Drug abuse and dependence: This behavior involves use of a legal or illegal drug that causes physical, mental, emotional, or social harm.  Dependence is marked by physiologic changes, primarily tolerance and withdrawal symptoms.  In recent years, problems related to substance abuse have emerged as major social and health concerns that affect everyone either directly or indirectly.

More than 400,000 babies are born each year after intrauterine exposure to illicit drug, especially crack cocaine.  Possible adverse effects include prematurity, low birth weight, withdrawal, smaller head circumference, malformations, failure to thrive, developmental delay, stroke, sudden infant death syndrome, and hyperactivity.  Studies shows that about 1 child in 600-700 children is born with the fetal alcohol syndrome and may be mentally retarded, malformed, or developmentally delayed or have neurological abnormalities.

Nearly 2% of children less than 13 years old are infected with HIV and 80% of infants born with HIV infection have mothers who used intravenous drugs or whose sexual partners did.  Studies also shows that 90% of adolescents drink, and 40% use cocaine, amphetamines, and similar drugs.  Diet pills, diuretics, amphetamines, and steroids, inhalants, and other chemicals have gained popularity among teenagers.

Drug - related academic, career, and social problems are found in every strata of society, and drug - related accidents and suicides are the leading cause of death among people who use drugs.  Studies shows about 12 million adults abuse alcohol.  Heroin, Crack,  and Over- the- counter (OTC) pills are on the rise.

America is a psychoactive  (mood-altering) drug-oriented society.  We use psychoactive drugs to satisfy curiosity, reduce pain, influence mood, change activity levels, reduce tension and anxiety, decrease fatigue and boredom, improve social interactions, temporarily escape reality, and heighten sensation.  Unfortunately, every psychoactive substance, including caffeine, nicotine, and some prescription and OTC medications as well as licit and illicit drugs has the potential for abuse, because the main effect is to produce a pleasant "feeling".  Many people are able to use drugs without becoming dependent.  They do not progress to the point where they experience problems as a result of their drug use, and they do not have psychological carvings, tolerance to the drug, or signs and symptoms of withdrawal when they do not use it.  People who become dependent experience progressively severe physical, emotional, familial, social, and occupational problems.  Yet, they cannot reduce or stop their drug use and usually deny that it is causing problems.

Progression of dependence: Three stages, each has specific characteristics.--Early, middle. and late. (some characteristics may or may not apply to all dependents)

Early Stage:  or experimental stage.  Ability to function is only mildly impaired

Drug use: as the amount and frequency of use increase, the dependent periodically decreases or stops using the drug to prove to himself that he still has control. His family and others may comment on his drug- related behavior and sometimes worry that he may be too involved with drugs. However, when the subject of drugs comes up, he usually either makes light of it or becomes hostile and tries to hide his drug use from them.

Physical effects: Mood swings, decrease self-esteem; negative feelings such as shame, guilt, remorse, resentment, irritability and fear.

Family relationships: He may avoid and neglect his family and or significant others, and argue with them about his drug use and behavior.

Social effects: He prefers to limit his socialization to activities in which drugs are used and to friends who use moderately to heavily.  He may have legal problems or be arrested for driving while intoxicated, for being drunk in public, assault, or for disorderly conduct.

Occupational effects: He may be consistently late for work or absent. His attitude may cause problems at work. May have financial difficulties related to spending significant amounts of money on drugs. If he is a student, he may be truant and have other drug- related attitudes and behaviors, such as; decrease in grades and loss of motivation.

Prognosis: Some patients in the early state of dependence improve without treatment. Others continue to progress to later stage.

Middle Stage:Ability to function is moderately impaired

Drug use: Has difficulty controlling his drug use. Efforts to stop or reduce use are followed by heavier use, and his drug- related behavior and attitudes continue even when he is not using drugs. He no longer experiences the good "feelings" that drugs once gave him; now he uses the drug just to feel "normal". He has become sophisticated at finding, buying, and using drugs, and a pattern of using has developed in regard to time, place, and situation.

Physical effects: When he is abstinent, the dependent experiences signs and symptoms of withdrawal that are the opposite of the effects of the drug he has been using. By using the drug again, he can stop the effects of withdrawal. Example: someone who is alcoholic may drink in the morning to relieve tremors. Physical problems increase and may include anorexia, weight change, nausea, diarrhea, malnutrition, gastritis, sexual problems, promiscuity and associated venereal diseases or HIV infection, accidental injuries, suicide attempts, overdoses, blackouts, infections, visual problems, headaches, and memory loss.

Emotional effects: Extreme mood swings. Depression, he feels ashamed, guilty, remorseful, resentful, fearful, and irritable and is full of self- pity and blames others, He denies to himself and others that drugs are causing his problems, and he copes with his situation by using more drugs. His thoughts and conversation revolve around drugs.

Family relationships: The dependent embarrasses and alienates his family and others by his drug- related behavior, such as; arguing, fighting, lying, stealing, and self-indulgence. Physical abuse, molestation, incest, and neglect of children may surface. Family members' efforts to keep the family intact and survive involve unhealthy adaptive patterns called codependency, and separation and divorce may occur anywise.

Social effects: He tends to isolate himself or limit his socialization to drugging friends. He may continue to attend church. He may continue to have legal problems because of driving while intoxicated, being in possession of a controlled substance, disorderly conduct, assault, warrants for unpaid ticket, etc. If he is a student, he may have escalating problems at school or may drop out.

Occupational effects: He may lose his job, or go from job to job. His employer may ask him to seek treatment.

Prognosis: The dependent may remain in the middle stage for a short time or for may years, or he may bypass it and progress into the late stage. Only a few who have reached the middle stage improve on their own, and if they are multiple drug users, their progression is even faster.

Late Stage: the dependent's ability to function is severely impaired in all areas.

Drug use: When the dependent experiences incapacitation effects but cannot control the use of a particular drug, he may replace that drug with another drug that he thinks he has more control over. Example; an amphetamine user who is experiencing paranoia may stop using amphetamines and switch to another drug such as alcohol. Drug use is nearly continuous. The dependent uses in an attempt to avoid emotional and physical pain, and he cannot achieve the level of "feeling normal".

Physical effects: Medical problems may develop, such as malnourishment, impotence, liver disease, pancreatitis, pulmonary edema, overdose, blackouts after even moderate use. If the dependent is an intravenous drug user, he may be exposed to HIV, or septicemia, abscessed, or endocarditis may develop. He may be suicidal or homicidal.

Emotional effects: Lost of self-esteem. He neglects his personal appearance, and no longer cares about the opinions of his family or society. His judgment and problem-solving skills are poor, and he turns to drugs and crime to survive. He is manipulative; is in denial as to his problems; and externalizes his feelings of guilt, shame, remorse, self-pity, hostility, and resentment.

Family relationships: He is generally alienated from his family and may be institutionalized or homeless.

Social effects: the dependent's only associates are drug dealers and the people he uses with.

Occupational effects: Typically unemployed, may be on social welfare, and in need of rehabilitation or special education.

Prognosis: most people in the late stage of dependence do not improve without treatment.

Route of Administration: four major routes by which drugs are administered are oral, across mucous membranes, inhalation, and parenteral. Most persons choose a route because of convenience, speed, and duration of action. Each having its own advantages and drawbacks.

Oral route: The most common way to take drugs is to swallow them. It is absorbed primarily in the small intestine rather than in the stomach. However, if food is present in the stomach, drug absorption may be delayed, and dilute the concentration of a drug, delaying absorption and reducing maximum serum levels of the drug. Once absorbed into the bloodstream, it moves through the liver before it reaches the brain.

Absorption across mucous membranes:  The mucous membranes that line the throat, vagina, and rectum have a larger blood supply than most tissues, and drugs are rapidly absorbed across these membranes.  Sniffing drugs allows the chemicals to be rapidly absorbed across the mucous membranes of the nose and sinus cavities.  Drugs commonly taken by this route include cocaine, and amyl nitrate, "Sniffing glue" is an incorrect term, because glue and solvent vapors are actually inhaled and absorbed through the lining of the lungs rather than through the lining of the nose and sinus cavities.  Sniffing drugs such as cocaine can perforate or destroy the nasal septa.  The rectal route is rarely used.

Inhalation:  When a drug is inhaled, it crosses the alveolar membrane and is absorbed into the bloodstream.  Inhalation can be an effective route for some drugs, because the surface area of the lungs is large and the diffusion distance is short.  However, a drug must be in a gaseous form (as with solvents) or in fine particles or in smoke (marijuana or hashish) to cross the alveolar membrane.  The major drawback to this route is that only relatively small amounts of a drug can be absorbed at a time.

Parenteral routes:  A drug can be introduced into the bloodstream by subcutaneous, intramuscular, or intravenous injection.  Subcutaneous injection, also called "skin popping", involves injecting the drug immediately under the skin.  The effects of a drug occur more rapidly with this route than with the oral route but more slowly than with the intravenous route.

Drawbacks to the subcutaneous route include local or generalized infections that can occur when the needle and drug are not sterile.  In addition, insoluble materials tend to remain at the site of injection rather than enter the bloodstream.  Thus, the skin may be tattooed or scarred at injection sites; infections may occur there also.

Intramuscular injection sends the drug much more deeply into the body.  The drug is injected into the muscle mass, where it is slowly absorbed into the bloodstream.  just as with subcutaneous injection, the risks of infection, scarring, and tissue damage are high, but some drug abusers prefer this route because the drug can be quickly injected right through clothing.  Drawback- pain at the site of injection.

With intravenous injection, also called "mainlining" or injecting a drug directly into a vein, relatively large amounts of a drug can be instantly placed directly into the bloodstream.  Usually, the forearms and the area around the elbow are used, although other sites may be used, such as the ankles, scrotum, and the underside of the tongue.  Relatively large particles may lead to clot formation, which can block blood vessels and lead to tissue damage or even death.  Over time, repeated intravenous injections irritate veins and cause the vessels to collapse.  Intravenous drug users are among those at highest risk of AIDS.

Most drugs are distributed unevenly throughout the body. For example, some drugs bind strongly to blood elements, others dissolves more quickly in body fat, and some have an affinity for bone.  To enter the brain, drugs must be highly fat soluble. (Fat - soluble drugs can cross the placenta, affect the fetus, and be present in the milk of lactating women).

Alcohol is a special case.  It crosses all barriers, is distributed evenly in the body, and does not bind selectively to any particular tissue.  Some gaseous anesthetics and solvents behave in the same way.

WITHDRAWAL:  When a person with a drug dependence suddenly reduces or stops using a drug that he has been habitually (daily) using, painful and distressing physical and  psychological signs and symptoms develop.  The syndrome is called withdrawal.  The signs and symptoms of withdrawal are the opposite of the effects experienced by the dependent while he is using the drug, and they vary in severity and duration.

Opiods have analgesic and calming qualities.  Withdrawal from opioids results in extreme excitability and extremely painful, flu -like signs and symptoms.  Opiate withdrawal causes severe physical  discomfort and can even be  life-threatening.

Alcohol, barbiturates, and the benzodiazepines can calm, induce sleep, and decrease pain.  In contrast, withdrawal from these substances results in tremors, agitation, nausea, diarrhea, insomnia, headache, gastrointestinal distress, psychological pain and other life-threatening signs and symptoms.

Treatment:

Treatment of acute drug intoxication is symptomatic and depends on the drug ingested.  Includes fluid replacement therapy and nutritional and vitamin supplements, if indicated; detoxification with  the same drug or a pharmacologically similar drug (exceptions; cocaine, hallucinogens, and marijuana are not used for detoxification); sedatives to induce sleep; anticholinergics and antidiarrheal agents to relieve GI distress; and antianxiety drugs for severe agitation, especially in cocaine abusers; and treatment of medical complications.

Treatment of drug dependence commonly involves a triad of care:  detoxification, long- - term rehabilitation ( up to 2 years), and aftercare.  The latter means a lifetime of abstinence, usually aided by participation in Narcotics Anonymous or a similar self-help group program.

Detoxification is the controlled and gradual withdrawal of an abused drug.  Other medications may be given to control the effects of withdrawal and reduce the patient's discomfort and the associated risks.  Depending  on the abused drug, detoxification is managed on an inpatient or an outpatient basis.  Chronic opiate abusers are frequently detoxified with methadone substitution.  Bromocriiptine is sometimes given to aid cocaine detoxification.

After withdrawal, the patient requires rehabilitation to prevent recurrence of drug abuse.  Rehabilitation programs are available for both inpatients and outpatients; they usually last 1 month or longer and may include individual, group, and family psychotherapy.  During and after rehabilitation, participation in a drug-oriented self- -help group may be helpful.  The largest such group is Narcotics Anonymous.  There are also; Potsmokers Anonymous, Pills Anonymous, and Cocaine Anonymous

Source: Diagnosing and Managing Chemical Dependency, 1990, by J. Beasley. Comprehensive Medical Care, Amityville, NY