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Drugs, Brains, and Behavior The Science of Addiction

Drugs, Brains, and Behavior The Science of Addiction 43
Drugs, Brains, and Behavior The Science of Addiction Image: White Matter Fibers, Parietal Areas • www.humanconnectomeproject.orgThis publication is in the public domain and may be used or reproduced in its entirety without permission from NIDA. Citation of the source is appreciated. NIH Pub No. 145605 Printed April 2007 Revised February 2008, August 2010, July 2014CONTENTS Preface............................................................................................................................................................................ 1 Introduction.................................................................................................................................................................... 3 I. Drug Abuse and Addiction ........................................................................................................................................... 5 II. Preventing Drug Abuse: The Best Strategy................................................................................................................. 11 III. Drugs and the Brain................................................................................................................................................ 15 IV. Addiction and Health................................................................................................................................................ 21 V. Treatment and Recovery ............................................................................................................................................ 25 VI. Advancing Addiction Science and Practical Solutions............................................................................................... 29 References .................................................................................................................................................................... 31 I“Drug addiction is a brain disease that can be treated.” Nora D. Volkow, M.D. Director National Institute on Drug AbusePREFACE How Science Has Revolutionized the Understanding of Drug Addiction or much of the past century, scientists studying drug abuse labored in the shadows of powerful myths and misconceptions about the nature of addiction. When scientists began to study addictive behavior in the 1930s, people addicted to drugs were thought to be Fmorally flawed and lacking in willpower. Those views shaped society’s responses to drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punishment rather than prevention and treatment. Today, thanks to science, our views and our responses to addiction and other substance use disorders have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of compulsive drug use, enabling us to respond effectively to the problem. As a result of scientific research, we know that addiction is a disease that affects both the brain and behavior. We have identified many of the biological and environmental factors and are beginning to search for the genetic variations that contribute to the development and progression of the disease. Scientists use this knowledge to develop effective prevention and treatment approaches that reduce the toll drug abuse takes on individuals, families, and communities. Despite these advances, many people today do not understand why people become addicted to drugs or how drugs change the brain to foster compulsive drug use. This booklet aims to fill that knowledge gap by providing scientific information about the disease of drug addiction, including the many harmful consequences of drug abuse and the basic approaches that have been developed to prevent and treat substance use disorders. At the National Institute on Drug Abuse (NIDA), we believe that increased understanding of the basics of addiction will empower people to make informed choices in their own lives, adopt sciencebased policies and programs that reduce drug abuse and addiction in their communities, and support scientific research that improves the Nation’s wellbeing. Nora D. Volkow, M.D. Director 1 National Institute on Drug AbuseMEDICAL SOCIAL ECONOMIC CRIMINAL JUSTICE The consequences of drug abuse are vast and varied and affect people of all ages.INTRODUCTION Why study drug abuse and addiction buse of and addiction to alcohol, nicotine, and illicit and prescription drugs cost Americans more than 700 billion a year in 1,2,3 increased health care costs, crime, and lost productivity. Every year, illicit and prescription drugs and alcohol contribute to the 4,5 A death of more than 90,000 Americans, while tobacco is linked to an estimated 480,000 deaths per year. (Hereafter, unless otherwise specified, drugs refers to all of these substances.) People of all ages suffer the harmful consequences of drug abuse and addiction. z Babies exposed to drugs in the womb may be born premature and underweight. This exposure can slow the child’s intellectual 6 development and affect behavior later in life. z Adolescents who abuse drugs often act out, do poorly academically, and drop out of school. They are at risk for unplanned pregnancies, violence, and infectious diseases. z Adults who abuse drugs often have problems thinking clearly, remembering, and paying attention. They often develop poor social behaviors as a result of their drug abuse, and their work performance and personal relationships suffer. z Parents’ drug abuse often means chaotic, stressfilled homes, as well as child abuse and neglect. Such conditions harm the well being and development of children in the home and may set the stage for drug abuse in the next generation. How does science provide solutions for drug abuse and addiction Scientists study the effects that drugs have on the brain and on people’s behavior. They use this information to develop programs for preventing drug abuse and for helping people recover from addiction. Further research helps transfer these ideas into practice in our communities. 3I. DRUG ABUSE AND ADDICTION What is drug addiction DECREASED BRAIN METABOLISM IN PERSON WHO ABUSES DRUGS ddiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug A seeking and use, despite harmful consequences.† It is considered a brain disease because drugs change the brain—they change its structure and how it works. These brain changes can be longlasting, and can lead to the harmful behaviors seen in people who abuse drugs. Healthy Brain Diseased Brain/Cocaine Abuser DECREASED HEART METABOLISM IN HEART DISEASE PATIENT Addiction is a lot like other diseases, such as heart disease. Both disrupt the normal, healthy functioning of the underlying organ, have serious harmful consequences, and are preventable and treatable, but if left untreated, can last a lifetime. Healthy Heart Diseased Heart Source: From the laboratories of Drs. N. Volkow and H. Schelbert †The term addiction as used in this booklet may be regarded as equivalent to a severe substance use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5, 2013). 5 LOW HIGH6 Why do people take drugs In general, people begin taking drugs for a variety of reasons: z To feel good. Most abused drugs produce intense feelings of pleasure. This initial sensation of euphoria is followed by other effects, which differ with the type of drug used. For example, with stimulants such as cocaine, the “high” is followed by feelings of power, selfconfidence, and increased energy. In contrast, the euphoria caused by opiates such as heroin is followed by feelings of relaxation and satisfaction. z To feel better. Some people who suffer from social anxiety, stressrelated disorders, and depression begin abusing drugs in an attempt to lessen feelings of distress. Stress can play a major role in beginning drug use, continuing drug abuse, or relapse in patients recovering from addiction. z To do better. Some people feel pressure to chemically enhance or improve their cognitive or athletic performance, which can play a role in initial experimentation and continued abuse of drugs such as prescription stimulants or anabolic/androgenic steroids. z Curiosity and “because others are doing it.” In this respect adolescents are particularly vulnerable because of the strong influence of peer pressure. Teens are more likely than adults to engage in risky or daring behaviors to impress their friends and express their independence from parental and social rules. Courtesy: Vivian FelsenNo single factor determines whether a person will become addicted to drugs. 7 addiction show physical changes in areas of the brain that are If taking drugs makes people feel good or critical to judgment, decision making, learning and memory, better, what’s the problem 7 and behavior control. Scientists believe that these changes alter When they first use a drug, people may perceive what seem to the way the brain works and may help explain the compulsive be positive effects; they also may believe that they can control and destructive behaviors of addiction. their use. However, drugs can quickly take over a person’s life. Why do some people become addicted to Over time, if drug use continues, other pleasurable activities drugs, while others do not become less pleasurable, and taking the drug becomes neces sary for the user just to feel “normal.” They may then compul As with any other disease, vulnerability to addiction differs from sively seek and take drugs even though it causes tremendous person to person, and no single factor determines whether a problems for themselves and their loved ones. Some people may person will become addicted to drugs. In general, the more risk start to feel the need to take higher or more frequent doses, factors a person has, the greater the chance that taking drugs even in the early stages of their drug use. These are the telltale signs of an addiction. RISK AND PROTECTIVE FACTORS FOR DRUG ABUSE AND ADDICTION Even relatively moderate drug use poses dangers. Consider how Risk Factors Protective Factors a social drinker can become intoxicated, get behind the wheel Aggressive behavior Good selfcontrol of a car, and quickly turn a pleasurable activity into a tragedy in childhood that affects many lives. Lack of parental Parental monitoring supervision and support Is continued drug abuse a voluntary Poor social skills Positive relationships behavior Drug experimentation Academic competence The initial decision to take drugs is typically voluntary. However, Availability of drugs School antidrug at school policies with continued use, a person’s ability to exert selfcontrol can Community poverty Neighborhood pride become seriously impaired; this impairment in selfcontrol is the hallmark of addiction. Brain imaging studies of people withChildren’s earliest interactions within the family are crucial to their healthy development and 8 risk for drug abuse. will lead to abuse and addiction. Protective factors, on RISK FACTORS the other hand, reduce a person’s risk of developing addiction. Risk and protective factors may be either envi ronmental (such as conditions at home, at school, and in the neighborhood) or biological (for instance, a person’s genes, their stage of development, and even their gender n n Genetics Chaotic home and abuse n n Gender Parent’s use and attitudes or ethnicity). n n Mental disorders Peer influences n Community attitudes n Early use n Route of administration n Poor school achievement n Availability n Effect of drug itself n Cost What environmental factors increase the risk of addiction z Home and Family. The influence of the home envi ronment, especially during childhood, is a very impor tant factor. Parents or older family members who abuse alcohol or drugs, or who engage in criminal behavior, can increase children’s risks of developing their own drug problems. What biological factors increase the risk of addiction z Peer and School. Friends and acquaintances can have Scientists estimate that genetic factors account for between 40 and 60 percent of a an increasingly strong influence during adolescence. person’s vulnerability to addiction; this includes the effects of environmental factors Drugusing peers can sway even those without risk fac on the function and expression of a person’s genes. A person’s stage of development tors to try drugs for the first time. Academic failure or and other medical conditions they may have are also factors. Adolescents and people poor social skills can put a child at further risk for with mental disorders are at greater risk of drug abuse and addiction than the general using or becoming addicted to drugs. population.9 z Method of Administration. Smoking a drug or injecting it into What other factors increase the risk of 9,10 a vein increases its addictive potential. Both smoked and injected addiction drugs enter the brain within seconds, producing a powerful rush z Early Use. Although taking drugs at any age can lead to addiction, of pleasure. However, this intense “high” can fade within a few research shows that the earlier a person begins to use drugs, the minutes, taking the abuser down to lower, more normal levels. 8 more likely he or she is to develop serious problems. This may Scientists believe this starkly felt contrast drives some people to reflect the harmful effect that drugs can have on the developing repeated drug taking in an attempt to recapture the fleeting brain; it also may result from a mix of early social and biological pleasurable state. vulnerability factors, including unstable family relationships, exposure to physical or sexual abuse, genetic susceptibility, or mental illness. Still, the fact remains that early use is a strong indicator of problems ahead, including addiction.Addiction is a developmental disease— 10 it typically begins in childhood or adolescence. The brain continues to develop into adulthood ImAGeS OF bRAIN Dev eLOPmeNT IN HeALTHy CHILDReN AND TeeNS (AGeS 5–20) and undergoes dramatic changes during adolescence. AGeS 5 20 One of the brain areas still maturing during adolescence is the prefrontal cortex—the part of the brain that enables us to assess situations, make sound decisions, and keep our emotions and SIDE VIEW 11 desires under control. The fact that this critical part of an adolescent’s brain is still a work in progress puts them at increased risk for making poor decisions (such as trying drugs or continuing to take them). Also, introducing drugs during this period of development may cause brain changes that have profound and longlasting consequences. Prefrontal Cortex TOP VIEW Blue represents maturing of brain areas. Source: PNAS 101:8174–8179, 2004.II. PREVENTING DRUG ABUSE: THE BEST STRATEGY Why is adolescence a critical time for preventing drug addiction s noted previously, early use of drugs increases a person’s chances of developing addiction. Remember, drugs change brains—and this can lead to addiction and other serious problems. So, preventing early use of drugs or alcohol may go a long way in reducing A these risks. If we can prevent young people from experimenting with drugs, we can prevent drug addiction. Risk of drug abuse increases greatly during times of transition. For an adult, a divorce or loss of a job may lead to drug abuse; for a teenag 12 er, risky times include moving or changing schools. In early adolescence, when children advance from elementary through middle school, they face new and challenging social and academic situations. Often during this period, children are exposed to abusable substances such as cigarettes and alcohol for the first time. When they enter high school, teens may encounter greater availability of drugs, drug use by older teens, and social activities where drugs are used. At the same time, many behaviors that are a normal aspect of their development, such as the desire to try new things or take greater risks, may increase teen tendencies to experiment with drugs. Some teens may give in to the urging of drugusing friends to share the experience with them. Others may think that taking drugs (such as steroids) will improve their appearance or their athletic performance or that abusing substances such as alcohol or MDMA (ecstasy or “Molly”) will ease their anxiety in social situations. A growing number of teens are abusing ® prescription ADHD stimulants such as Adderall to help them study or lose weight. Teens’ stilldeveloping judgment and decisionmaking skills may limit their ability to accurately assess the risks of all of these forms of drug use. Using abusable substances at this age can disrupt brain function in areas critical to motivation, memory, learning, judgment, and behavior 7 control. So, it is not surprising that teens who use alcohol and other drugs often have family and social problems, poor academic perform ance, healthrelated problems (including mental health), and involvement with the juvenile justice system. 11National drug use surveys indicate some children are 12 already using drugs by age 12 or 13. Can researchbased programs The Drug Danger Zone: Most Illicit Drug Use Starts in the Teenage Years prevent drug addiction in 12 11.2 youth 10.4 Yes. The term “researchbased” means that 10 these programs have been rationally designed 1617 based on current scientific evidence, rigor 8.0 1820 8 ously tested, and shown to produce positive results. Scientists have developed a broad range of programs that positively alter the 6 1415 balance between risk and protective factors 4.5 for drug abuse in families, schools, and communities. Studies have shown that 4 0.3 researchbased programs, such as those 2.9 described in NIDA’s Preventing Drug Use 2125 2 among Children and Adolescents: A 26 or ResearchBased Guide for Parents, Older 1213 Educators, and Community Leaders, can 0 Age Group significantly reduce early use of tobacco, Source: SAMHSA, Center for Behavioral Health Statistics and Quality, 13 alcohol, and illicit drugs. National Survey on Drug Use and Health, 2011 and 2012. Percentage of PastYear Initiates among Those Who Have Never Used13 How do researchbased prevention programs work These prevention programs work to boost protective factors and eliminate or reduce risk factors for drug use. The programs are designed for various ages and can be designed for individual or group settings, such as the school and home. There are three types of programs: z Universal programs address risk and protective factors common to all children in a given setting, such as a school or community. z Selective programs target groups of children and teens who have factors that put them at increased risk of drug use. z Indicated programs are designed for youth who have already begun using drugs. Are all prevention programs effective in reducing drug abuse When researchbased substance use prevention programs are properly implemented by schools and communities, use of alco hol, tobacco, and illegal drugs is reduced. Such programs help teachers, parents, and health care professionals shape youths’ perceptions about the risks of substance use. While many social and cultural factors affect drug use trends, when young people 14 perceive drug use as harmful, they reduce their level of use.n n Prevention is the best strategy 14 DRUG USe DeCReASeS WHeN DRUGS ARe PeRCeIv eD AS HARmFUL, AND v ICe v eRSA 12THGRADe STUDeNTS RePORTING PASTmONTH 12THGRADe STUDeNTS RePORTING PASTmONTH mARIJUANA USe AND PeRCePTION OF HARm, CIGAReTTe USe AND PeRCePTION OF HARm, 1975 TO 2013 1975 TO 2013 80 80 70 Perceived Risk of Harm n 70 PastYear Use 60 Cigarette smoking among teens is at its 60 50 lowest point since Perceived Risk of Harm n NIDA began tracking 1/2 a pack+/day 40 50 it in 1975. But marijuana use has 30 increased over the 40 past several years as 20 perception of its 30 risks has declined. 10 0 20 Year Year Source: 2013 Monitoring the Future survey. University of Michigan, with funding from the National Institute on Drug Abuse. For more information on prevention, see NIDA’s most recent edition of Preventing Drug Use among Children and Adolescents: A Research Based Guide for Parents, Educators, and Community Leaders at Percent PercentIII. DRUGS AND THE BRAIN Introducing the Human brain he human brain is the most complex organ in the body. This threepound mass of gray and white matter sits at the center of all human activity—you need it to drive a car, to enjoy a meal, to breathe, to create an artistic masterpiece, and to enjoy everyday activi T ties. In brief, the brain regulates your body’s basic functions; enables you to interpret and respond to everything you experience; and shapes your thoughts, emotions, and behavior. The brain is made up of many parts that all work together as a team. Different parts of the brain are responsible for coordinating and per forming specific functions. Drugs can alter important brain areas that are necessary for lifesustaining functions and can drive the compul sive drug abuse that marks addiction. Brain areas affected by drug abuse include: z The brain stem, which controls basic functions critical to life, such as heart rate, breathing, and sleeping. z The cerebral cortex, which is divided into areas that control specific functions. Different areas process information from our senses, enabling us to see, feel, hear, and taste. The front part of the cortex, the frontal cortex or forebrain, is the thinking center of the brain; it powers our ability to think, plan, solve problems, and make decisions. z The limbic system, which contains the brain’s reward circuit. It links together a number of brain structures that control and regulate our ability to feel pleasure. Feeling pleasure motivates us to repeat behaviors that are critical to our existence. The limbic system is activated by healthy, lifesustaining activities such as eating and socializing— but it is also activated by drugs of abuse. In addition, the limbic system is responsible for our perception of other emotions, both positive and negative, which explains the moodaltering properties of many drugs. 1516 z Neurotransmitters—The Brain’s Chemical Messengers How do the parts of the brain communicate The messages are typically carried between neurons by chemicals The brain is a communications center consisting of billions of called neurotransmitters. neurons, or nerve cells. Networks of neurons pass messages back z Receptors—The Brain’s Chemical Receivers and forth among different structures within the brain, the spinal cord, The neurotransmitter attaches to a specialized site on the receiving and nerves in the rest of the body (the peripheral nervous system). neuron called a receptor. A neurotransmitter and its receptor oper These nerve networks coordinate and regulate everything we feel, ate like a “key and lock,” an exquisitely specific mechanism that ensures that each receptor will forward the appropriate message think, and do. only after interacting with the right kind of neurotransmitter. z Neuron to Neuron z Transporters—The Brain’s Chemical Recyclers Each nerve cell in the brain sends and receives messages in the Located on the neuron that releases the neurotransmitter, trans form of electrical and chemical signals. Once a cell receives and porters recycle these neurotransmitters (that is, bring them back processes a message, it sends it on to other neurons. into the neuron that released them), thereby shutting off the signal between neurons. To send a message, a brain Here’s how people communicate. Here’s how brain cells communicate. cell (neuron) releases a chemical (neurotransmitter) into the space (synapse) between it and the next cell. The neurotransmitter crosses the synapse and attaches to proteins (recep tors) on the receiving brain cell. This causes changes in the receiving cell—the Transmitter Receptor Neurotransmitter Receptor message is delivered. Concept courtesy: B.K. MadrasMost drugs of abuse target the brain’s reward 17 system by flooding it with dopamine. How do drugs work in the brain Drugs are chemicals that affect the brain by tapping into its communication system and interfering with the way neurons normally send, receive, and process information. Some drugs, such as marijuana and heroin, can activate neurons because their chemical structure mimics that of a natural neurotransmitter. This similarity in structure “fools” receptors and allows the drugs to attach onto and activate the neurons. Although these drugs mimic the brain’s own chemicals, they don’t activate neurons in the same way as a natural neurotransmitter, and they lead to abnormal messages being transmitted through the network. Other drugs, such as amphetamine or cocaine, can cause the neurons to release abnormally large amounts of natural neuro transmitters or prevent the normal recycling of these brain chemicals. This disruption produces a greatly amplified message, ultimately disrupting communication channels. How do drugs work in the brain to produce pleasure Most drugs of abuse directly or indirectly target the brain’s reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that regulate movement, emotion, motivation, and feelings of pleasure. When activated at normal levels, this system rewards our natural behaviors. Overstimulating the system with drugs, however, produces euphoric effects, which strongly reinforce the behavior of drug use—teaching the user to repeat it.18 How does stimulation of the brain’s Why are drugs more addictive than pleasure circuit teach us to keep natural rewards taking drugs When some drugs of abuse are taken, they can release 2 to 10 times the amount of dopamine that natural rewards such as eating and sex Our brains are wired to ensure that we will repeat lifesustaining activ 15 do. In some cases, this occurs almost immediately (as when drugs ities by associating those activities with pleasure or reward. Whenever are smoked or injected), and the effects can last much longer than this reward circuit is activated, the brain notes that something impor those produced by natural rewards. The resulting effects on the brain’s tant is happening that needs to be remembered, and teaches us to do it pleasure circuit dwarf those produced by naturally rewarding behav again and again without thinking about it. Because drugs of abuse 16,17 stimulate the same circuit, we learn to abuse drugs in the same way. iors. The effect of such a powerful reward strongly motivates peo ple to take drugs again and again. This is why scientists sometimes say DRUGS OF Ab USe TARGeT THe b RAIN’S PLeASURe CeNTeR that drug abuse is something we learn to do very, very well. Brain reward (dopamine) pathways Drugs of abuse increase dopamine Dopamine Dopamine Transporter Transporter F Fr ro on nt ta all C Co or rt te ex x Ventral Ventral Tegmental Tegmental Dopamine Area Area Dopamine Receptor Cocaine Dopamine N Nu uc clle eu us s A Ac cc cu um mb be en ns s WHILE EATING FOOD WHILE USING COCAINE These brain circuits are important for natural Typically, dopamine increases in response to natural rewards such as food. rewards such as food, music, and sex. When cocaine is taken, dopamine increases are exaggerated, and communication is altered.Longterm drug abuse impairs brain functioning. 19 ing surges in dopamine (and other neurotransmitters) by What happens to your brain producing less dopamine or by reducing the number of if you keep taking drugs receptors that can receive signals. As a result, dopamine’s For the brain, the difference between normal rewards and impact on the reward circuit of the brain of someone who drug rewards can be described as the difference between abuses drugs can become abnormally low, and that per someone whispering into your ear and someone shouting son’s ability to experience any pleasure is reduced. into a microphone. Just as we turn down the volume on a This is why a person who abuses drugs eventually feels flat, radio that is too loud, the brain adjusts to the overwhelm lifeless, and depressed, and is unable to enjoy things that were previously pleasurable. Now, the person needs to keep taking drugs again and again just to try and bring his DeCReASeD DOPAmINe TRANSPORTeRS IN A or her dopamine function back up to normal—which only 18 meTHAmPHeTAmINe AbUSeR makes the problem worse, like a vicious cycle. Also, the person will often need to take larger amounts of the drug to produce the familiar dopamine high—an effect known as tolerance. How does longterm drug taking affect brain circuits We know that the same sort of mechanisms involved in the development of tolerance can eventually lead to profound Drug Abuser Healthy Control changes in neurons and brain circuits, with the potential to severely compromise the longterm health of the brain. For20 example, glutamate is another neurotransmitter that influences the What other brain changes reward circuit and the ability to learn. When the optimal concentration occur with drug abuse of glutamate is altered by drug abuse, the brain attempts to compen Chronic exposure to drugs of abuse disrupts the way critical brain sate for this change, which can cause impairment in cognitive function. structures interact to control and inhibit behaviors related to drug use. Similarly, longterm drug abuse can trigger adaptations in habit or Just as continued abuse may lead to tolerance or the need for higher nonconscious memory systems. Conditioning is one example of this drug dosages to produce an effect, it may also lead to addiction, which type of learning, in which cues in a person’s daily routine or environ can drive a user to seek out and take drugs compulsively. Drug addic ment become associated with the drug experience and can trigger tion erodes a person’s selfcontrol and ability to make sound deci uncontrollable cravings whenever the person is exposed to these cues, sions, while producing intense impulses to take drugs. even if the drug itself is not available. This learned “reflex” is extreme ly durable and can affect a person who once used drugs even after many years of abstinence. For more information on drugs and the brain, order NIDA’s Teaching Packets CDROM series or the Mind Over Matter series at These items and others are available to the public free of charge.IV. ADDICTION AND HEALTH What are the medical consequences of drug addiction eople who suffer from addiction often have one or more accompanying medical issues, which may include lung or cardiovascular dis ease, stroke, cancer, and mental disorders. Imaging scans, chest Xrays, and blood tests show the damaging effects of longterm drug Pabuse throughout the body. For example, research has shown that tobacco smoke causes cancer of the mouth, throat, larynx, blood, 19 lungs, stomach, pancreas, kidney, bladder, and cervix. In addition, some drugs of abuse, such as inhalants, are toxic to nerve cells and may damage or destroy them either in the brain or the peripheral nervous system. Does drug abuse cause mental disorders, or vice versa THe ImPACT OF ADDICTION CAN b e Drug abuse and mental illness often coexist. In some cases, mental disorders such as anxiety, FARReACHING depression, or schizophrenia may precede addiction; in other cases, drug abuse may trigger or exacerbate those mental disorders, particularly in people with specific vulnerabilities. z Cardiovascular disease z Stroke z Cancer z HIV/AIDS z Hepatitis B and C z Lung disease z Mental disorders 21Addiction and HIV/AIDS are intertwined epidemics. 22 z Increased spread of infectious diseases How can addiction harm other people Injection of drugs such as heroin, cocaine, and methamphetamine Beyond the harmful consequences for the person with the addiction, 21 currently accounts for about 12 percent of new AIDS cases. drug abuse can cause serious health problems for others. Three of the Injection drug use is also a major factor in the spread of hepatitis more devastating and troubling consequences of addiction are: C, a serious, potentially fatal liver disease. Injection drug use is not the only way that drug abuse contributes to the spread of infectious z Negative effects of prenatal drug exposure on infants and children diseases. All drugs of abuse cause some form of intoxication, which interferes with judgment and increases the likelihood of risky sexu A mother's abuse of heroin or prescription opioids during pregnan al behaviors. This, in turn, contributes to the spread of HIV/AIDS, cy can cause a withdrawal syndrome (called neonatal abstinence hepatitis B and C, and other sexually transmitted diseases. syndrome, or NAS) in her infant. It is also likely that some drug exposed children will need educational support in the classroom to help them overcome what may be subtle deficits in developmental areas such as behavior, attention, and thinking. Ongoing research is 1 OUT OF 3 U.S. AIDS DeATHS ARe investigating whether the effects of prenatal drug exposure on the 22 ReLATeD TO DRUG Ab USe brain and behavior extend into adolescence to cause developmental problems during that time period. z Negative effects of secondhand smoke Secondhand tobacco smoke, also called environmental tobacco smoke (ETS), is a significant source of exposure to a large number of substances known to be hazardous to human health, particularly to children. According to the Surgeon General’s 2006 Report, The Health Consequences of Involuntary Exposure to Tobacco Smoke, involuntary exposure to secondhand smoke increases the risks of heart disease and lung cancer in people who have never 20 smoked by 25–30 percent and 20–30 percent, respectively.Tobacco use is responsible for an estimated 23 23 5 million deaths worldwide each year. What are some effects TOb ACCO SmOKe AFFeCTS THe WHOLe b ODy of specific abused substances 25 26 Monoamine Oxidase B Smoking causes cancer throughout the body. z Nicotine is an addictive stimulant found in cigarettes and other forms of tobacco. Tobacco smoke increases a user’s risk Throat of cancer, emphysema, bronchial disorders, and cardiovascu Larynx (voice box) Mouth Esophagus lar disease. The mortality rate associated with tobacco addic tion is staggering. Tobacco use killed approximately 100 mil Lung Blood (leukemia) lion people during the 20th century, and, if current smoking Stomach Kidney Pancreas trends continue, the cumulative death toll for this century has Bladder Cervix 24 been projected to reach 1 billion. z Alcohol consumption can damage the brain and most body organs. Areas of the brain that are especially vulnerable to alcoholrelated damage are the cerebral cortex (largely z Prescription medications, including opioid pain relievers (such as ® ® ® responsible for our higher brain functions, including problem solving OxyContin and Vicodin ), antianxiety sedatives (such as Valium ® ® ® and decision making), the hippocampus (important for memory and and Xanax ), and ADHD stimulants (such as Adderall and Ritalin ), learning), and the cerebellum (important for movement coordination). are commonly misused to selftreat for medical problems or abused for purposes of getting high or (especially with stimulants) improving z Marijuana is the most commonly abused illegal substance. This drug performance. However, misuse or abuse of these drugs (that is, taking impairs shortterm memory and learning, the ability to focus attention, them other than exactly as instructed by a doctor and for the purposes and coordination. It also increases heart rate, can harm the lungs, prescribed) can lead to addiction and even, in some cases, death. and can increase the risk of psychosis in those with an underlying Opioid pain relievers, for instance, are frequently abused by being vulnerability. crushed and injected or snorted, greatly raising the risk of addiction and overdose. Unfortunately, there is a common misperception that because medications are prescribed by physicians, they are safe even when used illegally or by another person than they were prescribed for.Nearly half of high school seniors report having used 14 24 marijuana, and 6.5 percent are daily marijuana users. z Inhalants are volatile substances found in many household prod but do not exist. Users also may have traumatic experiences and emotions that can last for many hours. ucts, such as oven cleaners, gasoline, spray paints, and other aerosols, that induce mindaltering effects; they are frequently the z Heroin is a powerful opioid drug that produces euphoria and feel first drugs tried by children or young teens. Inhalants are extremely ings of relaxation. It slows respiration, and its use is linked to an toxic and can damage the heart, kidneys, lungs, and brain. Even a increased risk of serious infectious diseases, especially when taken healthy person can suffer heart failure and death within minutes of intravenously. People who become addicted to opioid pain relievers a single session of prolonged sniffing of an inhalant. sometimes switch to heroin instead, because it produces similar effects and may be cheaper or easier to obtain. z Cocaine is a shortacting stimulant, which can lead users to take z Steroids, which can also be prescribed for certain the drug many times in a single session (known as a “binge”). medical conditions, are abused to increase muscle Cocaine use can lead to severe medical consequences related to the mass and to improve athletic performance or physi heart and the respiratory, nervous, and digestive systems. cal appearance. Serious consequences of abuse can z Amphetamines, including methamphetamine, are powerful stim include severe acne, heart disease, liver problems, ulants that can produce feelings of euphoria and alertness. stroke, infectious diseases, depression, and suicide. Methamphetamine’s effects are particularly longlasting and harmful z Drug combinations. A particularly dangerous to the brain. Amphetamines can cause high body temperature and and common practice is the combining of two or more drugs. can lead to serious heart problems and seizures. The practice ranges from the coadministration of legal drugs, like z MDMA (Ecstasy or “Molly”) produces both stimulant and mind alcohol and nicotine, to the dangerous mixing of prescription altering effects. It can increase body temperature, heart rate, blood drugs, to the deadly combination of heroin or cocaine with fentanyl pressure, and heartwall stress. MDMA may also be toxic to nerve (an opioid pain medication). Whatever the context, it is critical to cells. realize that because of drug–drug interactions, such practices often pose significantly higher risks than the already harmful individual z LSD is one of the most potent hallucinogenic, or perceptionalter drugs. ing, drugs. Its effects are unpredictable, and abusers may see vivid colors and images, hear sounds, and feel sensations that seem real For more information on the nature and extent of common drugs of abuse and their health consequences, go to NIDA’s Web site ( to view the popular Research Reports (, DrugFacts fact sheets and other publications.V. TREATMENT AND RECOVERY Can addiction be treated successfully Addiction is a treatable disease. Research in the science of addiction and the treatment of substance use disorders has led to YES. the development of evidencebased interventions that help people stop abusing drugs and resume productive lives. Can addiction be cured Not always—but like other chronic diseases, addiction can be managed successfully. Treatment enables people to counteract addiction’s powerful disruptive effects on their brain and behavior and regain control of their lives. bRAIN ReCOv eRy WITH PROLONGeD AbSTINeNCe These images showing the den sity of dopamine transporters in a brain area called the striatum illustrate the brain’s remarkable potential to recover, at least partially, after a long abstinence from drugs—in this case, 27 methamphetamine. Healthy Person METH Abuser METH Abuser 1 month abstinence 14 months abstinence 25Addiction need not be a life sentence. 26 Does relapse to drug abuse mean COmPARISON OF ReLAPSe RATeS beTWeeN DRUG ADDICTION AND OTHeR CHRONIC ILLNeSSeS treatment has failed 100 No. The chronic nature of the disease means that relapsing to drug 80 abuse at some point is not only possible, but likely. Relapse rates (i.e., 50 to 70 50 to 70 60 how often symptoms recur) for people with addiction and other sub 40 to 60 30 to 50 40 stance use disorders are similar to relapse rates for other wellunder stood chronic medical illnesses such as diabetes, hypertension, and 20 asthma, which also have both physiological and behavioral compo 0 Drug Type I Hypertension Asthma nents. Treatment of chronic diseases involves changing deeply imbed Addiction Diabetes ded behaviors, and relapse does not mean treatment has failed. For a Relapse rates for people treated for substance use disorders are compared with those for people person recovering from addiction, lapsing back to drug use indicates with diabetes, hypertension, or asthma. Relapse is common and similar across these illnesses (as is adherence/nonadherence to medication). Thus, drug addiction should be treated like any other that treatment needs to be reinstated or adjusted or that another treat chronic illness; relapse serves as a trigger for renewed intervention. 28 ment should be tried. Source: JAMA, 284:16891695, 2000 What are the principles of effective substance How can medications help treat use disorder treatment drug addiction Research shows that combining treatment medications (where avail Different types of medications may be useful at different stages of treat able) with behavioral therapy is the best way to ensure success for ment to help a patient stop abusing drugs, stay in treatment, and avoid most patients. Treatment approaches must be tailored to address each relapse. patient’s drug use patterns and drugrelated medical, psychiatric, and z Treating Withdrawal. When patients first stop using drugs, they social problems. can experience a variety of physical and emotional symptoms, including depression, anxiety, and other mood disorders, as well as Percent of Patients Who Relapse27 restlessness or sleeplessness. Certain treat z Preventing Relapse. Science has taught meDICATIONS USeD TO ment medications are designed to reduce us that stress, cues linked to the drug expe TReAT DRUG ADDICTION these symptoms, which makes it easier to rience (such as people, places, things, and stop the drug use. moods), and exposure to drugs are the most common triggers for relapse. n Tobacco Addiction z Staying in Treatment. Some treatment Medications are being developed to inter • Nicotine replacement medications are used to help the brain fere with these triggers to help patients sus therapies (available as a patch, adapt gradually to the absence of the tain recovery. inhaler, or gum) abused drug. These medications act slowly to stave off drug cravings and have a calm • Bupropion ing effect on body systems. They can help • Varenicline How do behavioral therapies treat patients focus on counseling and other psy n Opioid Addiction drug addiction chotherapies related to their drug treat • Methadone ment. Behavioral treatments help engage people in • Buprenorphine substance use disorder treatment, modifying • Naltrexone their attitudes and behaviors related to drug n Alcohol and Drug Addiction use and increasing their life skills to handle stressful circumstances and environmental • Naltrexone cues that may trigger intense craving for drugs • Disulfiram and prompt another cycle of compulsive use. • Acamprosate Behavioral therapies can also enhance the effectiveness of medications and help people remain in treatment longer. Discoveries in science lead to advances in drug abuse treatment.Treatment must address the whole person. 28 How do the best treatment programs help patients recover from the pervasive effects of addiction Gaining the ability to stop abusing drugs is just one part of a long and complex recovery process. When people enter treatment for a sub stance use disorder, addiction has often taken over their lives. The compulsion to get drugs, take drugs, and experience the effects of drugs has dominated their every waking moment, and abusing drugs has taken the place of all the things they used to enjoy doing. It has disrupted how they function in their family lives, at work, and in the community, and has made them more likely to suffer from other seri z Cognitive Behavioral Therapy seeks to help patients recognize, avoid, ous illnesses. Because addiction can affect so many aspects of a per and cope with the situations in which they are most likely to abuse drugs. son’s life, treatment must address the needs of the whole person to be z Contingency Management uses positive reinforcement such as providing successful. This is why the best programs incorporate a variety of reha rewards or privileges for remaining drug free, for attending and participating bilitative services into their comprehensive treatment regimens. in counseling sessions, or for taking treatment medications as prescribed. Treatment counselors may select from a menu of services for meeting the specific medical, psychological, social, vocational, and legal needs z Motivational Enhancement Therapy uses strategies to evoke rapid and of their patients to foster their recovery from addiction. internally motivated behavior change to stop drug use and facilitate treat ment entry. For more information on substance use disorder treatment, see Principles of Drug Addiction Treatment: A ResearchBased z Family Therapy (especially for youth) approaches a person’s drug Guide ( and Principles problems in the context of family interactions and dynamics that may con tribute to drug use and other risky behaviors. of Adolescent Substance Use Disorder Treatment: A ResearchBased Guide ( stanceusedisordertreatmentresearchbasedguide). VI. ADVANCING ADDICTION SCIENCE AND PRACTICAL SOLUTIONS Leading the Search for Scientific Solutions NIDA Studies o address all aspects of drug abuse and its harmful consequences, NIDA’s research program ranges from DRUG ABUSE ADDICTION basic studies of the addicted brain and behavior to health services research. NIDA’s research program at All Levels T develops prevention and treatment approaches and ensures they work in realworld settings. In this con text, NIDA is strongly committed to developing a research portfolio that addresses the special vulnerabilities and health disparities that exist among ethnic minorities or that derive from gender differences. bringing Science to RealWorld Settings z Clinical Trials Network (CTN) CTN “road tests” researchbased drug abuse treatments in community treatment programs around the country. z Criminal Justice Drug Abuse Treatment Studies (CJDATS) Led by NIDA, CJDATS is a network of research centers, in partnership with criminal justice professionals, drug abuse treatment providers, and Federal agencies responsible for developing integrated treatment approaches for criminal justice offenders and testing them at multiple sites throughout the Nation. z Juvenile Justice Translational Research on Interventions in the Legal System (JJTRIALS) JJTRIALS is a sevensite cooperative research program designed to identify and test strategies for improving the delivery of evidencebased substance abuse and HIV prevention and treatment services for justiceinvolved youth. Sharing Free Information With the Public NIDA further increases the impact of its research on the problems of addiction by sharing free information about its findings with professional audiences and the general public. Special initiatives target students and teachers as well as designated populations and ethnic groups. 2930 Principles of Adolescent Substance Use NIDA’s Special Initiatives for Special Initiative for Clinicians Disorder Treatment: A ResearchBased Students, Teachers, and Parents Guide—This guide discusses the urgency of treating addictions and other substance use Heads Up: Real News About NIDAMED— Tools and resources to increase disorders in teenagers, answers common Drugs and Your Body—A awareness of the impact of substance use on questions about how young people are treated drug education series created by patients' overall health and help clinicians and for drug problems, and describes effective NIDA and SCHOLASTIC INC. for students in those in training identify patient drug use early and treatment approaches supported by scientific grades 6 to 12. prevent it from escalating to abuse or addiction. evidence. Principles of Drug Abuse Treatment NIDA for Teens: The Science Publications on Prevention for Criminal Justice Populations: Behind Drug Abuse—An inter and Treatment Principles A ResearchBased Guide—NIDA’s active Web site geared specifically researchbased guide for treating people with Preventing Drug Use among Children and to teens, with ageappropriate addiction who are involved with the criminal Adolescents: A ResearchBased Guide for facts on drugs. justice system provides 13 essential treatment Parents, Educators, and Community principles, and includes answers to frequently Leaders—NIDA’s researchbased guide for prevent asked questions and resource information. ing drug abuse among children and adolescents pro Drug Facts Chat Day— vides 16 principles derived from effective drugpre A Web chat between NIDA vention research and includes answers to questions For more information: scientists and teens, held through school computer labs once a year on risk and protective factors as well as on commu All NIDA publications are available at Some publications during National Drug Facts Week (below). nity planning and implementation. are also available in print, free of charge. Principles of Drug Addiction Treatment: A To order print copies call the DRUGPubs ResearchBased Guide—This guide summarizes National Drug Facts Week— Research Dissemination Center at the 13 principles of effective treatment, answers A weeklong observance that 1–877–NIH– N IDA or go to common questions, and describes types of treatment, encourages communitybased Watch NIDA videos providing examples of scientifically based and tested events and dialogue between teens and scientists (NIDA TV) at: treatment components. during National Drug Facts Week (below). References 1. National Drug Intelligence Center. The Economic Impact of Illicit Drug Use on American Society. Washington, DC: United States Department of Justice, 2011. 2. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcoholuse disorders. Lancet 373(9682):22232233, 2009. 3. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs — 2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 4. Centers for Disease Control and Prevention (CDC). AlcoholRelated Disease Impact (ARDI). Atlanta, GA: CDC. 5. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 6. Shankaran S, Lester BM, Das A, Bauer CR, Bada HS, Lagasse L, Higgins R. Impact of maternal substance use during pregnancy on childhood outcome. Semin Fetal Neonatal Med 12(2):143150, 2007. 7. Fowler JS, Volkow ND, Kassed CA, Chang L. Imaging the addicted human brain. Sci Pract Perspect 3(2):416, 2007. 8. Lynskey MT, Heath AC, Bucholz KK, Slutske WS, Madden PAF, Nelson EC, Statham DJ, Martin NG Escalation of drug use in earlyonset cannabis users vs cotwin controls. JAMA 289:42733, 2003. 9. Verebey K, Gold MS. From coca leaves to crack: the effects of dose and routes of administration in abuse liability. Psychiatr Annals 18:513–520, 1988. 10. Hatsukami DK, Fischman MW. Crack cocaine and cocaine hydrochloride: Are the differences myth or reality. JAMA 276:15801588, 1996. 11. Gogtay N, Giedd JN, Lusk L, Hayashi KM, Greenstein D, Vaituzis AC, Nugent TF 3rd, Herman DH, Clasen LS, Toga AW, Rapoport JL, Thompson PM. Dynamic mapping of human cortical development during childhood through early adulthood. Proc Natl Acad Sci 101(21):81748179, 2004. 12. Krohn MD, Lizotte AJ, Perez CM. The interrelationship between substance use and precocious transitions to adult statuses. J Health Soc Behav 38(1):87103, 1997. 13. National Institute on Drug Abuse. Preventing Drug Abuse among Children and Adolescents: A ResearchBased Guide for Parents, Educators, and Community Leaders (Second Edition) (NIH Publication No. 044212A). Rockville, MD, 2003. 14. Johnston, L. D., O'Malley, P. M., Miech, R. A., Bachman, J. G., Schulenberg, J. E. (2014). Monitoring the Future national survey results on drug use: 19752013: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan. 15. Di Chiara G, Imperato A. Drugs abused by humans preferentially increase synaptic dopamine concentrations in the mesolimbic system of freely moving rats. Proc Natl Acad Sci 85:52745278, 1988. 16. Fiorino DF, Phillips AG. Facilitation of sexual behavior and enhanced dopamine efflux in the nucleus accumbens of male rats after Damphetamine behavioral sensitization. J Neurosci 19:456463, 1999. 17. Di Chiara G, Tanda G, Cadoni C, Acquas E, Bassareo V, Carboni E. Homologies and differences in the action of drugs of abuse and a conventional reinforcer (food) on dopamine transmission: an interpretive framework of the mechanism of drug dependence. Adv Pharmacol 42:983987, 1998. 18. Volkow ND, Chang L, Wang GJ, Fowler JS, LeonidoYee M, Franceschi D, Sedler MJ, Gatley SJ, Hitzemann R, Ding YS, Logan J, Wong C, Miller EN. Association of dopamine transporter reduction with psychomotor impairment in methamphetamine abusers. Am J Psychiatry 158(3):377382, 2001. 19. U.S. Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, Ga.: Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; Washington, DC, 2004. 20. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. 21. Centers for Disease Control and Prevention. HIV/AIDS Statistics Overview. See 22. Centers for Disease Control and Prevention. HIV Surveillance Report, 2011; vol. 23. Published February 2013. Accessed May 2,2014. 23. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2005. Vol. 17. Rev ed. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2007: Also available at: 24. Ezzati M, and Lopez AD. Estimates of global mortality attributable to smoking in 2000. Lancet 362(9387):847852, 2003. 25. Richard Peto and Alan D Lopez. Global Health in the 21st Century, published by JosseyBass, New York, edited by C Everett Koop, Clarence E Pearson and M Roy Schwarz, 2000. 26. Fowler JS, Logan J, Wang GJ, Volkow ND, Telang F, Zhu W, Franceschi D, Pappas N, Ferrieri R, Shea C, Garza V, Xu Y, Schlyer D, Gatley SJ, Ding YS, Alexoff D, Warner D, Netusil N, Carter P, Jayne M, King P, Vaska P. Low monoamine oxidase B in peripheral organs in smokers. Proc Natl Acad Sci 100(20):1160011605, 2003. 27. Volkow ND, Chang L, Wang GJ, Fowler JS, Franceschi D, Sedler M, Gatley SJ, Miller E, Hitzemann R, Ding YS, Logan J. Loss of dopamine transporters in methamphetamine abusers recovers with protracted abstinence. J Neurosci 21(23):94149418, 2001. 28. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 284(13):16891695, 2000. 31NIH Pub No. 145605 Printed April 2007 Revised February 2008, August 2010, July 2014
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