INTERACTIONS WITH OTHER DRUGS

INTERACTIONS WITH OTHER DRUGS

Many people who experiment with hallucinogens combine them with other drugs. For example, it is not uncommon for people to take LSD or mushrooms and smoke marijuana at the same time. The effect of these combinations is highly individual and depends on the previous drug experience of the user, the doses, and the particular drugs involved. For example, smoking marijuana often triggers PHPD (flash­backs) in heavy LSD users. Many of these combinations produce bizarre, anxiety-provoking—but not dangerous—states.

The most troublesome reactions are those that are caused by the user taking something without knowing it. PCP is a frequent culprit in this regard. Marijuana can be adulterated with PCP without the user's knowledge and can induce a terrifying or dangerous state in the unsus­pecting users.

What about interactions with prescription drugs? Not surprisingly, other drugs that influence serotonin systems have been involved in reported interactions. There are multiple reports of serotonin-specific rcuptake inhibitors (SSRls) like Prozac (fluoxetine) triggering flashbacks in heavy LSD users. The opposite interaction also can happen: some patients who are taking SSRIs to treat depression report that they do not experience the effects of LSD. A more dangerous interaction could theo­retically happen if people combine SSRIs and avahuasca. The MAO inhib­itor in the ayahuasca can synergize with the increase in serotonin caused by the SSRI, leading to the dangerous "serotonin syndrome" that we dis­cuss in the "Ecstasy" chapter.

STRATEGIC APPROACH TO DRUG ABUSE

STRATEGIC APPROACH TO DRUG ABUSE

This section covers the principal elements of our model.* We use the term "structural—strategic- because we drew from the predominent practices of both these approaches, in addition to introducing some distinctive features of our own.T The general thrust is strategic, but many of the moment-to-moment or "micromoves" within sessions are of a more structural nature. In other words, the broad strokes tend to be strategic and the brushwork structural, with the single excep-tion of the regular use throughout of "noble ascriptions- (a description of which follows). More specifically, the procedure is to (1) apply

Minuchin's structural theory as a guiding paradigm; (2) work struc‑

turally within sessions through the actual enactment of new patterns, and the application of structural techniques such as joining, accom-modating, testing boundaries, restructuring, and so forth; (3) apply Haley's strategic model in terms of its emphasis on a specific plan,

extrasession events, change in the symptom, collaboration among treatment systems, and the

This therapy is goal-oriented and short-term. One advantage of a brief therapy model is that it catalyzes and compresses into a time span of 3 to 5 months a process that may otherwise be prolonged with no attendant increase in effectiveness. The short-term, contrac-tural arrangement forces more rapid change. If the therapist can maintain the family as an ally in this process, the approach can be quite effective.

Unlike prevalent practices in the drug-abuse field, we put heavy and continual emphasis on actively involving the addict's family of origin in therapy, even if he is not living with them. Part of the rationale for this rests on a developmental framework. As discussed earlier, these families have commonly gotten stuck at the stage when it is appropriate for the IP to leave home. They have not been able to traverse this stage and instead become fixed in a cycle in which the addict either moves out and then back in, or remains inappropriately and overly tied to the family in other ways. By convening the whole family, the therapist can more easily help them to go through this correctly. In a sense, the family is being asked to return to an earlier stage that was not successfully negotiated. and to do it -right" this time. Thus parental control is reinstated and then gradually and appro-priately relaxed. It should be noted that this process frequently intensifies the whole experience for the family, as members are brought closer together. Sometimes the result of this -compression" 162 is a counterreaction in which family members begin to insist on separation with much less of their previous ambivalence. During this period the therapist should attempt to prevent the process from running its usual course by slowing it down and planning the IP's departure carefully; an example of such a strategy is given in Chapter 7.

It has become clear to us that family treatment must first deal with the triad composed of addict and both parents (or parent surrogates) before proceeding further. It is our experience, and that of some others,152 that if this step is skipped, therapy will falter and possibly fail. In some cases with married addicts we started with the marital pair and found that it only served to stress or dissolve the marriage; thus, the addict would end up back with his parents. However, families differ in the ease with which the transition from family of origin to family, of procreation can be made. Sometimes the parents can be eased out of the picture (or, as in Chapter 10, their involvement reduced) within a few sessions, while other cases may require that they be involved throughout treatment. The key is to

start with the parent-addict triad and to move away from it in accordance with the parents' readiness to release the addict. We attempt to include all siblings living at home or in the immediate vicinity. The rule of thumb is to see how family members interact before concluding that any member is not needed in the sessions. Certainly absent siblings can behave homeostatically and undercut in-session accomplishments, and we consider it important both to get direct input from them and to gain some control over their interferences. For example, it is not uncommon for a male addict to have a powerful older sister who acts as a kind of mother surrogate. Agreements or contracts negotiated in the session, but without her concurrence, probably would stand a slim chance of

success.

On the other hand, siblings may serve a number of functions in

the sessions. They may act as allies to the addict and help to get him to assert himself more appropriately. Or, as in Chapter 9, they can be rallied to strengthen the position of a parent who is taking an appropriate stand. Often they provide a useful alternative focus and prevent exclusive attention from being given to the addict. It is not unusual to find siblings who are also addicted or have problems as severe as those of the addict (e.g., the case in Chapter 12). Finally, siblings always provide additional data on family interactions, which

the therapist may use to advantage.

From the above it may be clear why we place such inordinate

emphasis on family recruitment and engaging members in therapy, as outlined in Chapter 3, 4, and 5. Because the drug taking of the IP is so intimately a part of the interactional behavior of the whole family, a therapist who does not have direct access to other family members operates at a severe disadvantage. In addition, efforts by members to control session attendance are usually attempts to resist change,r1" so decisions as to who should or should not attend therapy are best made

by the therapist, not the family.

It would not be accurate to view our treatment approach as

always limited just to the addict and his immediate family. This may be the primary system involved, but other interpersonal systems are also engaged, as appropriate. We deal with them if they are par-ticularly relevant to the case and can serve to facilitate or hinder therapeutic progress. Such systems might include friends, important relatives, vocational counselors, employers, school or legal authorities, and, of course, the staff of the drug-treatment program itself. The interfaces among these systems are discussed at greater length later in the chapter.

IS THERE A DEFICIENT BRAIN CHEMISTRY IN ADDICTS?

IS THERE A DEFICIENT BRAIN CHEMISTRY IN ADDICTS?

If everyone with a brain can become an addict, why are there (relatively) so few addicts? Could there be a unique group of people whose pleasure circuits are abnormal in some way so that these drugs feel particularly good? Or could there be a group of people whose pleasure circuits don't work very well, so that they are inclined to drink alcohol, smoke, or take cocaine to feel normal? There are probably people in each of these catego­ries. In studying these questions in human addicts, there is a real "chicken and egg" problem. If brain function is abnormal, it is impossible to know whether the abnormality was caused by years of substance abuse or was present before. This is one challenge about the aforementioned dopamine receptor finding. Some scientists have tried to solve this problem by studying the children of alcoholics. There are certain EEG (brain wave) changes that have been noted in some alcoholics and in their sons. How­ever, we don't really understand the significance of this EEG anomaly yet. The only way to be sure is to study these children until they become adults to see if this difference predicted alcoholism. Such studies are underway, but they take a long time. We can do these experiments in animals, and we have found that even with free access to cocaine, only a certain per­centage of animals (about a fifth) progress to the stage of compulsive use. Are these differences due to a deficient gene that could simply be repaired? The mapping of the human genome has really speeded up the search for genes related to addiction as well as other diseases. Many candi­dates have been identified. Some are specific to specific addictions. A vari­ant of one gene for the receptor through which ethanol acts is associated with alcoholism, and a variant for a receptor that narcotics act upon is associated with narcotic addiction. Others, like the dopamine D2 receptor, are related to all addictions. Others have been surprises. One of the best

genetic "predictors' of nicotine dependence is a gene that controls the breakdown of nicotine in the liver—not anything related to brain function at all. Finally, there are genes that seem to protect people from addictions.

Two genes involved in alcohol degradation fit into this category (see the

chapter on alcohol). So, as many scientists predicted, drug addiction is a complicated disorder that can involve many genes. Can we fix the affected genes? Not yet. Do we want to? Because most or these genes affect normal brain activities, we are not even vaguely close to knowing if changing them would treat addiction without causing other troubles. And even if we

could, the ethical questions raised by such manipulations are huge. Finally, it is important to realize that biology is not destiny. People are more than bags of genes that produce behavior. They are influenced bytheir environment and can control their behavior voluntarily. Simply possessing a particular gene that has been found in the brains of some alco‑ holics does not mean that an individual must become an alcoholic. If he or she abstains from alcohol, for one thing, there will never be a problem.

Maybe these slightly abnormal genes provide some benefit to the person that we don't fully understand. On the other hand, people with no genetic predisposition may experience such traumatic life circumstances (being sexually abused during childhood, for example) that they develop com­pulsive use of alcohol or other substances in an attempt to self-medicate their psychological trauma. The bottom line is that everyone with a brain can become an addict. Given the diversity of human brains, it is likely that some people will find the experience more compelling than others, but we have not really defined exactly what brain chemistry leads to this vulnerability yet.

GETTING THE ADDICT TO AGREE TO INVOLVE HIS FAMILY OF ORIGIN

IN CONTRAST to the analysis presented thus far concerning the functional value of addiction in families,6T.'"• [".15"' 1" 54' v" a number of investigators have given evidence that the family can also be important in the rehabilitation of the addict. When family members are involved in the treatment process, the system can be changed toward helping the abusing member overcome his addiction rather than serving as a force that maintains it. To this point, Eldred and Washington42 found in interviews with 158 heroin addicts that the people who the patients thought would be most helpful to them in their attempts to give up drugs were the members of their families of origin or their in-laws; second and third choices were an opposite-sex partner and the patient himself. A group of 462 heroin addicts interviewed by MACRO Systems researchers91 reported that the family was second only to treatment (70.9% vs. 79.6%) as the influence they perceived as most important in changing their lives. Finally, a 5-year follow-up study of narcotics addicts by Levy92 found that patients who successfully over-came their drug habits most often had family support.

Studies of the effectiveness of family treatment have shown this to be a promising approach with alcoholism and many other symp-toms, and family therapies for drug problems have been gaining

This chapter is an expansion and revision of a paper by the first four authors entitled "Engaging 'Resistant' Families in Treatment: I. Getting the Drug Addict to Recruit His Family Members'. and is reprinted with permission from the International Journal of the Addictions, 1980, 15, 1069-1089. (1) Marcel Dekker, Inc. momentum in recent years. t" In fact, a 1976 national survey of 2012 drug programs by Coleman and Davis3" indicated that 93% were providing some kind of family services for at least a portion of their clients—in many cases, family therapy. Consequently, if there is a validity to such efforts, it is important to be able to induct family members into the treatment program. This chapter presents tech-niques pertaining to the initial facet of this process, that is, dealing with the addict in recruiting his family.*

As noted in the literature review in Chapter 5, authors who have dealt with this matter have noted how difficult it can be to bring family members of compulsive drug abusers into treatment. Most family members, especially parents, generally refuse to become involved. This is particularly interesting in view of the aforementioned evidence that the majority of drug addicts—especially those who use opiates—maintain close ties to their families of origin. If they do not live with one or both parents they may reside nearby and be in frequent contact (see Appendix A for a review of these studies). Thus it becomes all the more important that methods for effectively involving members of addicts' families in the treatment process be developed.

The AFP research design called for a Family Evaluation Session (see Appendix C), which included at least the addict, both his parents or parent surrogates (e.g., stepmother, mother's boyfriend), and any siblings living nearby. This session was required before treatment could proceed. (Although not included in the Family Evaluation Session, spouses of married addicts were usually involved in the therapy that followed it.) Obviously, this put considerable pressure on us to succeed in our recruiting efforts. The general procedure was for the person responsible for inducting the family to function as both drug counselor and family therapist. In approximately 80% of the cases we were able to obtain cooperation from the addict toward including his family, and in 88% of these we were able to get the family—including both parents or parent surrogates—to physically appear at the treatment site together. In other words, two-thirds of the subset of families we were unable to recruit occurred because the addict

*it should be noted that the primary emphasis of this chapter is upon young adult addicts. Adolescents may also manifest resistance to family involvement, However, the way the therapist handles the process may differ when encountering an adolescent versus a young adult, Some pointers and strategies for getting adoles‑

cents to agree to having their families become involved in therapy are presented in Chapter 13. would not allow us to contact his family, which underscores the emphasis given to the initial patient interview in this chapter.

JOHN M. VAN DEUSEN/M. DUNCAN STANTON/

SAMUEI. M. SCUTT/THOMAS C. TODD/DAVID T. MOWATT

RISK FACTORS FOR ALCOHOL ADDICTION

RISK FACTORS FOR ALCOHOL ADDICTION

Anyone can become dependent on alcohol. Continued exposure to alco­hol changes  brain in ways that produce dependence. Although there are large differences in individuals' risk for dependency and addiction, any person who puts enough alcohol into his brain over a long enough time will become physically dependent on the drug. Putting aside for a moment the risk factors that have been identified for alcohol dependence, the numbers generally show that the chances of a man becoming addicted to alcohol increase markedly if he drinks more than about three to four drinks per day. For women, the number of drinks is about three. Another consistent finding is that people who become addicted to alcohol are often those who report that they drink to relieve their emotional or social diffi­culties. In other words, if someone drinks to self-medicate—to block out emotional or social problems—he is especially likely to become addicted. But self-medication simply cannot account for all of the alcohol addiction in the world, and the big question remains: Why do some people choose to drink enough to get addicted?

GENETIC FACTORS

Much of the evidence that genetic factors may lead to alcohol dependence has come from studies on twins and children of alcoholics who were adopted at birth and raised by nonalcoholic adoptive parents. Studies like these allow researchers to begin to tease apart the separate influences of nature and nurture in the development of alcohol addiction. At present it seems clear that the basis of alcoholism is partly genetic but that genetic factors alone cannot account for the development of the disease. The real value of the nature versus nurture studies so far is that they have identi­fied certain traits, or markers, that run in families and predispose people to alcohol dependence. Thus, they help to identify individuals who may be at risk for developing alcohol problems. If a person knows that he is at more risk than normal for this disease, then he can make better decisions about drinking.

It is very clear that alcoholism, like diabetes, runs in families. With no family history of alcoholism, the risk of developing alcohol abuse problems is about 10 percent for men and 5 percent for women. How­ever, the risk nearly doubles if there is a family history of alcohol prob­lems. For example, for women who have a first-degree relative (child, sibling, or parent) who is an alcoholic, the chances rise from 5 percent to 10 percent. For men with a first-degree relative who is an alcoholic, the risk goes from 10 percent to 20 percent. So, for both men and women, the risk is doubled. The risk goes to 30 percent for men and 15 percent for women who have both a first-degree relative and a second- (e.g., uncle, aunt, grandparent) or third-degree relative (e.g., cousin, great-grandparent) who is an alcoholic. So, being the child of an alco­holic increases the risk of developing alcohol abuse problems, but boys are at considerably more risk than girls.

It is important to know that these family studies do not conclusively demonstrate a genetic basis for alcoholism. It is likely that factors other than biological ones, such as being raised by an alcoholic parent, also contribute to drinking behavior. A number of studies show that being raised in a family in which alcohol is abused increases a child's chances of becoming alcohol dependent.

A SPECIAL RISK FOR MEN

Although genetic influences significantly affect the risk of alcoholism in both men and women, these influences appear to be particularly powerful in men. A number of studies compare the sons of alcoholic fathers with sons of nonalcoholic fathers. In general, it appears that the sons of alco­holic fathers are less impaired by alcohol than those of nonalcoholic fathers. However, early in the drinking session (when the pleasurable effects of alcohol prevail), the sons of alcoholics appear to be more affected by alcohol than others. This difference suggests that sons of alcoholic fathers may have a more powerful experience of the pleasurable effects of alcohol and a less powerful experience of the impairing effects of alcohol than other men, creating a setup for these men to continue drinking over time and making them more susceptible to addiction.

In addition, a specific type of alcoholism seems to occur mostly in men. This is called Type II alcoholism and is characterized by an onset of drinking problems in adolescence, aggressive behavior, trouble with the law, and the use of other drugs. Type II alcoholism is considered to be very strongly influenced by genetics. Type 1 alcoholism is more common and less severe than Type II alcoholism, occurs in both men and women, and begins in adulthood. Men with fathers or brothers who show signs of Type IT alcoholism should be particularly careful about alcohol use.

HOW TO SPOT A PROBLEM DRINKER

flealtfficare practitioners use several simple screening tests to assess whether an individual may have an alcohol problem. Before describing them, though, we must make two cautionary notes. First, a diagnosis of alcohol abuse, alcohol dependency, or alcoholism can only truly be made by a health pro­fessional trained specifically in addiction. These are very complex medical and psychological states, and no simple screening tool is adequate to make a foolproof assessment. Second, it sometimes does considerably more harm than good to confront a friend or relative with the impression that she may have a drinking problem. Although a concerned person may have the best of intentions and may be acting out of true concern, the other person may simply feel accused and withdraw from the very help being offered. The screening tests we describe in what follows are often used in doctors' offices and clinics as a first indication that there might be a problem.

The most widely used screening test is called the CAGE:

·   Have you ever felt the need to Cut down on your drinking?

·   Have you ever felt Annoyed by someone criticizing your drinking?

·   Have you ever felt Guilty about your drinking?

·  Have you ever felt the need for an Eye-opener (a drink at the begin­ning of the day)?

If the person gives two or more positive responses to these questions, there is a good chance that she has some degree of an alcohol problem. But remember that screening tests are, by their nature, imperfect. For example, it is easy to imagine that a person with a history of heavy drink‑

ing might answer yes to all of the questions, even if she hadn't had a drink for years.

Another screening test, which has proven particularly useful with women, is called the TWEAK:

·      Tolerance: How many drinks does it take to make you high?

·   Worried: Have close friends or relatives worried or complained about your drinking?

·  Eye-opener: Do you sometimes take a drink in the morning to wake up?

·        Amnesia (memory loss): Has a friend or family member ever told you

things you said or did while you were drinking that you could not remember?

·   (K)Cut: Do you sometimes feel the need to cut down on your drinking?

This test is scored differently from the CAGE, but a positive score of

three or more is considered to indicate that the person likely has a drinking problem.

One final word of caution regarding these screening techniques: they all rely on one critical component (which is not always so reliable)--the person's own responses. There are any number of reasons why a person might not respond fully accurately. Therefore, while these screening tools may be useful as a first-pass indicator of a possible problem, they must not be used in isolation to form impressions about a person.

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.