BRAIN/CENTRAL NERVOUS SYSTEM AND CLUB DRUGS
(Part 4 of a series on the central nervous system and drugs)
Introducing the Human Brain
The human brain is the most complex organ in the body. This three-pound 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 activities. In brief, the brain regulates your basic body 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 performing specific functions. Drugs can alter important brain areas that are necessary for life-sustaining functions and can drive the compulsive drug abuse that marks addiction. Brain areas affected by drug abuse:
– The brain stem controls basic functions critical to life, such as heart rate, breathing, and sleeping.
– The limbic system 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 such as eating – actions that are critical to our existence.
The cerebral cortex 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.
The Central Nervous System (CNS)
The CNS coordinates the functions of all parts of the body and consists of the brain and the spinal cord, as well as the retina. Together with the peripheral nervous system, it has a fundamental role in the control of behavior. The CNS is contained within the dorsal cavity, with the brain in the cranial cavity and the spinal cord in the spinal cavity. The brain is protected by the skull, while the spinal cord is protected by the vertebrae, and both are enclosed in the meninges.
The brain receives sensory inputs from the spinal cord as well as from its own nerves (e.g., olfactory and optic nerves) and devotes most of its volume to processing its various sensory inputs and initiating appropriate and coordinated motor outputs. Whereas, the spinal cord conducts sensory information from the peripheral nervous system (both somatic and autonomic) to the brain and transmits motor information from the brain to our various effectors such as skeletal muscles, cardiac muscle, and various glands.
The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions and transmit signals between different parts of the body. The peripheral nervous system consists of sensory neurons, clusters of neurons called ganglia, and nerves connecting them to each other and to the central nervous system. These regions are all interconnected by means of complex neural pathways.
Neurons send signals to other cells as electrochemical waves travelling along thin fibers called axons, which cause chemicals called neurotransmitters to be released at junctions called synapses. A cell that receives a synaptic signal may be excited, inhibited, or otherwise modulated. Sensory neurons are activated by physical stimuli impinging on them, and send signals that inform the central nervous system of the state of the body and the external environment. Motor neurons situated either in the central nervous system or in peripheral ganglia, connect the nervous system to muscles or other effecter organs. Central neurons, which are in vertebrates greatly outnumber the other types, make all of their input and output connections with other neurons. The interactions of all these types of neurons form neural circuits that generate an organism’s perception of the world and determine its behavior.
The brain and nervous system are made of billions of nerve cells, called neurons. Neurons have three main parts: cell body, dendrites, and axon. The axon is covered by the myelin sheath. The transfer of information between neurons is called neurotransmission. This is how neurotransmission works:
1. A message travels from the dendrites through the cell body and to the end of the axon.
2. The message causes the chemicals, called neurotransmitters, to be released from the end of the axon into the synapse. The neurotransmitters carry the message with them into the synapse. The synapse is the space between the axon of one neuron and the dendrites of another neuron.
3. The neurotransmitters then travel across the synapse to special places on the dendrites of the next neuron, called receptors. The neurotransmitters fit into the receptors like keys in locks.
4. Once the neurotransmitter has attached to the receptors of the second neuron, the message is passed on.
5. The neurotransmitters are released from the receptors and are either broken down or go back into the axon of the first neuron.
At the most basic level, the CNS sends signals from one cell to another or from one part of the body to another part. There are multiple ways that a cell can send signals to other cells. One is by releasing chemicals called hormones into the internal circulation, so that they can diffuse to distant sites. In contrast to this “broadcast” mode of signaling, the nervous system provides “point-to-point” signals. Neurons project their axons to specific target areas and make synaptic connections with specific target cells. Thus, neural signaling is capable of a much higher level of specificity than hormonal signaling. It is also much faster: the fastest nerve signals travel at speeds that exceed 100 meters per second.
At a more integrative level, the primary function of the nervous system is to control the body. It does this by extracting information from the environment using sensory receptors, sending signals that encode this information into the central nervous system, processing the information to determine an appropriate response, and sending output signals to muscles or glands to activate the response. The evolution of a complex nervous system has made it possible for various animal species to have advanced perception abilities such as vision, complex social interactions, rapid coordination of organ systems, and integrated processing of concurrent signals. In humans, the sophistication of the nervous system makes it possible to have language, abstract representation of concepts, transmission of culture, and many other features of human society that would not exist without the human brain.
This continuing education course will focus on the area of psychoactive chemicals and the central nervous system. The term psychoactive chemical simply means that a chemical has the capability to increase or decrease the speed of electrical impulses along the nervous system. This is accomplished simply by altering the various bio-chemicals or neurotransmitters at the neuronal gaps or synapses.
This is the fourth in a series of continuing education on the central nervous system and drugs. This CEU will address the following types of psychoactive drugs: (1) Prescription and Over-the-Counter medications: (2) Inhalants; (3) Steroids and (4) Club Drugs.
OTHER PSYCHOACTIVE DRUGS (Prescription and Over-the-Counter medications drugs, Inhalants, and Club Drugs): Excerpts were taken from the NIDA website.
Psychoactive chemicals are classified by their effects on the CNS. The classifications of depressants, stimulants, psychedelics/hallucinogens and others (prescription and over-the-counter medications, inhalants, steroids, and club drugs) are commonly used. Psychoactive chemicals act on the brain by affecting-the various neurotransmitters (neurotransmitters are brain chemicals that facilitate communication between brain cells). Many prescription drugs and compounds relate to either depressants or stimulants depending on what medical condition they are designed to treat; consequently, when the prescription drugs are used improperly they follow the same general characteristics as the parent chemical. For example, if a pain killer is abused it psychological and physiological effects would generally follow morphine or some other narcotic. The exact mechanisms by which they exert their effects on CNS is varied and diversified. This Continuing Education Unit addresses only the other classification of psychoactive drugs. Common types are:
Prescription and Over-The-Counter Medications: Prescription drug abuse means taking a prescription medication that is not prescribed for you, or taking it for reasons or in dosages other than as prescribed. Abuse of prescription drugs can produce serious health effects, including addiction.
Inhalants: Inhalants are breathable chemical vapors that users intentionally inhale because of the chemicals’ mind-altering effects. The substances inhaled are often common household products that contain volatile solvents, aerosols, or gases.
Steroids: Most anabolic steroids are synthetic substances similar to the male sex hormone testosterone. They are taken orally or are injected. Some people, especially athletes, abuse anabolic steroids to build muscle and enhance performance. Abuse of anabolic steroids can lead to serious health problems, some of which are irreversible.
Club Drugs: Club drugs tend to be used by young adults at bars, nightclubs, concerts, and parties. Club drugs include GHB, Rohypnol, ketamine, and others. [MDMA (Ecstasy), Methamphetamine, and LSD (Acid), are also considered club drugs (in some applications) and are covered in other parts of this Continuing Education Unit series.
Prescription and Over-The-Counter Medications
Prescription medications such as pain relievers, central nervous system (CNS) depressants (tranquilizers and sedatives), and stimulants are highly beneficial treatments for a variety of health conditions. Pain relievers enable individuals with chronic pain to lead productive lives; tranquilizers can reduce anxiety and help patients with sleep disorders; and stimulants help people with attention-deficit hyperactivity disorder (ADHD) focus their attention. Most people who take prescription medications use them responsibly. But when abused, that is, taken by someone other than the patient for whom the medication was prescribed or taken in a manner or dosage other than what was prescribed, prescription medications can produce serious adverse health effects, including addiction.
Patients, health care professionals, and pharmacists all have roles in preventing abuse and addiction to prescription medications. For example, patients should follow the directions for use carefully; learn what effects and side effects the medication could have; and inform their doctor/pharmacist whether they are taking other medications including over-the-counter (OTC) and health supplements, since these could potentially interact with the prescribed medication. The patient should read all information provided by the pharmacist. Physicians and other health care providers should screen for past or current substance abuse in the patient during routine examination, including asking questions about what other medications the patient is taking and why. Providers should note any rapid increases in the amount of a medication needed or frequent requests for refills before the quantity prescribed should have been finished, as these may be indicators of abuse. Similarly, some OTC medications, such as cough and cold medicines containing dextromethorphan, have beneficial effects when taken as recommended; but they can also be abused and lead to serious adverse health consequences. Parents should be aware of the potential for abuse of these medications, especially when consumed in large quantities, which should signal concern and the possible need for intervention.
Commonly Abused Prescription Medications include:
–Opioidsusually prescribed to treat pain.
–Depressantsused to treat anxiety and sleep disorders.
–Stimulants prescribed to treat ADHD and narcolepsy.
Opioids are analgesic, or pain-relieving, medications. Studies have shown that properly managed medical use (taken exactly as prescribed) of opioid analgesics are safe, can manage pain effectively, and rarely causes addiction. Among the compounds that fall within this class are hydrocodone (e.g., Vicodin), oxycodone (e.g., OxyContinan oral, controlled-release form of the drug), morphine, fentanyl, codeine, and related medications. Morphine and fentanyl are often used to alleviate severe pain, while codeine is used for milder pain. Other examples of opioids prescribed to relieve pain include propoxyphene (Darvon); hydromorphone (Dilaudid); and meperidine (Demerol), which is used less often because of its side effects. In addition to their effective pain-relieving properties, some of these medications can be used to relieve severe diarrhea (for example, Lomotil, also known as diphenoxylate) or severe coughs (codeine).
Opioids can be taken orally, or the pills may be crushed and the powder snorted or injected. A number of overdose deaths have resulted from the latter routes of administration, particularly with the drug OxyContin, which was designed to be a slow-release formulation. Snorting or injecting opioids results in the rapid release of the drug into the bloodstream, exposing the person to high doses and causing many of the reported overdose reactions.
Opioids act by attaching to specific proteins called opioid receptors, which are found in the brain, spinal cord, and gastrointestinal tract. When these compounds attach to certain opioid receptors in the brain and spinal cord, they can effectively change the way a person experiences pain.
In addition, opioid medications can affect regions of the brain that mediate what one perceives as pleasure, resulting in the initial euphoria or sense of well-being that many opioids produce. Repeated abuse of opioids can lead to addiction (a chronic, relapsing disease characterized by compulsive drug seeking and abuse despite its known harmful consequences).
Opioids can produce drowsiness, constipation, and, depending upon the amount taken, depress breathing. Taking a large single dose could cause severe respiratory depression or death.
These medications are only safe to use with other substances under physicians supervision. Typically, they should not be used with alcohol, antihistamines, barbiturates, or benzodiazepines. Because these other substances slow breathing, their effects in combination with opioids could lead to life-threatening respiratory depression.
Patients who are prescribed opioids for an extended period (months, years) may develop a physical dependence on them as repeated exposure can cause the body to physically adapt to their presence. Also, continued use may result in the body building a tolerance (that is, more of the drug is needed to achieve the desired effect compared with when it was first prescribed). A patient may also experience withdrawal symptoms upon abrupt cessation of drug use. Thus, individuals taking prescribed opioid medications should not only be given these medications under appropriate medical supervision, but they should also be medically supervised when stopping use in order to reduce or avoid severe withdrawal symptoms. Symptoms of withdrawal can include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (cold turkey), and involuntary leg movements.
Individuals who abuse or are addicted to opioid prescription medications can be treated. Initially, they may need to undergo medically supervised detoxification to help reduce withdrawal symptoms; however, that is just the first step. Options for effectively treating addiction to prescription opioids are drawn from research on treating heroin addiction. Behavioral treatments, usually combined with medications, have also been proven effective.
A second class of psychoactive drugs that can be abused as a prescription drug is depressants. Depressants (e.g., tranquilizers, sedatives) are medications that slow normal brain function. In higher doses, some CNS depressants can be used as general anesthetics or pre-anesthetics (barbiturates, such as mephobarbital (Mebaral) and sodium pentobarbital (Nembutal), are used as pre-anesthetics, promoting drowsiness and sleep).
Benzodiazepines, such as diazepam (Valium), alprazolam (Xanax), and estazolam (ProSom), can be prescribed to treat anxiety, acute stress reactions, panic attacks, convulsions, and sleep disorders. For the latter, benzodiazepines are usually prescribed only for short-term relief of sleep problems because of the development of tolerance and risk of addiction. Newer sleep medications, such as zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta), are now more commonly prescribed to treat sleep disorders. These medications are non-benzodiazepines that act at a subset of the benzodiazepine receptors and appear to have a lower risk for abuse and addiction.
CNS depressants are usually taken orally, sometimes in combination with other drugs or to counteract the effects of other licit or illicit drugs (e.g., stimulants). Most of the CNS depressants have similar actions in the brain: they enhance the actions of the neurotransmitter gamma-aminobutyric acid (GABA). GABA works by decreasing brain activity. Although different classes of CNS depressants work in unique ways, it is ultimately their common ability to increase GABA activity that produces a drowsy or calming effect. Despite their beneficial effects for people suffering from anxiety or sleep disorders, barbiturates and benzodiazepines can be addictive and should be used only as prescribed.
Depressants should not be combined with any medication or substance that causes drowsiness, including prescription pain medicines, certain OTC cold and allergy medications, and alcohol. If combined, they can slow both heart rate and respiration, which can be fatal.
Discontinuing prolonged use of high doses of CNS depressants can lead to serious withdrawal symptoms. Because the drug works by slowing the brains activity, when one stops taking a CNS depressant, this activity can rebound to the point that seizures can occur. Someone who is either thinking about ending use of a CNS depressant, or who has stopped and is suffering withdrawal should seek immediate medical treatment.
In addition to medical supervision during withdrawal, counseling in an inpatient or outpatient setting can help people who are overcoming addiction to CNS depressants. For example, cognitive-behavioral therapy (CBT) has been used successfully to help individuals in treatment for abuse of benzodiazepines. This type of therapy focuses on modifying a patients thinking, expectations, and behaviors while simultaneously increasing his or her skills for coping with various life stressors.
A third class of psychoactive drugs that can be abused as a prescription drug is stimulants. Stimulants (amphetamines [Adderall, Dexedrine] and methylphenidate [Concerta, Ritalin]) increase alertness, attention, and energy. They also increase blood pressure and heart rate, constrict blood vessels, increase blood glucose, and open up the pathways of the respiratory system. Historically, stimulants were prescribed to treat asthma and other respiratory problems, obesity, neurological disorders, and a variety of other ailments. As their potential for abuse and addiction became apparent, the prescribing of stimulants by physicians began to wane. Now, stimulants are prescribed for treating only a few health conditions, most notably ADHD, narcolepsy, and, in some instances, depression that has not responded to other treatments.
Stimulants may be taken orally, but some abusers crush the tablets, dissolve them in water, and then inject the mixture; complications can arise from this because insoluble fillers in the tablets can block small blood vessels. Stimulants have been abused for both performance enhancement and recreational purposes (i.e., to get high).
Stimulants have chemical structures that are similar to neurotransmitters called monoamines (includes dopamine and nor-epinephrine). Their therapeutic effect is achieved by slow and steady increases of dopamine that are similar to the natural production of this chemical by the brain. The doses prescribed by physicians start low and increase gradually until a therapeutic effect is reached. However, when taken in doses and routes other than those prescribed, stimulants can increase the dopamine levels in a rapid and highly amplified manner disrupting normal communication between brain cells, producing euphoria, and increasing the risk of addiction.
Taking high doses of a stimulant can result in an irregular heartbeat, dangerously high body temperatures, and/or the potential for cardiovascular failure or seizures. Taking some stimulants in high doses or repeatedly can lead to hostility or feelings of paranoia in some individuals. Stimulants should not be mixed with antidepressants, which may enhance the effects of a stimulant; or with OTC cold medicines containing decongestants, which may cause blood pressure to become dangerously high or may lead to irregular heart rhythms.
Treatment of addiction to prescription stimulants is based on behavioral therapies proven effective for treating cocaine or methamphetamine addiction. At this time, there are no proven medications for the treatment of stimulant addiction. Depending on the patient situation, the first step in treating prescription stimulant addiction may be to decrease the drugs dose slowly and attempt to treat withdrawal symptoms (mood changes, sleep and appetite disturbances). This process of detoxification could then be followed with one of many behavioral therapies: contingency management, for example, improves treatment outcomes by enabling patients to earn vouchers for drug-free urine tests; the vouchers can be exchanged for items that promote healthy living. Cognitive-behavioral- Therapy (CBT) which teaches patients skills to recognize risky situations, avoid drug use, and cope more effectively with problems has proving beneficial. Recovery support groups may also be effective in conjunction with a behavioral therapy.
Monitoring the Future (MTF) survey each year assesses the extent of drug use among 8th-, 10th-, and 12th-graders nationwide. Nonmedical use of any prescription drug is reported only for 12th-graders. In 2009, 16 million Americans age 12 and older had taken a prescription pain reliever, tranquilizer, stimulant, or sedative for nonmedical purposes at least once in the year prior to being surveyed. Source: National Survey on Drug Use and Health (Substance Abuse and Mental Health Administration Web Site). The NIDA-funded 2010 Monitoring the Future Study showed that 2.7% of 8th graders, 7.7% of 10th graders, and 8.0% of 12th graders had abused Vicodin and 2.1% of 8th graders, 4.6% of 10th graders, and 5.1% of 12th graders had abused OxyContin for nonmedical purposes at least once in the year prior to being surveyed. Source: Monitoring the FutureExternal link, please review our disclaimer. (University of Michigan Web Site).
Inhalants are a diverse group of volatile substances whose chemical vapors can be inhaled to produce psychoactive (mind-altering) effects. While other abused substances can be inhaled, the term inhalants are used to describe substances that are rarely, if ever, taken by any other route of administration. A variety of products common in the home and workplace contain substances that can be inhaled to get high; however, people do not typically think of these products (e.g., spray paints, glues, and cleaning fluids) as drugs because they were never intended to induce intoxicating effects. Yet young children and adolescents can easily obtain these extremely toxic substances and are among those most likely to abuse them. Inhalants generally fall into the following categories:
Volatile solventsliquids that vaporize at room temperature;
- Industrial or household products, including paint thinners or removers, degreasers, dry-cleaning fluids, gasoline, and lighter fluid;
- Art or office supply solvents, including correction fluids, felt-tip marker fluid, electronic contact cleaners, and glue;
- Aerosolssprays that contain propellants and solvents; Household aerosol propellants in items such as spray paints, hair or deodorant sprays, fabric protector sprays, aerosol computer cleaning products, and vegetable oil sprays;
- Gases found in household or commercial products and used as medical anesthetics;
- Household or commercial products, including butane lighters and propane tanks, whipped cream aerosols or dispensers (whippets), and refrigerant gases;
- Medical anesthetics, such as ether, chloroform, halothane, and nitrous oxide (laughing gas);
- Nitritesa special class of inhalants that are used primarily as sexual enhancers
Organic nitrites are volatiles that include cyclohexyl, butyl, and amyl nitrites, commonly known as poppers. Amyl nitrite is still used in certain diagnostic medical procedures. When marketed for illicit use, organic nitrites are often sold in small brown bottles labeled as video head cleaner, room odorizer, leather cleaner, or liquid aroma. These various products contain a wide range of chemicals such as-toluene (spray paints, rubber cement, gasoline), chlorinated hydrocarbons (dry-cleaning chemicals, correction fluids), hexane (glues, gasoline), benzene (gasoline), methylene chloride (varnish removers, paint thinners), butane (cigarette lighter refills, air fresheners), and nitrous oxide (whipped cream dispensers, gas cylinders).
Adolescents tend to abuse different products at different ages. Among new users, ages 12 to 15, the most commonly abused inhalants are glue, shoe polish, spray paints, gasoline, and lighter fluid. Among new users age 16 or 17, the most commonly abused products are nitrous oxide or whippets. Nitrites are the class of inhalants most commonly abused by adults. Inhalants can be breathed in through the nose or mouth in a variety of ways (known as huffing), such as sniffing or snorting fumes from a container, spraying aerosols directly into the nose or mouth, or placing an inhalant-soaked rag in the mouth. Users may also inhale fumes from a balloon or a plastic or paper bag that contains an inhalant. The intoxication produced by inhalants usually lasts just a few minutes; therefore, users often try to extend the high by continuing to inhale repeatedly over several hours.
The effects of inhalants are similar to those of alcohol, including slurred speech, lack of coordination, euphoria, and dizziness. Inhalant abusers may also experience lightheadedness, hallucinations, and delusions. With repeated inhalations, many users feel less inhibited and less in control. Some may feel drowsy for several hours and experience a lingering headache. Chemicals found in different types of inhaled products may produce a variety of additional effects, such as confusion, nausea, or vomiting. By displacing air in the lungs, inhalants deprive the body of oxygen, a condition known as hypoxia. Hypoxia can damage cells throughout the body, but the cells of the brain are especially sensitive to it. The symptoms of brain hypoxia vary according to which regions of the brain are affected: for example, the hippocampus helps control memory, so someone who repeatedly uses inhalants may lose the ability to learn new things or may have a hard time carrying on simple conversations.
Long-term inhalant abuse can also break down myelin, a fatty tissue that surrounds and protects some nerve fibers. Myelin helps nerve fibers carry their messages quickly and efficiently, and when damaged, can lead to muscle spasms and tremors or even permanent difficulty with basic actions such as walking, bending, and talking.
Although not very common, addiction to inhalants can occur with repeated abuse. According to the 2007 Treatment Episode Data Set, inhalants were reported as the primary substance abused by less than 0.1 percent of all individuals admitted to substance abuse treatment. Sniffing highly concentrated amounts of the chemicals in solvents or aerosol sprays can directly induce heart failure and death within minutes of a session of repeated inhalation. This syndrome, known as sudden sniffing death, can result from a single session of inhalant use by an otherwise healthy young person. Sudden sniffing death is particularly associated with the abuse of butane, propane, and chemicals in aerosols. High concentrations of inhalants may also cause death from suffocation by displacing oxygen in the lungs, causing the user to lose consciousness and stop breathing. Deliberately inhaling from a paper or plastic bag or in a closed area greatly increases the chances of suffocation. Even when using aerosols or volatile products for their legitimate purposes (i.e., painting, cleaning), it is wise to do so in a well-ventilated room or outdoors.
Because nitrites are abused to enhance sexual pleasure and performance, they can be associated with unsafe sexual practices that greatly increase the risk of contracting and spreading infectious diseases such as HIV/AIDS and hepatitis.
In 2009, 2.1 million Americans age 12 and older had abused inhalants. Source: National Survey on Drug Use and Health (Substance Abuse and Mental Health Administration Web Site). The NIDA-funded 2010 Monitoring the Future Study showed that 8.1% of 8th graders, 5.7% of 10th graders, and 3.6% of 12th graders had abused inhalants at least once in the year prior to being surveyed. Source: Monitoring the FutureExternal link, please review our disclaimer. (University of Michigan Web Site).
Anabolic-androgenic steroids (AAS) are synthetically produced variants of the naturally occurring male sex hormone testosterone. Anabolic refers to muscle-building, and androgenic refers to increased male sexual characteristics. Steroids refers to the class of drugs. These drugs can be legally prescribed to treat conditions resulting from steroid hormone deficiency, such as delayed puberty, as well as diseases that result in loss of lean muscle mass, such as cancer and AIDs. Some people, both athletes and non-athletes, abuse AAS in an attempt to enhance performance and/or improve physical appearance. AAS are taken orally or injected, typically in cycles rather than continuously. Cycling refers to a pattern of use in which steroids are taken for periods of weeks or months, after which use is stopped for a period of time and then restarted. In addition, users often combine several different types of steroids in an attempt to maximize their effectiveness, a practice referred to as stacking.
The immediate effects of AAS in the brain are mediated by their binding to androgen (male sex hormone) and estrogen (female sex hormone) receptors on the surface of a cell. This AASreceptor complex can then shuttle into the cell nucleus to influence patterns of gene expression. Because of this, the acute effects of AAS in the brain are substantially different from those of other drugs of abuse. The most important difference is that AAS are not euphorigenic, meaning they do not trigger rapid increases in the neurotransmitter dopamine, which is responsible for the high that often drives substance abuse behaviors. However, long-term use of AAS can eventually have an impact on some of the same brain pathways and chemicalssuch as dopamine, serotonin, and opioid systemsthat are affected by other drugs of abuse. Considering the combined effect of their complex direct and indirect actions, it is not surprising that AAS can affect mood and behavior in significant ways. Preclinical, clinical, and anecdotal reports suggest that steroids may contribute to psychiatric dysfunction. Research shows that abuse of anabolic steroids may lead to aggression and other adverse effects.1 For example, although many users report feeling good about themselves while on anabolic steroids, extreme mood swings can also occur, including manic-like symptoms that could lead to violence.2 Researchers have also observed that users may suffer from paranoid jealousy, extreme irritability, delusions, and impaired judgment stemming from feelings of invincibility.
Animal studies indicate that AAS are reinforcingthat is, animals will self-administer AAS when given the opportunity, just as they do with other addictive drugs. This property is more difficult to demonstrate in humans, but the potential for AAS abusers to become addicted is consistent with their continued abuse despite physical problems and negative effects on social relations.5 Also, steroid abusers typically spend large amounts of time and money obtaining the drug: this is another indication of addiction. Individuals who abuse steroids can experience withdrawal symptoms when they stop taking AASthese include mood swings, fatigue, restlessness, loss of appetite, insomnia, reduced sex drive, and steroid cravings, all of which may contribute to continued abuse. One of the most dangerous withdrawal symptoms is depression when persistent, it can sometimes lead to suicide attempts.
Steroid abuse can lead to serious, even irreversible health problems. Some of the most dangerous among these include liver damage; jaundice (yellowish pigmentation of skin, tissues, and body fluids); fluid retention; high blood pressure; increases in LDL (bad cholesterol); and decreases in HDL (good cholesterol). Other reported effects include renal failure, severe acne, and trembling. In addition, there are some gender- and age-specific adverse effects: For menshrinking of the testicles, reduced sperm count, infertility, baldness, development of breasts, increased risk for prostate cancer; For womengrowth of facial hair, male-pattern baldness, changes in or cessation of the menstrual cycle, enlargement of the clitoris, deepened voice; For adolescentsstunted growth due to premature skeletal maturation and accelerated puberty changes; risk of not reaching expected height if AAS is taken before the typical adolescent growth spurt. In addition, people who inject AAS run the added risk of contracting or transmitting HIV/AIDS or hepatitis, which causes serious damage to the liver.
There has been very little research on treatment for AAS abuse. Current knowledge derives largely from the experiences of a small number of physicians who have worked with patients undergoing steroid withdrawal. They have learned that, in general, supportive therapy combined with education about possible withdrawal symptoms is sufficient in some cases. Sometimes, medications can be used to restore the balance of the hormonal system after its disruption by steroid abuse. If symptoms are severe or prolonged, symptomatic medications or hospitalization may be needed.
Monitoring the Future is an annual survey used to assess drug use among the Nations 8th-, 10th-, and 12th-grade students. While steroid use remained stable among all grades from 2007 to 2008, there has been a significant reduction since 2001 for nearly all prevalence periods (i.e., lifetime, past-year, and past-month use) among all grades surveyed. The exception was past-month use among 12th-graders, which has remained stable. Males consistently report higher rates of use than females: for example, in 2008, 2.5 percent of 12th-grade males, versus 0.6 percent of 12th-grade females, reported past-year use.
In 2009, 2.1 million Americans age 12 and older had abused inhalants. Source: National Survey on Drug Use and Health (Substance Abuse and Mental Health Administration Web Site). The NIDA-funded 2010 Monitoring the Future Study showed that 8.1% of 8th graders, 5.7% of 10th graders, and 3.6% of 12th graders had abused inhalants at least once in the year prior to being surveyed. Source: Monitoring the FutureExternal link, please review our disclaimer. (University of Michigan Web Site).
Club drugs are a pharmacologically heterogeneous group of psychoactive drugs that tend to be abused by young adults at bars, nightclubs, concerts, and parties. Gamma hydroxybutyrate (GHB), Rohypnol, ketamine, are featured in this group. GHB (Xyrem) is a central nervous system (CNS) depressant that was approved by the Food and Drug Administration (FDA) in 2002 for use in the treatment of narcolepsy (a sleep disorder). This approval came with severe restrictions, including its use only for the treatment of narcolepsy, and the requirement for a patient registry monitored by the FDA. GHB is also a metabolite of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). It exists naturally in the brain, but at much lower concentrations than those found when GHB is abused.
Rohypnol (flunitrazepam) use began gaining popularity in the United States in the early 1990s. It is a benzodiazepine (chemically similar to sedative-hypnotic drugs such as Valium or Xanax), but it is not approved for medical use in this country, and its importation is banned.
Ketamine is a dissociative anesthetic, mostly used in veterinary practice.
GHB and Rohypnol are available in odorless, colorless, and tasteless forms that are frequently combined with alcohol and other beverages. Both drugs have been used to commit sexual assaults (also known as date rape) due to their ability to sedate and incapacitate unsuspecting victims, preventing them from resisting sexual assault. GHB is usually ingested orally, either in liquid or powder form, while Rohypnol is typically taken orally in pill form. Recent reports, however, have shown that Rohypnol is being ground up and snorted. Both GHB and Rohypnol are also abused for their intoxicating effects, similar to other CNS depressants. GHB also has anabolic effects (it stimulates protein synthesis) and has been used by bodybuilders to aid in fat reduction and muscle building. Ketamine is usually snorted or injected intramuscularly.
Affect on the Brain
GHB acts on at least two sites in the brain: the GABAB receptor and a specific GHB binding site. At high doses, GHBs sedative effects may result in sleep, coma, or death. Rohypnol, like other benzodiazepines, acts at the GABAA receptor. It can produce low grade amnesia, in which individuals may not remember events they experienced while under the influence of the drug. Ketamine is a dissociative anesthetic, so called because it distorts perceptions of sight and sound and produces feelings of detachment from the environment and self. Ketamine acts on a type of glutamate receptor (NMDA receptor) to produce its effects, which are similar to those of the drug PCP., Low-dose intoxication results in impaired attention, learning ability, and memory. At higher doses, ketamine can cause dreamlike states and hallucinations; and at higher doses still, ketamine can cause delirium and amnesia.
Repeated use of GHB may lead to withdrawal effects, including insomnia, anxiety, tremors, and sweating. Severe withdrawal reactions have been reported among patients presenting from an overdose of GHB or related compounds, especially if other drugs or alcohol are involved. Like other benzodiazepines, chronic use of Rohypnol can produce tolerance, physical dependence, and addiction. There have been reports of people binging on ketamine, a behavior that is similar to that seen in some cocaine- or amphetamine-dependent individuals. Ketamine users can develop signs of tolerance and cravings for the drug.
Uncertainties about the sources, chemicals, and possible contaminants used to manufacture many club drugs make it extremely difficult to determine toxicity and associated medical consequences. Nonetheless, we do know that: Coma and seizures can occur following use of GHB. Combined use with other drugs such as alcohol can result in nausea and breathing difficulties. GHB and two of its precursors, gamma butyrolactone (GBL) and 1,4 butanediol (BD), have been involved in poisonings, overdoses, date rapes, and deaths. Rohypnol may be lethal when mixed with alcohol and/or other CNS depressants. Ketamine, in high doses, can cause impaired motor function, high blood pressure, and potentially fatal respiratory problems.
There is very little treatment information available for persons who abuse or are dependent upon club drugs. There are no GHB detection tests for use in emergency rooms, and as many clinicians are unfamiliar with the drug, many GHB incidents likely go undetected. According to case reports, however, patients who abuse GHB generally present a mixed picture of severe problems and generally respond well to treatment (often involves a residential program).
Treatment for Rohypnol follows accepted protocols for any benzodiazepine, which may consist of a 3- to 5-day inpatient detoxification program with 24-hour intensive medical monitoring and management of withdrawal symptoms, since withdrawal from benzodiazepines can be life-threatening.
Patients with a ketamine overdose are managed through supportive care for acute symptoms, with special attention to cardiac and respiratory functions.
Extent of Abuse
The NIDA-funded 2010 Monitoring the Future Study showed that 0.5% of 8th graders, 0.6% of 10th graders, and 1.5% of 12th graders had abused Rohypnol; 0.6% of 8th graders, 0.6% of 10th graders, and 1.4% of 12th graders had abused GHB; and 1.0% of 8th graders, 1.1% of 10th graders, and 1.6% of 12th graders had abused ketamine at least once in the year prior to their being surveyed. Source: Monitoring the FutureExternal link, please review our disclaimer. (University of Michigan Web Site).
Qs and As (Note: Qs are general in nature and not necessarily directed specifically at Club drugs)
Q-1: How Do drugs Produce Euphoria?
Drugs change the way the brain works by changing the way nerve cells communicate. Nerve cells, called neurons, send messages to each other by releasing chemicals called neurotransmitters. Neurotransmitters work by attaching to key sites on neurons called receptors. Learn more about how neurotransmitters work in the section How Does Your Brain Communicate?
There are many neurotransmitters, but dopamine is one that is directly affected by most stimulants. Dopamine makes people feel good when they do something they enjoy, like eating a piece of chocolate cake or riding a roller coaster. Stimulants cause a buildup of dopamine in the brain, which can make people who abuse stimulants feel intense pleasure and increased energy. They can also make people feel anxious and paranoid. And with repeated use, stimulants can disrupt the functioning of the brains dopamine system, dampening users ability to feel any pleasure at all. Users may try to compensate by taking more and more of the drug to experience the same pleasure.
Q 2: What Are the Short-Term Effects?
In the short term, some drugs especially stimulants can produce joyful feelings, increase wakefulness, and decreases appetite. Users can become more talkative, energetic, or anxious and irritable. Other short-term effects of stimulants can include increased body temperature, heart rate, and blood pressure; dilated pupils; nausea; blurred vision; muscle spasms; and confusion. Stimulants can also cause the bodys blood vessels to narrow, constricting the flow of blood, which forces the heart to work harder to pump blood through the body. The heart may work so hard that it temporarily loses its natural rhythm. This is called fibrillation and can be very dangerous because it stops the flow of blood through the body.
Q 3: What Are the Long-Term Effects?
As with many types of drugs, repeated abuse can cause addiction. That means that someone repeatedly seeks out and uses the drug despite its harmful effects. Repeated drug use changes the brain in ways that contribute to the drug craving and continued drug seeking and use that characterizes addiction. Other effects of long-term stimulant abuse can include paranoia, aggressiveness, extreme anorexia, thinking problems, visual and auditory hallucinations, delusions, and severe dental problems.
For example, repeated use of cocaine can lead to tolerance of its euphoric effects, causing the user to take higher doses or to use the drug more frequently (e.g., binge use) to get the same effects. Such use can lead to bizarre, erratic behavior. Some cocaine users experience panic attacks or episodes of full-blown paranoid psychosis, in which the individual loses touch with reality and hears sounds that arent there (auditory hallucinations). Different ways of using cocaine can produce different adverse effects. For example, regularly snorting cocaine can lead to hoarseness, loss of the sense of smell, nosebleeds, and a chronically runny nose. Cocaine taken orally can cause reduced blood flow, leading to bowel problems.
Repeated use of methamphetamine can cause violent behavior, mood disturbances, and psychosis, which can include paranoia, auditory hallucinations, and delusions (e.g., the sensation of insects creeping on the skin. The paranoia can result in homicidal and suicidal thoughts. Methamphetamine can increase a persons sex drive and is linked to risky sexual behaviors and the transmission of infectious diseases, such as HIV. However, research also indicates that long-term methamphetamine use may be associated with decreased sexual function, at least in men.
Q 4: Can These Drugs Be Lethal?
Yes, in rare instances, sudden death can occur on the first use of cocaine or unexpectedly thereafter. And, like most drugs, stimulants can be lethal when taken in large doses or mixed with other substances. Stimulant overdoses can lead to heart problems, strokes, hyperthermia (elevated body temperature), and convulsions, which if not treated immediately can result in death. Abuse of both cocaine and alcohol compounds the danger, increasing the risk of overdose.
Q 5: What Are the Differences Between Cocaine and Methamphetamine?
They act in different ways to increase dopamine in the brain. Cocaine works by blocking the dopamine transporter; that is, it doesnt allow dopamine to be recycled back into the neuron after it has done its work. Methamphetamine interferes with this recycling process as well, but it also causes too much dopamine to be released. Another difference is that cocaine disappears from the brain quickly, while methamphetamine has a much longer duration of action. The longer presence in the brain ultimately makes methamphetamine more harmful to brain cells.
Q 6: If a Pregnant Woman Uses Stimulants, Will the Baby Be Hurt?
In the United States between 2006 and 2007, 22.6 percent (or 20,000) of teens ages 15 to 17 used an illicit drug during their pregnancy. Scientists have found that exposure to cocaine during fetal development may lead to subtle but significant deficits later in life, including problems with attention and information processingabilities that are important for success in school. Research is also underway on the effects of methamphetamine use during pregnancy. So far, the data suggest that it may affect fetal growth and contribute to poor quality of movement in infants.
Research in this area is particularly difficult to interpret because it is often hard to single out a drugs specific effects among the multiple factors that can all interact to affect maternal, fetal, and child outcomes. These factors include exposure to all drugs of abuse, including nicotine and alcohol; extent of prenatal care; possible neglect or abuse of the child; exposure to violence in the environment; socioeconomic conditions; maternal nutrition; other health conditions; and exposure to sexually transmitted diseases.
Q 7: What Treatments Are Available for Stimulant Abuse?
Several behavioral therapies are effective in treating addiction to stimulants. These approaches are designed to help the person think differently, change their expectations and behaviors, and increase their skills in coping with various stresses in life. One form that is showing positive results in people addicted to either cocaine or methamphetamine is called contingency management, or motivational incentives (MI). These programs reward patients who refrain from using drugs by offering vouchers or prizes. MI may be particularly useful for helping patients to initially stop taking the drug and for helping them to stay in treatment.
Currently, there are no medications approved by the U.S. Food and Drug Administration to treat people who are addicted to stimulants, although that is an active area of research for NIDA.
As with other drugs of abuse, it is possible for individuals to become dependent upon or addicted too many stimulants. Withdrawal symptoms associated with discontinuing stimulant use include fatigue, depression, and disturbance of sleep patterns. Repeated use of some stimulants over a short period can lead to feelings of hostility or paranoia. Further, taking high doses of a stimulant may result in dangerously high body temperature and an irregular heartbeat. There is also the potential for cardiovascular failure or lethal seizures.
Stimulants should be used in combination with other medications only under a physician’s supervision. Patients also should be aware of the dangers associated with mixing stimulants and OTC cold medicines that contain decongestants; combining these substances may cause blood pressure to become dangerously high or lead to irregular heart rhythms.
Q 8: How does the brain communicate?
The brain is a communications center consisting of billions of neurons, or nerve cells. Networks of neurons pass messages back and forth to different structures within the brain, the spinal column, and the peripheral nervous system. These nerve networks coordinate and regulate everything we feel, think, and do. The brain communicates via:
Neuron to Neuron: Each nerve cell in the brain sends and receives messages in the form of electrical impulses. Once a cell receives and processes a message, it sends it on to other neurons.
Neurotransmitters: The messages are carried between neurons by chemicals called neurotransmitters. (
Receptors: The neurotransmitter attaches to a specialized site on the receiving cell called a receptor. A neurotransmitter and its receptor operate like a “key and lock,” an exquisitely specific mechanism that ensures that each receptor will forward the appropriate message only after interacting with the right kind of neurotransmitter.
Transporters: Located on the cell that releases the neurotransmitter, transporters recycle these neurotransmitters (i.e., bringing them back into the cell that released them), thereby shutting off the signal between neurons.
To send a message a brain cell releases a chemical (neurotransmitter) into the space separating two cells called the synapse. The neurotransmitter crosses the synapse and attaches to proteins (receptors) on the receiving brain cell. This causes changes in the receiving brain cell and the message is delivered.
Q 9: How do drugs work in the brain?
Drugs are chemicals. They work in the brain by tapping into the brain’s communication system and interfering with the way nerve cells 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 lock onto and activate the nerve cells. Although these drugs mimic brain chemicals, they don’t activate nerve cells 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 nerve cells to release abnormally large amounts of natural neurotransmitters or prevent the normal recycling of these brain chemicals. This disruption produces a greatly amplified message, ultimately disrupting communication channels. The difference in effect can be described as the difference between someone whispering into your ear and someone shouting into a microphone.
Q 10: How do drugs work in the brain to produce pleasure?
All 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, cognition, motivation, and feelings of pleasure. The overstimulation of this system, which rewards our natural behaviors, produces the euphoric effects sought by people who abuse drugs and teaches them to repeat the behavior.
Q 11: How does stimulation of the brain’s pleasure circuit teach us to keep taking drugs?
Our brains are wired to ensure that we will repeat life-sustaining activities by associating those activities with pleasure or reward. Whenever this reward circuit is activated, 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. Because drugs of abuse stimulate the same circuit, we learn to abuse drugs in the same way.
Q 12: Why are drugs more addictive than natural rewards?
When some drugs of abuse are taken, they can release 2 to 10 times the amount of dopamine that natural rewards do. In some cases, this occurs almost immediately (as when drugs are smoked or injected), and the effects can last much longer than those produced by natural rewards. The resulting effects on the brain’s pleasure circuit dwarfs those produced by naturally rewarding behaviors such as eating and sex.16,17 The effect of such a powerful reward strongly motivates people to take drugs again and again. This is why scientists sometimes say that drug abuse is something we learn to do very, very well.
Q 13: What happens to your brain if you keep taking drugs?
Just as we turn down the volume on a radio that is too loud, the brain adjusts to the overwhelming surges in dopamine (and other neurotransmitters) by producing less dopamine or by reducing the number of receptors that can receive and transmit signals. As a result, dopamine becomes abnormally low, and the ability to experience any pleasure is reduced. This is why the abuser eventually feels flat, lifeless, and depressed, and is unable to enjoy things that previously brought them pleasure. Now, they need to take drugs just to bring their dopamine function back up to normal. And, they must take larger amounts of the drug than they first did to create the dopamine high – an effect known as tolerance.
Q 14: How does long-term drug taking affect brain circuits?
We know that the same sort of mechanisms involved in the development of tolerance can eventually lead to profound changes in neurons and brain circuits, with the potential to severely compromise the long-term health of the brain. For example, glutamate is another neurotransmitter that influences the reward circuit and the ability to learn. When the optimal concentration of glutamate is altered by drug abuse, the brain attempts to compensate for this change, which can cause impairment in cognitive function. Similarly, long-term drug abuse can trigger adaptations in habit or non-conscious memory systems. Conditioning is one example of this type of learning, whereby environmental cues become associated with the drug experience and can trigger uncontrollable cravings if the individual is later exposed to these cues, even without the drug itself being available. This learned “reflex” is extremely robust and can emerge even after many years of abstinence.
Q 15: What other brain changes occur with abuse?
Chronic exposure to drugs of abuse disrupts the way critical brain structures interact to control behavior – behavior specifically related to drug abuse. Just as continued abuse may lead to tolerance or the need for higher drug dosages to produce an effect, it may also lead to addiction, which can drive an abuser to seek out and take drugs compulsively. Drug addiction erodes a person’s self-control and ability to make sound decisions, while sending intense impulses to take drugs.
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