DOING YOUR OWN RESEARCH

DOING YOUR OWN RESEARCH

If reading this book has raised your level of interest and you want more specific information, or you want the straight story about a new develop­ment, there is no substitute for doing your own research.

Reading both scholarly review articles and original research papers is much easier than most people believe. In fact, one of the first steps in writing this book was gathering such research. Much of the library work for the first edition was done by two college students, neither of whom had any previous experience using a medical library. Should you decide to investigate for yourself, here are some suggestions about where to begin.

Public libraries are not likely to have the sorts of journals and books you will need. Because there is such a vast amount of medical literature pub­lished, most universities with a medical school have a separate library just to house all this information. Find a medical library at a nearby medical school. If for some reason you cannot get to a medical school, check to sec if there is a college or university biology department nearby and use the

library they use.

Next, go to the library and make friends with the reference librarian, because you will need his or her help until you are familiar with the library and the search mechanisms. The most efficient way of searching the literature is to use MEDLINE or PubMed, databases of the National Library of Medicine, a US government institution that allows you  

search almost all the published medical literature on any subject you can think of related to health. You can search by author, title, subject, key­word, institution, and many other descriptors.

In most cases you will find far more information than you need. A good place to start is with reviews. Reviews are documents that consoli­date and summarize the research and literature available in a given area, and they are usually written in less technical language. Reading several recent reviews about the topic you are researching will help you form a base of knowledge about the subject. Practice using MEDLINE by start­ing out with simple concepts; for example, search for marijuana articles. There are hundreds of them, and many of the titles will be so technical that they might seem indecipherable. So tell the computer to select mari­juana review articles. This will reduce the number markedly.

If you have read Buzzed, then you know that one of the active ingredi­ents in marijuana is THC. Try searching for THC and you will get more articles. Refine your search by asking for reviews of THC and you will get articles different from those you did when you searched for marijuana in general. Play with the database and have fun. Search for all kinds of com­binations of keywords, like THC and learning, or THC and adolescent. You will soon have an idea of the enormous amount of information there is about just this chemical. Understand, though, that no one study tells the whole story.

As a final note, we caution you not to accept everything you read as directly applicable to the human condition. Often scientists employ very high levels of a chemical to test for toxic effects in animals, and sometimes the chemical levels they use in/on animals are hundreds or thousands of times higher than a human would ever use, taking into account the weight of the human compared to the animal. Consequently, some of the toxic effects seen in animals may not apply to humans. On the other hand, ani­mal experiments cannot reveal many subtle effects of chemicals, particu­larly psychological ones, and thus animal studies almost certainly miss some important effects that humans will experience. So, as you read a sci­entific paper, remember that it is just a small part of the literature about a drug, and while the data may be true, it is important to understand that data in the context of everything else known about the drug.

ADDICTION AND THE FAMILY CYCLE

ADDICTION AND THE FAMILY CYCLE

We are proposing that drug addiction can be thought of as part of a cyclical process involving three or more individuals, commonly the addict and his two parents or parent surrogates. These people form an intimate, interdependent, interpersonal system. At times the equi-librium of this interpersonal system is threatened, such as when discord between the parents is amplified to the point of impending separation. When this happens the addict becomes activated, his behavior changes, and he creates a situation that dramatically focuses attention upon himself This behavior can take a number of forms. For example, he may lose his temper, come home high, commit a serious crime, or overdose on drugs. Whatever its form, however, this action allows the parents to shift focus from their marital conflict to a parental overinvolvement with him. In effect, the movement is from an unstable dyadic interaction (e.g., parents alone) to a more stable triadic interaction (parents and addict). By focusing on the problems of the addict, no matter how severe or life-threatening, the parents choose a course that is apparently safer than dealing with long‑standing marital conflicts. Consequently—after the marital crisis has been successfully avoided—the addict shifts to a less provocative stance and begins to behave more competently. This is a new step in the sequence. As the addict demonstrates increased competence, indi-cating that he can function independently of the family—for example, by getting a job, getting married, enrolling in a methadone program, or detoxifying—the parents are left to deal with their previously unresolved conflicts. At this point in the cycle marital tensions increase and the threat of separation arises. The addict then behaves in an attention-getting or self-destructive way, and the dysfunctional triadic cycle continues.

This cycle can vary in its intensity. It may occur in subdued form in treatment sessions or during day-to-day interactions and conver-sations around the home. For example, a parent hinting at vacation-ing without the spouse may trigger a spurt of loud talking by the addict. If the stakes are increased, the cycle becomes more explosive and the actions of all participants grow more serious and more dramatic; for example, the parents threatening divorce might well be followed by the addict's overdosing. Whatever the intensity level, however, we have observed such patterns so often that we have almost come to take them for granted. Viewed from this perspective, the behavior of the addict serves an important protective function and helps to maintain the homeostatic balance of the family system.

The onset of the addictive cycle appears in many cases to occur at the time of adolescence and is intensified as issues of the addict's leaving home come to the fore. This developmental stage heralds difficult times for most families and requires that the parents renego-tiate their relationship—a relationship that will not include this child. However, since the parents of the addict are unable to relate to each other satisfactorily, the family reacts with panic when the integrity of the triadic relationship is threatened. Thus we find that most addicts' families become stabilized or stuck at this develop-mental stage in such a way that the addict remains intimately in-volved with them on a chronic basis. In addition to staying closely tied to the home, his failure to separate and become autonomous may take several other forms: (1) he may fail to develop stable, intimate (particularly heterosexual) relationships outside the family; (2) he may fail to become involved in a stable job, in school, or in another age-appropriate activity; (3) he may obtain work that is well below his capabilities; (4) he may become an addict.

PSEUDOINDIVIDUATION

The drug addict is locked in a dilemma. On the one hand he is under great pressure to remain intensely involved in the family (it may fall apart without him), while on the other, sociocultural and psycho-biological forces dictate that he establish intimate outside relation-ships. Addiction is the unique paradoxical solution to the addict and his family's dilemma of maintaining or dissolving the triadic inter-action. On the systems level, the addiction cycle serves to give the appearance of dramatic movement within the family as the triad is dissolved, reestablished, dissolved, and reestablished again. In addi-tion, the addict becomes involved in a homeostatic pattern of shuttling back and forth between his peers and his home. An interpersonal analysis of the system reveals, however, that the addict forms rela-tionships with the drug culture that in effect reinf orce his dependence on the family. Again, the outside relationships can be considered as the arena for pseudoindependent and pseudocompetent behavior by the addict while, paradoxically, the greater his involvement with the peer group, the more he becomes helpless, that is, addicted. This helplessness is redefined in a dependency-engendering way by the family, that is, as -sickness,- and is therefore acceptable.

SEPARATION' AND DEATH

The fear that these families show of the addict's departure or de-velopment of outside relationships, that is, their fear of separation, has another paradoxical quality. At the same time that he is held back from attachments to others he is engaged in activity that can poten-tially end his life—for example, through drug overdose. Yet this ultimate separation—death—is not viewed with the same terror as are other types of separation. The family seems to feel that his demise will somehow preserve the family system or pattern. In the short run this may be so. Upon the addict's death, the triadic inter-action is ostensibly dissolved, but in fact the parents are united in grief and, once again, can focus their attention on their child. Unlike addiction, however, this solution is only temporary. We have ob-served that the parents eventually find that marital conflicts once again lead to either (1) the formation of a new triad (e.g., another child becomes addicted, suicidal, or in other ways troublesome), or (2) the dissolution of their marital relationship.

Children Of Alcoholic Parents

            CHILDREN AND ADOLESCENTS

By far, alcohol is the drug used most often by high school students. Although most seniors cannot buy alcohol legally, 80 percent of them have tried alcohol and about one in five report that they have drunk heav­ily (more than five drinks in a row) in the past two weeks. This is actually good news, because the number of teens drinking heavily has declined somewhat in recent years. But that's not the end of the story. Recent stud­ies show that among students who engaged in heavy drinking, half had consumed ten or more drinks in one episode and a quarter had consumed fifteen. So, while heavy drinking at the "low" end of the scale (about five drinks in an episode) has declined recently, the rates of extreme heavy drinking have remained high.

The story among college students is not as simple as the media sometimes portray. Reports of "binge drinking" among college students can be mis­leading. First, the term hinge drinking is a bad one. Many people think of an alcohol binge as a period of several days during which a person stays drunk nearly all the time. This, of course, is a very dangerous pattern of drinking but is not what is meant by the media when they report on binge drinking among college students. In that context, binge drinking refers to a man haying five or more drinks in one sitting or a woman having four or more—clearly enough to put a person at risk for trouble, but hardly a binge in the traditional sense. We prefer to think of the four- or five-drink level as "high-risk drinking"—a more descriptive term. About 40 percent of college stu­dents report this level of high-risk drinking in the past two weeks, but there are also a significant number of college students who don't drink at all—about 20 to 25 percent depending upon the college. So it's important for students to know that, while a lot of students drink, not everybody on campus gets drunk every weekend, and a solid number of students don't drink at all. Still, there are often negative consequences for those who do. Nearly 600,000 college students suffer unintentional alcohol-related inju­ries each year, and more than 1,800 die from those injuries. In addition, 25 percent of college students report negative academic consequences related to their drinking each year, and more than 150,000 develop a health prob­lem related to alcohol use. Clearly, college drinking remains highly preva­lent and continues to take a toll on students' lives.

The problems associated with underage drinking are well known, and in recent years research has continued to show that alcohol affects the brain of younger people very differently from the way it affects that of adults. Part of this may be related to brain development. For example, we know that the brain does not finish developing until a person is in his midtwenties and that one of the last regions to mature is the frontal lobe area, which is intimately involved with the ability to plan and make com­plex judgments. Young brains also have rich resources for acquiring new memories and seem to be "built to learn." It is no accident that people in our society are educated during their early years, when they have more capacity for memory and learning. However, with this greater memory capacity come additional risks associated with the use of alcohol. Studies using animals have shown that when the brain is young, it is more sus­ceptible to some of the dangerous effects of alcohol, especially on learn­ing and memory function. And one study in humans showed that people in their early twenties were more vulnerable to the effects of alcohol on learning than were people just a few years older, in their late twenties. So it appears that children and adolescents who drink are powerfully impairing the brain functions on which they rely so heavily for learning. This is already indicated by very detailed cellular studies on learning-re­lated brain regions. In these studies (which, of course, can only be done using brain tissue from animals), it is clear that alcohol decreases the ability of brain circuits to change in the ways they must for learning to  basic cellular functioning occur far more strongly when the alcohol expo‑sure occurs during adolescence, compared to adulthood. In other words,it appears that adolescence is not only a time when single doses of alcohol affect the brain differently but also a time of enhanced vulnerability to the long-term effects of repeated alcohol exposure—even down to the level of individual brain cells. This adds to a strong and growing scientific literature that tells us that adolescents should hold off on drinking.

Another very good reason for teens to hold off on drinking is that there is a very strong relationship between the age at which one starts to drink and the likelihood of developing dependence on alcohol. People who start

drinking in their early to midteens are far more likely to develop alcohol

dependency, and to experience recurring episodes of dependency, than

are people who start drinking at age twenty-one or older. There are cer­tainly a number of reasons for this increased risk, and not all of them are biological, but it is clear from animal studies that adolescents develop tol­erance to some of alcohol's effects more rapidly than adults. In humans this could lead to a greater motivation to drink repeatedly. So, although it has always been controversial, our current state laws requiring a person to be twenty-one to drink make good sense from this perspective.

Most parents tend to be clueless when it comes to their children's drinking. For example, while 52 percent of tenth graders report having drunk alcohol in the past year, only 10 percent of parents of tenth graders believe that their child has consumed alcohol in that period. Interestingly, parents report believing that about 60 percent of tenth graders have con­sumed alcohol within the past year. So parents actually tend to overesti­mate the proportion of kids who drink—they just don't think it's their kids who are drinking! There are similar gaps between older teens' reported drinking and parents' beliefs about their drinking. Parents of twelfth graders are starting to see the light, but they still underestimate their kids' drinking significantly. The important message for parents is that alcohol is out there and its use is getting thrust at their children from many angles. Talk to your children about them.

WİLKİE WİLSON

Acohol Dependence

It is important to distinguish between alcohol dependence and alcohol abuse. Generally, alcohol abuse refers to patterns of drinking that give rise to health problems, social problems, or both. Alcohol dependence (often called alcoholism) refers to a disease that is characterized by abnormal seeking and consumption of alcohol that leads to a lack of control over drinking. Dependent individuals often appear to crave alcohol. They seem driven to drink even though they know that their drinking is causing problems for them. The signs of physical depen­dence begin within hours after an individual stops drinking. They include anxiety, tremors (shaking), sleep disturbances, and, in more extreme cases, hallucinations and seizures. Until a chronic drinker actually stops drinking, it is quite difficult to make a definitive assess­ment of alcohol dependence. But for most practical purposes, this for­mal diagnosis is unnecessary, because the social and medical problems that most alcoholics experience should be recognizable to health profes­sionals. See the section "How to Spot a Problem Drinker" on page 55 for some general guidelines.

PRENATAL EXPOSURE

The dangers of prenatal alcohol exposure have been noted since the time of Aristotle in ancient Greece. However, it was not until 1968 that formal reports began to emerge. The early studies of fetal alcohol syndrome (FAS) described gross physical deformities and profound mental retarda­tion among children of heavy-drinking alcoholic mothers. Although this was a very important set of findings, at first there was no evidence that women who drank more moderately were placing their children at risk. In fact, for many years, pregnant women were often encouraged to have a glass of wine with dinner or take a drink now and then during pregnancy to help them fall asleep or just to relax.

It took a while for the effects of moderate prenatal drinking to be noticed, because the children have none of the very obvious defects asso­ciated with the full-blown fetal alcohol syndrome. However, it is now clear that there is a less severe, but very well documented, pattern of defi­cits associated with more moderate prenatal drinking—a pattern described as fetal alcohol effects (FAE). School-age children with FAS or FAE are frequently described as hyperactive, distractible, and impulsive, with short attention spans—behaviors similar to those observed in chil­dren with attention deficit disorder (ADD). However, the FAS and FAR children differ from ADD children in that they are more intellectually

impaired. In recent years the term fetal alcohol spectrum disorders (FASD) has emerged as an umbrella term to include the full range of neurological, cognitive, behavioral, and learning disabilities associated with prenatal alcohol exposure.

The impairments of intelligence and behavior in people with FASD appear to persist into adulthood and are probably lifelong, resulting in IQ scores markedly below average, often well into the moderately retarded range. Those with PAS scored worse than those with RAE, but both were significantly below normal, hampered in reading and spell­ing and most profoundly deficient in mathematical skills. More import­ant, the FAE patients did not perform any better than the FAS patients on academic achievement tests, though their IQs were somewhat higher. What all this means is that even moderate drinking during pregnancy can create permanent intellectual disabilities. Some studies using animal models of FAE even suggest that just one drink per day impairs the function of brain areas related to learning in the adult offspring.

The bottom line is that there is no identified safe level of drinking during pregnancy. The smart decision for a woman is simply not to drink if she is pregnant or thinks that she might be.