre for Credentialing and Education of Addiction Professionals (ICCE). 4. The International Centre for Credentialing and Education of Addiction Professionals (ICCE), with the advice and assistance of the Professional Testing Corporation, prepare the examinations. 5. The ICCE examinations will be weighted in approximately the following manner: No. Subject ICCE I ICCE II ICCE III I. Pharmacology of Psychoactive 25% 25% 20% Substances II. Counselling Practice 40% 30% 20% III. Theoretical Base of Counselling 15% 20% 30% IV. Professional Issues 20% 25% 30% A 16 CHAPTER 1 Content outline I. Pharmacology of psychoactive substances A. Definitions of pharmacology 1. Relationship to Addiction Counselling 2. Content Areas of Pharmacology a. Terminology b. Physiological Effects c. Psychological Effects d. Withdrawal Syndrome e. Drug Interactions B. Drug classification 1. Alcohol 2. Depressants a. Anti-Anxiety (Minor Tranquilizers) b. Barbiturates c. Sedative-Hypnotics d. Psychotropics (Major Tranquilizers) 3. Cocaine 4. Other stimulants a. Amphetamines and Amphetamine Type Stimulants b. Nicotine c. Caffeine 5. Opiates a. Natural Derivatives b. Synthetics c. Antagonists 6. Hallucinogens 7. Cannabis A INTRODUCTION 17 8. Other a. Inhalants b. Designer Drugs c. Steroids d. Nonprescription Drugs C. The addiction process 1. The Disease Model 2. Stages of Addiction D. Detoxification E. Pharmacotherapy 1. Antabuse 2. Use II. Counselling practice A. Client evaluations 1. Screening 2. Intake 3. Assessment 4. Diagnostic Criteria B. Treatment planning 1. Problems, Identifications, and Ranking 2. Goals and objectives 3. Treatment Process and Resources Defined 4. Levels of Care A 18 CHAPTER 1 C. Counselling 1. Problems and Ramifications 2. Examination of Attitudes/ Feelings 3. Consideration of Alternative Solutions 4. Skills a. Individuals b. Group c. Family/ Significant Other D. Client Care/ Case Management E. Client and Family Education 1. Alcohol and Drug Information 2. Relapse and Recovery 3. Life Skills Enhancement F. Continuing Care G. Special Issues/ Populations 1. Adolescence 2. Geriatrics/ Elderly 3. Gender 4. Sexual 5. Cultural 6. Criminal Justice 7. Suicide 8. Co-occurring Disorders 9. Survivors of Abuse 10. Chronic Illness, Communicable Diseases, and Disabilities H. Gangs I. Conflict Resolutions A INTRODUCTION 19 III. Theoretical base of counselling A. Addiction Counselling 1. Core Skill Groups a. Treatment Admission (Screening, Intake, and Orientation) b. Clinical Assessment c. Ongoing Treatment Planning d. Counselling Services e. Case Management f. Discharge/ Continuing Care g. Legal, Ethical, and Professional Growth 2. Disease Model and Stages 3. 12 Step Philosophy 4. Relapse Prevention 5. Family a. Systems Theory b. Children of Alcoholics/ Addicts c. Codependency B. Human Growth and Life Stage Development 1. Childhood 2. Adolescence 3. Adulthood 4. Geriatrics C. Behavioural/ Cognitive/ Analytical Theories 1. Cognitive Approaches 2. Learning Theory Approaches 3. Psychoanalytic Approaches 4. Perceptual – Phenomenological Approaches 5. Stages of Change 6. Motivational Interviewing A 20 CHAPTER 1 D. Co-occurring Disorders IV. Professional issues A. Laws and Regulations 1. Confidentiality 2. Discrimination 3. Drug Testing 4. Record Keeping and Documentation B. Ethics 1. Non-Discrimination 2. Counsellor Responsibility and Well-being 3. Competence 4. Legal Standards 5. Public Statements 6. Publication Credit 7. Client Welfare 8. Confidentiality 9. Client Rights and Responsibility 10. Inter-professional Relationships 11. Remuneration (Unauthorized Payments or Gifts) 12. Societal Obligations C. Supervision D. Leadership and Management E. Research and Outcome Studies A CHAPTER 2 Pharmacology of Psychoactive Substances Psychoactive Substances.................................................................... 23 Substance use related problems..................................................... 27 Substance Use Disorders (SUD)........................................................ 28 Addiction as a disease......................................................................... 30 Pharmacology........................................................................................ 34 Brain and substance use..................................................................... 37 Schedule of controlled substances................................................. 45 Classification of Psychoactive Substances................................... 46 Opioids................................................................................................. 46 Depressants........................................................................................ 50 Stimulants........................................................................................... 57 Hallucinogens.................................................................................... 61 Cannabis.............................................................................................. 63 Dissociative anaesthetics.............................................................. 66 Inhalants.............................................................................................. 68 Khat (Miraa)........................................................................................ 69 Anabolic steroids............................................................................... 70 Pharmacotherapy.................................................................................. 72 References................................................................................................ 75 PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 23 Psychoactive Substances Psychoactive Substance (PAS) is a substance (drug) that affects the body’s Central Nervous System (CNS) and changes how people behave or perceive what is happening around them. The CNS consists of the brain and the spinal cord. Psychoactive substances include legal drugs, illicit or illegal drugs, designer drugs and some medications. a) Legal drugs: What is considered as a legal drug in one country can be illegal in another. Just because it is legal, does not make it safe for use. Apart from the harm caused to the individual, legal drugs can harm others in the family or community because of the effect on the person’s thoughts, feelings and behaviour. Alcohol and tobacco are two of the most common legal psychoactive drugs that can lead to Substance Use Disorders (SUD). Tobacco use can also cause health problems in others who inhale the second hand smoke. b) Illegal or illicit drugs: Countries usually have laws and enforcement efforts to restrict the production, distribution and consumption of psychoactive drugs declared as being illegal / illicit. Imprisonment or even death sentences may be listed a punishment for those who break these legal directives. The severity and duration of the punishment and the level of enforcement varies from country to country. The United Nations has tried to bring countries together and put in place internationally applicable control measures to restrict production, trade and supply of psycho active substances and thereby reduce the negative impact of substance use. None of the substances were declared as ‘illegal’ but brought under different levels of control depending on the schedule in which the specific substance was placed in. A brief description of the UN conventions has been presented in a box on page 25 and 26 while the Schedule of Drugs has been discussed on page 45 of this guide. c) Designer Drugs: Designer drug is a term used to describe PAS which are created by modifying the molecular structure of an illicit drug to a certain degree to get around existing drug laws. MDMA (ecstasy) discussed in the section on stimulants is one such drug. A 24 CHAPTER 2 d) Medications: Medications can protect one from diseases (e.g. vaccinations), cure disease (e.g. tuberculosis) or enhance a person’s physical or mental well-being (such as anti-hypertensives or anti-depressants). When medications (e.g. anxiety relieving medications, pain killers etc) are NOT used as per the doctor’s instructions, it can lead to many problems including addiction. Risk of SUD problems arise when a person uses the medically prescribed drugs: In a larger dose than what is prescribed (e.g. instead of using 4 mg. of benzodiazepines given, the person may take 8mg); More frequently than prescribed (e.g. using the cough suppressant few times a day instead of the night time dosage only); For a longer period than directed (e.g. continuing to use the pain killer well beyond the duration of a week as instructed by the doctor); and Using medications without medical advice or for reasons other than what is prescribed (e.g. anti - allergy drugs may be used for the drowsiness it causes). Over the Counter Drugs (OTC): These are medications that can be bought without a doctor’s prescription compared to prescription drugs. Acetaminophen given for fever and pain, Non Steroidal Anti-inflammatory Drugs (NSAIDs) such as like Ibuprofen and anti allergy medicines are some OTC drugs. Pain relievers, anti- allergy drugs, medication for coughs and cold may be abused for the mood changing effects. When used in excessive quantities OTC drugs that contain chlorpheniramine, dextromethorphan, pseudoephedrine, caffeine can cause sedation, disorientation and other mood changes. It can also lead to dangerous side effects such as seizures, memory loss, coma or even death. The type of drugs that can be sold as OTC drugs can vary from country to country. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 25 CONVENTIONS The UN International Drug Control Conventions are designed to ensure the safe use of potentially dangerous psychotropic substances. The treaties recognize that these substances often have legitimate scientific and medicinal uses that must be protected but that their abuse creates public health, social and economic problems. Vigorous measures, involving close international cooperation are required to restrict their use to legitimate purposes. The Conventions list the controlled substances in different schedules with different levels of control, depending on the balance between therapeutic usefulness and the risk of abuse. Countries that become party to the Conventions are obliged to adopt appropriate legislation, introduce necessary administrative and enforcement measures and cooperate with international drug control agencies and with other parties to the Conventions. Internationally devised measures are thus translated into national controls by individual member States within their own legal systems. The single convention on narcotic drugs (1961) Single Convention on Narcotic Drugs of 1961 (“1961 Convention”) The 1961 Convention is an international Convention that does not allow the production and supply of narcotic drugs, except under a license for a specific purpose, such as medical treatment or research. This Convention consolidates and adds to past drug regulatory Conventions – which had only regulated opium, coca, and their derivatives – by broadening their scope to include cannabis and synthetic opioids such as methadone and fentanyl. 1961 The Convention, signed by 184 states, required governments to work with the UN Office on Drugs and Crime (UNODC) to pass their own laws in order to carry out its provisions. The Convention was used as a basis for Parties to standardize their national drug policies. The 1961 Convention empowered the Commission on Narcotic Drugs (CND) and the World Health Organization (WHO) to add and revise the drugs listed on the Convention’s four schedules (or categories) of controlled substances based on restrictiveness in this order: Schedule I, Schedule II, Schedule III, and finally Schedule IV. The Single Convention only allowed for drugs with morphine like, cocaine-like, and cannabis-like effects to be added to the schedules. Moreover, by merging the Permanent Central Board and the Drug Supervisory Board, the 1961 Convention established the International Narcotics Control Board (INCB) – an independent organ of the UN responsible for the implementation of drug Conventions. Indeed, the 1961 Convention was a major step forward in international drug control. A 26 CHAPTER 2 Convention on psychotropic substances of 1971 (“1971 con- vention”) Since the 1961 Convention was limited to plant-based drugs such as cannabis, coca, and opium and as a response to the expansion of synthetic drug abuse in the 1960s and 70s, the 1971 Convention was designed by the UN in order to control psychoactive drugs such as amphetamines, barbiturates, benzodiazepines, and psychedelics. The Convention restricts the import and export of such drugs to what is needed medically, using international cooperation to restrict the trafficking of psychotropic drugs. Like the 1961 Convention, psychotropic drugs under the 1971 Convention are categorized under four schedules according their dependence-inducing properties balanced against their therapeutic potential. Scheduling is determined largely by the WHO and the CND. United nations convention against illicit traffic in narcotic drugs and psychotropic substances of 1988 (“1988 convention”) The 1988 Convention complements the other two Conventions by providing specific measures against drug trafficking, including provisions against money laundering and the diversion of precursor chemicals – an issue only marginally addressed by earlier international regulations. The Convention provides for international cooperation through, for example, extradition of drug traffickers, controlled deliveries and transfer of proceedings, and calls on parties to introduce trafficking activities as criminal offences in their national legislation. The 1988 Convention’s objective was to establish global cooperation between various law enforcement bodies such as customs agents, police officers, and judicial authorities, providing them with the legal guidelines to effectively interdict illicit trafficking, to arrest and try offenders, and to deprive them of any gains made by illicit trafficking. The Convention also strengthens efforts against illicit production and manufacturing of narcotic and psychotropic drugs by enforcing strict monitoring of the chemicals often used in illicit production. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 27 Substance Use Related Problems: Apart from addiction, substance use can also lead to: Physical and mental health problems: In addition to general deterioration of health, substances affect particular organs and can cause mental health problems; Poor health care: Substance users often fail to access medical care and when they do, often fail to follow through with the medical regimen prescribed; Safety risks: Driving or operating machinery under the influence of substances increase risk of accidents causing harm, disability or death to the substance user as well as others; Risks related to unprotected sex: Loss of inhibition, drug induced changes in sexual behaviour and disregard for safety messages about condom use increase risk of sexually transmitted diseases including HIV and Hepatitis; Risks related to injecting use: Using injecting equipment which are not sterile increases transmission of HIV, Hepatitis as well as other blood borne infections. Among people who inject drugs, it was estimated that 13.1% of were HIV positive and about half (52%) were infected with Hepatitis C1 Poor work performance leading to decreased productivity at the work spot; Strained family relationships, emotional trauma, domestic violence and financial instability which affect the person using substances as well as others in the family; Increased risk of conflicts, violence and crime in the community; and Risks of suicide, overdose and death. 1 United Nations Office on Drugs and Crime, World Drug Report 2014, downloaded from http://www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf on 24th April 2015 A 28 CHAPTER 2 Substance Use Disorders (SUD) Two classification systems are used to describe the criteria based on which one can diagnose Substance Use Disorders (SUD). The World Health Organisation (WHO) develops the International Classification of Diseases (ICD) which carries of classification of all diseases both physical as well as mental health. The second system, Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA) deals with mental health problems only. Both the WHO and APA revise the diagnostic criteria and develop a newer version at specified intervals. Currently, the tenth version of ICD (ICD 10) released in 2007 and Fifth version of DSM (2013) is being used. Substance use related problems are labeled ‘Harmful Use’ and ‘Dependence Syndrome’ in the World Health Organisation’s International Classification of Diseases (ICD). Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) uses the term ‘Substance Use Disorders’ (SUD) – which can be at the mild, moderate or severe level. In addition to this, DSM 5 also describes problems related to: yy Substance intoxication; yy Substance withdrawal; and yy Substance-induced mental disorders. The earlier versions of DSM used the terms ‘substance abuse’ (using substances in a manner that is harmful) and ‘substance dependence’ (addiction to the substance). DSM 5 on the other hand lists 11 criteria to diagnose Substance Use Disorders. In the DSM 5 presence of 2 to 3 of the 11 criteria indicate mild level of SUD, 4 to 5 point to moderate level and six or more are considered as severe level of SUD. The 11 criteria are listed below: yy Needs more of the substance to experience the same level (Tolerance) yy Unable to reduce quantity or stop use in spite of trying yy Uses more quantity of substance or for a longer period of time than the person meant to yy Experiences craving to use the substance yy Has problems in relationships due to substance use but persists in using it A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 29 yy Spends a lot of time on substance use related activities yy Reduced involvement or time spent on social, recreational or work related activities yy Uses substances in spite of the impact on physical or mental health yy Unable to carry out responsibilities expected of the person at work, home etc. because of substance use yy Using substances in situations that may be physically dangerous yy Experiences withdrawal symptoms when substance use is stopped or reduced In common practice, the term, ‘addiction’ is used to refer to compulsive drug seeking and use despite harmful consequences. Some of the terms used in relation to addiction are: yy Tolerance: The decreased effect produced after the same amount of a psychoactive substance is repeatedly administered or when increasingly larger amounts are needed to get the same effect experienced earlier with a smaller amount of psychoactive substance. yy Cross tolerance: Repeated use of an substance leading to tolerance to another substance with similar pharmacological action. For example, person who uses alcohol regularly can develop tolerance to benzodiazepines or other depressant drugs without using these drugs regularly. yy Dependence: A person who uses psychoactive substances can develop physical or psychological dependence or both. yy Psychological dependence: The person feels comfortable only if the substance use is continued and experiences craving or strong desire to use to use the substance. yy Physical or Physiological dependence: A state of adaptation to a specific psychoactive substance characterised by withdrawal symptoms if use is discontinued. yy Withdrawal: Signs and symptoms that occur when a person stops using a psychoactive substance on which he or she is physically dependent. A 30 CHAPTER 2 Addiction As A Disease The disease concept of addiction can be discussed in terms of: yy Signs and symptoms yy Changes in structure or functioning of the body yy Etiological cause, environment and genetic vulnerability yy Pathogenesis or progression of the disease yy Chronic brain disease (different from diseases which can be cured) yy Relapsing nature of the disease. Each of these view points are discussed below in detail. Signs and Symptoms yy Diagnosis of a disease is made based on specific signs and symptoms. yy Signs: objective, physical indication of disease which can be noticed or measured by others (e.g. blood pressure, temperature, changes seen in brain PET scan). yy Symptoms: subjective, based on report by the person and cannot be seen or measured by others (e.g. stomach ache, tiredness, craving for drug). yy Addiction to alcohol or drugs is also a disease with specific signs and symptoms. yy DSM 5 criteria (listed earlier) also show how the SUD diagnosis is made based on specific indicators. Changes in structure and functioning yy Any alteration of the normal structure or function of any body part, organ, or system that can be identified by a characteristic set of symptoms and signs can be termed as a ‘disease’. yy By studying the functioning and structure of the brain using PET scans etc we know that addiction is a disease because PAS: act on the neurotransmitters in the brain change the way we think, feel and behave alters the functioning and structure of the brain. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 31 Techniques used to study brain activity and understand addiction MRI - Magnetic Resonance Imaging PET - Positron Emission Tomography SPECT - Single Positron Emission Computed Tomography Brain PET scans of a person using PAS is different from that of a non addicted person just like as a diseased heart looks different from a healthy heart. In PET scans, active neurons which metabolise more glucose are shown as red or yellow and the neurons that are not active are seen as blue or purple in colour. With people who use substances, PET brain scan shows lesser amount of red and yellow areas when compared to brain scans of those who do not use substances. This shows that neuron activity is lesser in those who use PAS. These changes continue to be seen even after the person stops using the substance. Etiological cause, environment and genetic vulnerability. yy Diseases are often discussed in terms of what causes the disease. For example, when sore throat is caused by bacteria, the bacteria is considered as the etiological agent or cause. With addiction, the psychoactive substance is the agent or the cause. yy The environment, lifestyle and the person’s genetic makeup are important factors in the development of a disease. This applies to SUD also. Environment: where the person lives (availability of drugs, attitudes towards drug use etc.) Lifestyle: how the persons functions (leisure activities, coping styles etc.) Genetic makeup: the genes one is born with can reduce or increase the chances of developing a disease. 40 to 60% of the person’s vulnerability to addiction is shown to be genetic in nature. The DNA sequence of any two individuals is 99.9 percent identical. The variation of just 0.1 percent contributes to so much variation amongst us – differences in the way we look as well as vulnerability to diseases such as heart disease, diabetes, addiction etc. A 32 CHAPTER 2 Pathogenesis or progression of the disease: yy Diseases can also be described in terms of how the disease develops and what it can lead to if left untreated (pathogenesis or progression of the disease). yy Though all people who use substances do not face problems, a significant number of people who use psychoactive substances develop Substance Use Disorders (SUDs). Four stages of progression can be described as follows: i) Experimental or recreational Use: All people who use PAS start off by just wanting to experiment or for recreation. They may be curious to experience how it feels to use a drug or may use it just to have fun or do it because others are using it or asking them to. This first stage happens usually in a social setting, small to moderate amounts may be consumed and it is not used frequently. Recreational use is the least severe level, wherein problems are rare but can happen (e.g. accidents). ii) Circumstantial or Occasional Use: At this stage, the person uses the substance for a specific reason or in certain situations. (e.g. relax, feel confident) iii) Intensified or Regular Use: The person starts using substances daily or almost daily in small to moderate doses to deal with ongoing problems (e.g. deal with anxiety) or maintain level of performance (e.g. work continuously). The person is likely to experience problems due to substance use. iv) Compulsive or Addictive Use: This is the most dangerous and severe stage wherein the person may continue using high doses daily or almost daily. Using drugs becomes more important than other things in life (family, work etc.) and continues using in spite of problems caused. yy It is important to recognise that substance use can cause harm at any stage. Chronic brain disease yy Chronic disease is one that is long lasting and that cannot be cured but can be managed. Hypertension and diabetes are also chronic diseases. With treatment, the person can lead a productive and fulfilling life but the condition cannot be changed. yy In this same way, once a person becomes addicted, it is not possible for the person to reduce or limit or control use of the substance. Giving up the use of that substance totally (abstinence) is the only solution possible. yy The popular statement of the 12 step groups ‘once an alcoholic always an alcoholic’ refers to this. It will not be possible for the person to return to controlled or social use of alcohol after he becomes addicted. However, he can learn to give up the use completely and lead a healthy, productive and satisfying life without substance use. Addiction is a disease that can be treated and the term ‘cure’ is not used. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 33 Relapsing nature of the disease yy Relapsing is part of all chronic diseases. People with SUD may give up drugs and yet after a period of time return to using substances again. This is referred to as relapse. yy Research shows that relapse rates for SUD is similar to that of other chronic diseases such as diabetes, hypertension and asthma. yy Sometimes stress or being in high risk situations can cause craving and the person in recovery may take the substance. If the person uses it just once or for a very short period it is called as a lapse. yy If the person fails to handle a lapse, the person can return to old pattern of substance use which is referred to as relapse. yy Relapses are preventable and it is also possible for a person to reestablish a drug free life after a relapse. Relapse is a process and does not take place suddenly. As relapse is a process, with the right effort one can prevent a relapse. Triggers can set off a craving to use substances. Triggers can be : external : people, places or things internal : thoughts or feelings External triggers are such as meeting people who use substances, being in places where drugs are used or even seeing drug use related paraphernalia such as needles or drugs. Internal triggers include thoughts about the drug induced effect, thinking about the good times related to drug use or even visualizing drug use. Feeling sad, happy or stressful can also act as triggers. Craving can lead to a lapse. Here, the person may use substances once or a few times. This is usually followed by a lot of guilt and a sense of failure. It is important to get help before the lapse escalates into a relapse wherein the person returns to regular or problematic drug use as earlier. People with SUD need to be able to recognize their triggers and make plans to address it so that it does not lead to a relapse. Triggers can set off a craving, craving can lead to a lapse and the lapse can escalate into a relapse. As relapse is a process, at every stage of the process, efforts can be made to prevent it. A 34 CHAPTER 2 Pharmacology: Pharmacology is the branch of science that studies the effects of psychoactive substances on the body and the brain. Psychoactive substances change: yy thoughts and judgment yy mood state (feelings) yy perceptions and yy behaviour Some of the effects of substances may be positive (enjoyable) making it desirable while some effects are negative (nausea, panic attack etc.) The effect experienced after using substances depends on: yy type of substance used yy quantity of intake yy route of administration or way it is taken yy person’s age yy length of time a person has used the substance regularly With alcohol, many other factors also influence the effect (e.g. sex, body weight etc.) Pharmacology examines: yy Absorption yy Distribution yy Metabolism and yy Elimination of substances from the body Absorption and distribution Psychoactive substances are used in different ways and the speed with which the substance‘s effect is felt depends on the route or mode of administration. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 35 Time for Route onset of Absorption and distribution route effect Smoking / Inhaling 7 – 10 sec. Enters from lungs directly into blood stream (e.g. cannabis, inhalants) Oral 20–30 min. Tablets and liquids (other than alcohol) enter the intestines and travel to the liver before entering the bloodstream* Alcohol is absorbed directly from the stomach (20%) and the rest (80%) from the small intestines. Alcohol then enters the blood stream and rapidly reaches all parts of the body. Injecting (parenteral) i) Intravenous 15 –30 sec. Injected directly to the blood stream ii) Intramuscular 3–5 min. Injected into muscles below the skin and fat tissues iii) Subcutaneous 3–5 min. Injected into just beneath the skin Snorting / sniffing 3–5 min. Absorbed into blood stream through the mucous membranes in the nasal passage (nose) (e.g. cocaine) Sublingual Few minutes Placed under tongue and absorbed into blood stream (LSD, buprenorphine) Bucal Few minutes Placed between teeth and gums and absorbed into the blood (oral tobacco use) Transdermal Few minutes Absorbed through a patch placed on the skin (nicotine patch) Topical Minutes to Applied on skin and absorbed slowly into the blood hours stream (creams, lotions, opium paste applied on lips) Rectal Few minutes Absorbed into blood stream through the rectum wall. Vaginal Few minutes Absorbed into blood stream through the vaginal to an hour wall * First pass effect: When the substance is taken in the form of tablets or liquids it passes through the liver where some of the active ingredients are broken down before entering the general circulation thereby reducing the effect. On the other hand, alcohol enters the blood stream directly through a process of diffusion and thereby misses the first pass effect. A 36 CHAPTER 2 Metabolism and elimination: Metabolism is a complex chemical process wherein the substances are broken down. The liver is largely responsible for metabolism and breaks down substances into metabolites which are then excreted. Elimination is primarily through urine or faeces and in smaller amounts through sweat, saliva, or breath. Different substances take different lengths of time to break down and be eliminated. Alcohol is metabolised by the liver at a steady rate irrespective of the quantity of alcohol used. The liver metabolises about one drink of alcohol in one hour. This is referred to as zero order transmission. Substances other than alcohol are broken down and eliminated at a rate that is dose dependent. Half of the amount used will be eliminated after the half life time period. This is referred to as first order transmission. The amount of time it takes to eliminate half of the original dose of a substance from the body is called the substance’s half-life. Different substances have different half life periods. A short half life means the drug effects will be felt for a short time and will leave the body quickly. Long half life means a long time will be needed to detoxify or fully clear the substance from the body. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 37 Brain and Substance Use The nervous system in the body consists of the: yy Central Nervous System (CNS) and yy Peripheral Nervous System (PNS). Central nervous system (CNS) The CNS consists of the brain and the spinal cord. There are billions of nerve cells in the CNS which connect different parts of the brain as well as the spinal cord. The brain is covered with a series of tightly pressed-together cells and forms a protective layer called Blood Brain Barrier (BBB). The BBB protects the brain by permitting the passage of only certain chemicals. Water soluble substances which are larger (e.g. aspirin, antibiotics etc) can’t get through the BBB. Fat soluble substances with a small molecular structure can easily pass through. Most psychoactive substances are fat soluble and can thereby enter and change the way the brain works. Antipsychotics and antidepressants used to treat mental disorders can cross the BBB but do not produce the same immediate pleasurable effects. So these are not generally abused or lead to addiction. All the other nerve cells in the body other than the brain and the spinal cord are considered as the Peripheral Nervous System (PNS) Peripheral nervous system (PNS) The PNS contains two major parts: yy The Somatic Nervous System controls voluntary muscles and influence movements in the body. Information from the environment as well as the skin, muscles and joints is sent to the CNS and instructions from the CNS are sent to the muscles and the body is able to respond appropriately. yy Autonomic Nervous System (ANS) controls the involuntary internal functions such as breathing, digestion, circulation etc. A 38 CHAPTER 2 The ANS has three divisions namely the - the sympathetic, parasympathetic and enteric. yy The Parasympathetic Nervous System is in charge of ‘rest and digestive functions’ and maintains stability in body functions. The Sympathetic and Parasympathetic Nervous Systems work in coordination and complement each other. When a person sees a danger (e.g. animal that is running towards him to attack), the Sympathetic Nervous System responds and the person is able to fight or run away. Once the danger has passed, the parasympathetic system takes over and calms him down and restores the balance in the body making the heart rate etc., come back to the normal range. yy The Enteric Nervous System (ENS) controls activities in the gastrointestinal tract. Though it is influenced by the CNS it can function independently too. A diagrammatic representation of the nervous system is presented here. It is important remember that all the parts are connected and work in coordination with each other and maintain homeostasis (balance and stability in the way the body works). Nervous system Central Nervous System Peripheral Nervous System Brain & Spinal cord Nerves in other parts apart from brain & spinal cord Autonomic Nervous Somatic Nervous System (involuntary) System (voluntary) Sympathetic Para Sympathetic Enteric Nervous Nervous System Nervous System System A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 39 Parts of the brain: Different parts of the brain carry out different tasks as shown in the picture below: Cerebral cortex Limbic system Brain stem Major parts of the brain and functions affected by substance use are presented in the form of a table below: Part of brain Functions Brain stem Heart rate, breathing, eating and sleeping. Cerebellum Skilled repetitive movements and maintain balance and posture Cerebral cortex Largest part of the brain. The folds cover most of the other brain structures. Involved in thinking, perceiving and producing and understanding language. Different lobes are involved in managing various functions. A 40 CHAPTER 2 Limbic system Regulating emotions, motivation. The reward circuit that includes the reward, memory and judgment centre is largely located in the limbic system. The reward centre consists of the Ventral Tegmental Area (VTA) located at the right end of the curve marked reward and the Nucleus Accumbens (at left end of the curve marked reward - see picture). Amygdala which is involved in feelings such as fear, anger, pleasure etc. and hippocampus (memory formation) are also involved The cerebral cortex can also be viewed in terms of four lobes with specific functions as shown below: Lobe Functions Temporal lobe Memory, emotions, hearing and language Frontal lobe Decision making, problem solving and planning Parietal Processing sensory information from the body Occipital Vision Reward circuit in the brain: yy All psychoactive substances activate the ‘reward circuit’ situated in the limbic region. yy The brain’s reward circuit, in the limbic system, is critical to the development of addiction. yy The limbic system links together a number of brain structures that control emotional memory and regulate the ability to feel pleasure. yy Our brains are wired to ensure that we repeat life-sustaining activities by associating those activities with pleasure or reward. Feeling pleasure motivates us to repeat behaviours such as eating, sex etc. yy The limbic system is activated when we perform these activities and also when we use PAS. yy Whenever this reward circuit is activated naturally, the brain notes that something important is happening that needs to be remembered and teaches us to do it again and again, without thinking about it. yy Because psychoactive substances stimulate the same circuit, people learn to A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 41 abuse substances in the same way. Due to the pleasurable effects people repeat use of substances and this later leads to addiction. yy Other parts of the brain that are affected by psychoactive substances include: Reticular Activating System (RAS): Part of the mid brain involved in sleep and wakefulness. Hypothalamus is involved in managing body temperature, thirst, hunger, sleep, moods, and release of many hormones in the body. Medula Oblongata is the lowest part of the brain stem that coordinates many life sustaining activities such as breathing, blood pressure and also transfers messages to the spinal cord. Understanding the brain from the evolution point of view yy Only the brain stem and cerebellum are present in reptiles and this is referred to as the ‘reptilian brain’ which had only basic functions. yy In the next stage of evolution, limbic system or the feeling part of the brain developed and was called as the mammalian part of the brain. yy The human brain which is more evolved and complex also has the cerebral cortex which is the thinking centre of the brain. This is sometimes referred to as the new brain to distinguish this from the old brain which consists of the more primitive structures (such as the brain stem and limbic region). Normally, the decision making centre of the brain in the cerebral cortex controls our actions. yy Psychoactive substances activate VTA and nucleus accumbens directly and override the cortex in controlling the behaviour. When addiction develops the inability to control substance use and continuing to use drugs in spite of the problems caused is due to the inability of the cerebral cortex to exercise control. A 42 CHAPTER 2 Brain communication The brain consists of billions of neurons or nerve cells. Neurons pass messages back and forth to different structures within the brain, the spinal column and the peripheral nervous system. yy Each neuron contains: Cell body with a nucleus; A tail called the axon; Axon tips at the end of the axon; and Many dendrites (branch-like projections from the cell body). Effect of psychoactive substances on neurotransmitters There are about 100 neurotransmitters in the body and each influence the functioning in a different way. Different psychoactive substances affect different neurotransmitters and thereby the effect on thoughts, feelings and behaviour also varies. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 43 PAS increase or decrease specific neurotransmitters and the neurons transmit abnormal messages. Neurotransmitters released due to substance use, interfere with routine normal messages between the neurons. Normal communication between the neurons is blocked and this affects the functioning. The following table presents the major effects of some neurotransmitters usually affected by PAS. Neurotransmitter Effect of neurotransmitters Acetylecholine Muscle contraction Regulates memory Dopamine Feelings of pleasure and other actions GABA (Gamma-aminobutyric acid) Produces sleep Reduces anxiety Forming memories Glutamate Learning and memory Norpeinephrine (also a hormone) In PNS : part of fight or flight response In brain : regulates blood pressure and calmness Serotonin Mood Basic survival functions such as sleeping and eating Sensory perception In spinal cord, inhibitory in pain pathways Almost all PAS affect the reward pathway involving the VTA and nucleus accumbens and increase the level of dopamine in the synapse increasing pleasurable feelings. The reward pathway is usually activated when a person engages in pleasurable activities that are essential for survival (e.g. food, procreation which are natural rewards etc). PAS acts on the same pathway and increase the pleasurable feelings. But the PAS effect differs in many ways: yy Intensity is 2 to 10 times more powerful; yy Effect is felt almost immediately; and yy Effect lasts longer than those produced by natural rewards. When the reward circuit is activated, pleasurable feelings are experienced. The brain remembers the action and repeats the activity without thinking. Using PAS excites the reward circuit in the brain increasing the pleasurable feelings. The brain remembers the pleasurable feeling caused by use of the substance and the person repeatedly uses it. This leads to increase in dopamine levels in the body. A 44 CHAPTER 2 Over a period of time, the body recognises the high level of dopamine and responds by reducing the amount of dopamine produced and reducing the number of receptors that can be activated by dopamine. This reduces the level of pleasure experienced and the person takes a larger amount of PAS to feel good. The persons thus develops tolerance (the need for more drugs to get the same effect). The person starts giving more importance to PAS than other things in life such as work or family. The person ability to control use is affected and continues to crave or need PAS even if it is affecting him / her. PAS interfere with the way neurons communicate. i) Increase level of neurotransmitters: PAS can increase amount of neurotransmitters released or block some neurotransmitters and thereby enhancing the effect of particular neurotransmitters. ii) Mimic: Marijuana and heroin can activate the neurons because the structure is similar to the molecules naturally produced in the body. Marijuana works like ‘anandamide’ which is naturally formed in the body. Opioids resemble the body’s natural endorphins and enkephalins that produce pleasurable feelings and block pain. iii) Blocking the re-uptake of neurotransmitters: Cocaine blocks the transporter and dopamine remains in the synapse for longer periods. As it continues to be present in the synapse it repeatedly binds with the receptors increasing the neuron activity. In normal circumstances, the neurotransmitters are taken back into the sending neuron and the signal stops. But cocaine prevents the re-uptake of the neurotransmitter which increases the intensity and duration of the effect. iv) Interfere in a number of ways: Alcohol affects many neurotransmitters. Alcohol causes sedation, slows down reflexes and also changes the mood of person. It binds to GABA receptors and reduces the neuron activity, giving a sedative effect. In addition, it blocks the receptors that glutamate usually binds with. This reduces the glutamate’s excitatory effect adding to the slowing down effect. Alcohol also binds to the acetylcholine receptors which inhibits or reduces the neuron’s activity. As with other PAS, alcohol also affects the dopamine level in the body. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 45 Schedule of Controlled Substances Most countries classify medications to indicate level of addiction potential. The following table describes the Schedule of Drugs adopted by United States of America, based on the likelihood of causing dependence. Please note that the drug schedule can vary from country to country Schedule I No medical use Heroin, LSD, ecstasy, High potential for abuse peyote, methaqualone Schedule II High potential for abuse Hydromorphone May lead to severe physical / (Dilaudid), psychological dependence Methodone, Meperidine Can be prescribed by physician with (Demerol), severe restrictions Oxycodene (Oxy Contin), Amphetamine (Dexedrine), Methamphetamine and Methyl phenidate (Ritalin) Schedule III Less potential for abuse than Buprenorphine Schedule II. Ketamine May lead to moderate to low Anabolic steroids physical dependence or high psychological dependence Need to be prescribed by a physician Schedule IV Lower potential for abuse compared Alprazolam (Xanax) to Schedule III Diazepam (Valium) Need to be prescribed by a physician Lorazepam (Ativan) Schedule V Low potential for abuse compared Cough relief preparations to Schedule IV containing codeine Need to be prescribed by a physician A 46 CHAPTER 2 Classification of Psychoactive Substances Psychoactive substances can be categorised based on the effects. S.No. Drug Category Main effects 1. Opioids Pain relieving with some sedation: Opium based drugs or those which produce opium like effects 2. Depressants Sleep inducing, anxiety relieving drugs that affect coordination by reducing the activity of the CNS. e.g. Alcohol and sleeping pills 3. Stimulants Increased alertness and reduced appetite and sleep caused by increased activity of the CNS e.g. Nicotine, cocaine 4. Hallucinogens Distort or change perceptions dramatically e.g. LSD 5. Other categories a. Cannabis Mood elation followed by relaxation, derived from cannabis plant b. Inhalants Excitement followed by dullness, slurring of speech, caused by sniffing gasoline, sprays etc c. Dissociative Anaesthetic effects, feeling weightless and poor anaesthetics coordination d. Khat Drug from Miraa plant leaves which increases alertness and excitement 1. Opioids Pain relieving drugs with a high potential for addiction. Sometimes referred to as narcotic drugs. Can be studied under three broad categories. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 47 Natural (from plant Semi – Synthetic Synthetic source – Poppy Plant) (manufactured with (manufactured in the the combination of laboratory) natural and synthetic substances) Meperidine Pentazocine Methadone Buprenorphine LAAM Opium Propoxyphene Oxycodone Heroin (Di-acetyl Hydrocodone Morphine Codeine morphine) Hydromorphone 1.1 Opioids of natural origin: Opium: extracted from the poppy plant (Papaver Somniferum). Opium is smoked or brewed and drunk. Morphine: Used medically to handle severe pain. Morphine is usually injected but it can be administered orally in a tablet form Codeine: Used in cough suppressant medications and in anti- diarrhoeal preparations. Codeine preparations are available as syrups and tablets. 1.2 Semi-synthetic drug: Heroin: Heroin has strong pleasure inducing effects. It can be snorted, smoked or injected. Heroin is sometimes ‘chased’ wherein heroin is placed on a spoon or silver foil, heated from beneath and the smoke is then inhaled through a pipe or straw. 1.3 Synthetic drugs: Meperidine and Pentazocine in form of tablets or injections is used medically to relieve moderate to severe pain. Methadone has a long duration of action and is used in maintenance programs. Persons dependent on heroin are given oral methadone once a day. It prevents withdrawal A 48 CHAPTER 2 symptoms and helps them lead a productive lifestyle with better employment, health status, reduce deviant behaviour such as crimes that they may engage in to pay for drugs and reduce risks related to injecting practices. Buprenorphine (trade names such as Subutex, Suboxone) and levo-alphaacetylmethadol (LAAM) are used in substitution programs to help people dependent on heroin. Oxycodone is used medically for pain relief in the form of slow release tablets or patches. However, it has been widely abused in the form of injections. Hydrocodone (trade name - Vicodin) and hydromorphone (trade name -Dilaudid) are other drugs commonly abused. Pharmacological reactions: Absorption: Morphine and other morphine like drugs are absorbed well when injected or smoked and poorly absorbed when administered orally. yy If taken orally it is absorbed from the gastrointestinal tract and has to pass through the liver where it is rapidly broken down. yy Moreover when injected, it by- passes the liver an the effects are felt more rapidly and intensity of effect is also higher when compared to the oral route. Therefore drug dependents prefer to inject or smoke the drug rather than the oral route. Distribution: Not absorbed evenly by all the parts of the body. yy Only small amounts reach the brain but even minute amounts are sufficient to cause a effect. yy In pregnant women, small quantities of the drug cross the placental barrier and fetal dependence can develop. yy When heroin reaches the brain it acts on the limbic system, releases dopamine and produces intense feelings of pleasure. It acts on the spinal cord and blocks pain messages from reaching the brain which accounts for the pain relieving effects. Heroin also acts on the brain stem leading to reduced heart and respiration. It is due to this that heroin overdose can lead to death. Metabolism: Apart from methadone and buprenorphine, other narcotic drugs are rapidly metabolised by the liver. Excretion: Excretion is largely through urine. A small amount passes through the lungs and bile. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 49 OPIOIDS Name of drugs Opium, morphine, codeine, heroin and other synthetic opioids such as methadone, buprenorphine etc.. Short-term effects A surge of pleasurable feelings Reduction in sensation of pain Drowsiness, sedation, decreased physical activity Mental clouding, inability to concentrate Reduced heart rate, blood pressure and breathing becomes shallow and slow Pin point (constricted) pupils, droopy eye-lids, reduced sharpness of vision Reduced appetite, constipation Itchy skin or rash Nausea, vomiting in those who are using it for the first few times Long-term effects Mood instability Reduced libido (sexual interest) Constipation Constriction of pupils (which affects night vision) Respiratory problems due to smoking or inhaling the drug Among women, menstrual irregularity and fetal abnormality if used during pregnancy. Tolerance and dependence Tolerance develops needing increase in drug dosage. After chronic use, no amount of the drug produces the desired intensity of effects. User develops physical and psychological dependence and continues to use the drug to avoid withdrawals. Cross tolerance can occur with other drugs of same category. A 50 CHAPTER 2 Withdrawal symptoms Restlessness, irritability, anxiety, depression Watery discharge from eyes and nose (lacrimation and rhinorrhea) Sweating, yawning or sneezing, gooseflesh (pilo-erection), body chills alternating with flushing and excessive sweating (which gave rise to the term ‘cold turkey’) Diarrhoea, vomiting, stomach cramps and body pain Increase in heart rate and blood pressure Major withdrawal symptoms peak between 48 and 72 hours after the last dose and typically subside after about a week. Overdose Slow and shallow irregular breathing, sweaty skin, marked decrease in blood pressure, cyanosis (body becomes cold and bluish), convulsions, coma and possible death. Other risks Complications due to injecting use Injecting substances that do not readily dissolve can block blood vessels that lead to the lungs, liver, kidneys, or brain. This can cause infection or even death of small patches of cells in vital organs. Additives in street heroin may also cause problems. 2. Depressants Depressants are drugs which depress or slow down the functions of the central nervous system. The drugs which come under this category include: Alcohol is one of the oldest and most commonly abused drug. Alcohol is legally available in most countries. Alcohol is discussed separately in this section. Barbiturates: Barbiturates are used for sedation, induce anaesthesia or prevent seizures. Amobarbital, phenobarbital and pentobarbital are some of the common barbiturates used. The high potential for addiction and availability of safer alternatives has led to decline of barbiturate use in recent years. Phenobarbital continues to be used to handle seizures. These can be administered orally as well as injected. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 51 Benzodiazepines or minor tranquilizers (anxiolytics): These are the most widely prescribed drugs for management of anxiety. Diazepam, lorazepam, chlordiazepoxide are some commonly used drugs in this category. These can be administered as tablets or injections. Flunitrazepam (Rohypnol) is a benzodiazepine which is known as the date rape drug. Gamma Hydroxy Butrate (GHB) is also a depressant drug with similar effects. Other sedative-hypnotics such as meprobamate, methaqualone etc. 2.1 Alcohol Alcoholic beverages are of different types such as beer, wine, whisky, rum, brandy etc. All alcoholic beverages contain the same mood-changing chemical ‘ethyl alcohol’ (C2 H5 OH) though in varying percentages. Alcohol is a product of fermentation from agricultural products such as cereals, fruits or molasses which is distilled to make beverages with a higher content of ethyl alcohol. Name of the beverage Percentage of ethyl alcohol Distilled spirits such as brandy, whisky, rum etc. 40 to 55% Wine 10 to 20% Beer 6 to 8% Ethyl alcohol (or ethanol) is the only type of alcohol that can be consumed without immediate harm. When alcoholic beverages are produced illicitly, poisonous methyl alcohol (methanol) can be formed. It can cause nausea, vomiting, unconsciousness, loss of eye sight and death. Pharmacological reactions: Absorption and distribution: Alcohol is absorbed well when taken orally. Unlike other food, alcohol does not need digestion. It is rapidly absorbed into the blood stream from the stomach (20%) and small intestine (80%). From here, it is carried to almost all the organs including the brain. yy The level of alcohol in a person’s blood stream is referred to as Blood Alcohol Content (BAC) or Blood Alcohol Level (BAL). This is an estimation of the individual’s level of intoxication. Even if two individuals drink the same quantity of alcohol the BAC level may vary. A 52 CHAPTER 2 yy Some of the factors that influence BAC are: a) Type of alcoholic beverage: If a person consumes beverage with a higher alcohol content (e.g. Brandy) the BAC will be higher than if he drank an equal quantity of a beverage with lower alcohol content (e.g. Beer). b) Higher the quantity of alcohol consumed; higher the BAC. c) Speed of drinking: the more rapidly alcohol is consumed, higher the BAC d) Body weight: greater the weight of a person, lower will be his BAC. e) Presence of food in the stomach: slows down the rate of alcohol absorption f ) Sex: If a man and woman of equal weight size drink the same amount of alcohol BAC will be higher among women when compared to man, as women have more body fat and lesser water content in their body. The level of liver enzymes that breakdown down alcohol is also lesser in women. Once it reaches the brain, alcohol affects various parts of the brain including the: yy Cerebral cortex and thereby affects thought processes and lowers inhibition yy Limbic system that affects memory and emotions yy Cerebellum and thus affects fine movements and leads to poor coordination yy Hypothalamus which may lead to sexual arousal. As BAC increases it may increase sexual desire but sexual performance declines yy Pituitary gland causing a drop in anti-diuretic hormone and as a result the kidneys do not absorb as much water as usual leading to more urine output. yy RAS (Reticular Activating System) that makes one sleepy. yy Medulla oblongata which reduces the heart rate, and breathing. With higher amounts this can lead to unconsciousness and death. Alcohol passes through the placental barrier easily and can adversely affect the development of the baby referred to as ‘Fetal Alcohol Syndrome’ (FAS). A ‘safe’ level of alcohol ingestion during pregnancy has not been established. Brain damages that can occur with FAS can result in lifelong problems with memory, attention and problem solving ability in the child. Metabolism: The liver plays a major role in the breakdown or oxidation of alcohol at the rate of about 1 standard drink per hour (1 drink = 30ml of distilled spirits; 650 ml of beer generally equals 2 units). The effect peeks within 20 to 30 minutes and subsides in about an hour. The enzyme alcohol aldehydrogenase (ADH) first changes alcohol into acetaldehyde which in turn is converted to acetic acid. This is later transformed into carbon dioxide, water and carbohydrates. A PHARMACOLOGY OF PSYCHOACTIVE SUBSTANCES 53 Excretion: The liver metabolises about 90% of alcohol. About 2 - 10% is excreted through the breath and urine. A small amount (0.5%) is excreted through sweat etc. Short-term effects of alcohol Lowered inhibition leading to feeling relaxed, a sense of well being or sometimes hostile or depressed Increased reaction time, poor motor coordination leading to accidents Poor judgment, decreased insight, memory impairment Slurred speech Blurred vision Drowsiness Long-term effects of alcohol Irritation of the lining of esophagus (food pipe) and stomach Gastro intestinal problems include gastritis, peptic ulcer, gastro intestinal haemorrhage Increased risk for cancer of mouth, throat and esophagus, stomach and liver Fatty liver, hepatitis, cirrhosis (destruction of liver cells) Pancreatic effects include pancreatitis (inflammation of the pancreas), diabetes. Cardiovascular effects include damage to the heart muscles – cardiomyopathy (deterioration of heart muscles), change in heart rhythm, increased risk of high blood pressure Poor sleep pattern Neuritis Suppression of blood cell production, increased likelihood of anaemia, structural abnormalities in RBCs (red blood cells), reduced WBCs (white blood cells) and low platelet count Immune system dysfunction, malnutrition Muscle weakness and wasting Kidney problems, increased urine output and gout Sexual dysfunction both in male and female: Impotence in male, testicular and ovarian atrophy, menstrual irregularity in females, fetal alcohol syndrome if taken during pregnancy A 54 CHAPTER 2 Depression or other mental health problems; suicide attempts Paranoia (suspicious) feelings are also common. Brain damage due to Wernicke encephalopathy and Korsakoff’s psychosis caused by thiamine (vitamin B1) deficien

ICCE Study Guide for Addiction Professionals (PDF)

Document Details

Tags

Related

Summary

Full Transcript

Upgrade to continue