Drug Abuse Sourcebook, 6th Ed.

Preface

About This Book

Drug abuse remains a growing problem in the United States. A survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) found that an estimated 24.6 million Americans ages 12 or older—9.4 percent of the population—had used an illicit drug or abused a prescription medication. This figure represented an increase from previous years mainly due to the widespread prevalence of marijuana use and increasing prescription drug misuse. There are spots of good news, however. The same survey also found that the abuse of other illicit drugs, such as heroin and cocaine, had decreased in recent years. Nevertheless, the medical, social, and familial costs of substance use are enormous—nearly $740 billion a year according to the U.S. Department of Justice (DOJ).

Drug Abuse Sourcebook, Sixth Edition provides updated information about the abuse of illegal drugs and the misuse of prescription and over-the-counter medications. It offers facts and statistics related to U.S. drug-using populations and presents details about specific drugs of abuse, including their health-related consequences, addiction potential, and other harms to individuals, their families, and communities. Drug treatment and recovery options are discussed, along with information on drug testing and drug-use prevention strategies for parents, employers, individuals, and others seeking help for themselves or a loved one. The book concludes with glossaries of terms related to drug abuse and directories of resources for additional help and information.

How to Use This Book

This book is divided into parts and chapters. Parts focus on broad areas of interest. Chapters are devoted to single topics within a part.

Part I: Facts and Statistics about Drug Abuse in the United States presents core data regarding the drug abuse problem, detailing the prevalence of drug abuse and the costs to society in terms of medical care, hospitalization, social consequences, and treatment outcomes. It also discusses federal regulation of prescriptions, laws pertaining to illegal and legal drugs, and the current debate over medical and legalized marijuana.

Part II: Drug Abuse and Specific Populations describes drug use initiation and the effects of drug abuse on various groups of people, including children, adolescents, and women. It also addresses different social factors affecting drug abuse, such as socioeconomic or employment status, and it considers drug use in inmate, veteran, senior, and disabled populations.

Part III: Drugs of Abuse provides facts about illicit and misused substances, such as performance enhancers, cannabinoids, inhalants, hallucinogens, narcotics, sedatives, and stimulants, including anabolic steroids, marijuana, Rohypnol, ecstasy (MDMA), LSD, heroin, hydrocodone, cocaine, methamphetamine, and many others. The part concludes with information about new and emerging drugs of abuse.

Part IV: The Causes and Consequences of Drug Abuse and Addiction explains the science behind addiction and what is known about the risk factors that can lead to drug dependency. Concerns related to coexisting alcohol problems or multidrug use are addressed, and the medical, legal, financial, and social ramifications of drug abuse are discussed. The part also looks at the connection between substance abuse and infectious diseases, and it addresses related mental-health issues, including suicide ideation.

Part V: Drug-Abuse Treatment and Recovery offers suggestions for recognizing the existence of a drug problem and options for taking steps toward achieving and maintaining a healthy lifestyle, including first aid, intervention, and detoxification. It provides details about various treatment approaches and reports on strategies for sustaining recovery. The part also discusses the legal rights of those in recovery and concerns related to the criminal-justice system.

Part VI: Drug-Abuse Testing and Prevention lays the groundwork for responses to drug abuse—in society, in schools, and especially in the home. It discusses the influence of parents on their children’s choices related to drug abuse, and it addresses concerns about preventing drug abuse in the workplace. Drug testing is discussed in detail, and federal drug-abuse prevention campaigns are described.

Part VII: Additional Help and Information provides resources for readers seeking further assistance. It includes a glossary of terms related to drug abuse and a listing of street terms for common drugs of abuse. It concludes with directories of state substance abuse agencies and other organizations providing resources on drug abuse and addiction.

Bibliographic Note

This volume contains documents and excerpts from publications issued by the following U.S. government agencies: Centers for Disease Control and Prevention (CDC); Centers for Medicare & Medicaid Services (CMS); DEA Diversion Control Division; Federal Bureau of Investigation (FBI); Get Smart About Drugs; Just Think Twice; National Cancer Institute (NCI); National Institute of Justice (NIJ); National Institutes of Health (NIH); National Institute on Drug Abuse (NIDA); National Institute on Drug Abuse (NIDA) for Teens; Office of Disease Prevention and Health Promotion (ODPHP); Office on Women’s Health (OWH); Substance Abuse and Mental Health Services Administration (SAMHSA); U.S. Department of Health and Human Services (HHS); U.S. Drug Enforcement Administration (DEA); and U.S. Food and Drug Administration (FDA).

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Part One

Facts and Statistics about Drug Abuse in the United States

Chapter 1

Prevalence of Drug Abuse in the United States

Although progress has been made in substantially lowering rates of substance abuse in the United States, the use of mind- and behavior-altering substances continues to take a major toll on the health of individuals, families, and communities nationwide.

Substance abuse—involving drugs, alcohol, or both—is associated with a range of destructive social conditions, including family disruptions, financial problems, lost productivity, failure in school, domestic violence, child abuse, and crime. Moreover, both social attitudes and legal responses to the consumption of alcohol and illicit drugs make substance abuse one of the most complex public-health issues. Estimates of the total overall costs of substance abuse in the United States, including lost productivity and health- and crime-related costs, exceed $600 billion annually.

Facts and Statistics on Substance Use in the United States

The Substance Abuse and Mental Health Services Administration (SAMHSA) conducts the annual National Survey on Drug Use and Health (NSDUH), a major source of information on substance use, abuse, and dependence among Americans age 12 years and older. Survey respondents report whether they have used specific substances ever in their lives (lifetime), over the past year, and over the past month (also referred to as current use). Most analyses focus on past-month use.

The following are facts and statistics on substance use in the United States in 2013, the most recent year for NSDUH survey results. Approximately 67,800 people responded to the survey in 2013.

Illicit-Drug Use

Illicit-drug use in the United States has been increasing. In 2013, an estimated 24.6 million Americans age 12 or older—9.4 percent of the population—had used an illicit drug in the month prior to when the survey was conducted. This number is up from 8.3 percent in 2002. The increase mostly reflects a rise in use of marijuana, the most commonly used illicit drug.

Figure 1.1. Illicit-Drug Use 2013

Marijuana use has increased since 2007. In 2013, there were 19.8 million current users—about 7.5 percent of people age 12 or older—up from 14.5 million (5.8%) in 2007.

Use of most drugs other than marijuana has stabilized over the past decade or has declined. In 2013, 6.5 million Americans age 12 or older (or 2.5%) had used prescription drugs nonmedically in the previous month. Prescription drugs include pain relievers, tranquilizers, stimulants, and sedatives. And 1.3 million Americans (0.5%) had used hallucinogens (a category that includes ecstasy and LSD (lysergic acid diethylamide)) in the past month.

Cocaine use has decreased in the last few years. In 2013, the number of current users age 12 or older was 1.5 million. This number is lower than in 2002 to 2007 (ranging from 2.0 to 2.4 million).

Methamphetamine use was higher in 2013, with 595,000 current users, compared with 353,000 users in 2010.

Most people use drugs for the first time when they are teenagers. There were just over 2.8 million new users of illicit drugs in 2013, or about 7,800 new users per day. Over half (54.1%) were under 18 years of age.

More than half of new illicit-drug users begin with marijuana. Next most common are prescription pain relievers, followed by inhalants (which is most common among younger teens).

Drug use is highest among people in their late teens and twenties. In 2013, 22.6 percent of 18- to 20-year-olds reported using an illicit drug in the past month.

Figure 1.2. Use of Selected Illicit Drugs

Figure 1.3. First Specific Drugs Associated with Initiation of Illicit-Drug Use 2013

Figure 1.4. Illicit-Drug Use by Age 2012 and 2013

Drug use is increasing among people in their fifties and early sixties. This increase is, in part, due to the aging of the baby boomers, whose rates of illicit-drug use have historically been higher than those of previous generations.

Figure 1.5. Illicit-Drug Use among Adults Age 50 to 64

Alcohol

Drinking by underage persons (ages 12 to 20) has declined. Current alcohol use by this age group declined from 28.8 to 22.7 percent between 2002 and 2013, while binge drinking declined from 19.3 to 14.2 percent and the rate of heavy drinking went from 6.2 to 3.7 percent.

Binge and heavy drinking are more widespread among men than women. In 2013, 30.2 percent of men and 16.0 percent of women 12 and older reported binge drinking in the past month. And 9.5 percent of men and 3.3 percent of women reported heavy alcohol use.

Driving under the influence of alcohol has also declined slightly. In 2013, an estimated 28.7 million people, or 10.9 percent of persons age 12 or older, had driven under the influence of alcohol at least once in the past year, down from 14.2 percent in 2002. Although this decline is encouraging, any driving under the influence remains a cause for concern.

Note: Binge drinking is five or more drinks on the same occasion. Heavy drinking is binge drinking on at least five separate days in the past month.

Tobacco

Fewer Americans are smoking. In 2013, an estimated 55.8 million Americans age 12 or older, or 21.3 percent of the population, were current cigarette smokers. This reflects a continual but slow downward trend from 2002, when the rate was 26 percent.

Teen smoking is declining more rapidly. The rate of past-month cigarette use among 12- to 17-year-olds went from 13 percent in 2002 to 5.6 percent in 2013.

Figure 1.6. Cigarette Use among Youth Age 12 to 17 by Gender

Substance Dependence/Abuse and Treatment

Rates of alcohol dependence/abuse declined from 2002 to 2013. In 2013, 17.3 million Americans (6.6% of the population) were dependent on alcohol or had problems related to their alcohol use (abuse). This is a decline from 18.1 million (or 7.7%) in 2002.

Figure 1.7. Specific Illicit-Drug Dependence or Abuse in 2013

After alcohol, marijuana has the highest rate of dependence or abuse among all drugs. In 2013, 4.2 million Americans met clinical criteria for dependence or abuse of marijuana in the past year—more than twice the number for dependence/abuse of prescription pain relievers (1.9 million) and nearly five times the number for dependence/abuse of cocaine (855,000).

There continues to be a large treatment gap in this country. In 2013, an estimated 22.7 million Americans (8.6%) needed treatment for a problem related to drugs or alcohol, but only about 2.5 million people (0.9%) received treatment at a specialty facility.

_____________

This chapter contains text excerpted from the following sources: Text in this chapter begins with excerpts from Substance Abuse, Office of Disease Prevention and Health Promotion (ODPHP), U.S. Department of Health and Human Services (HHS), July 20, 2018; Text under the heading Facts and Statistics on Substance Use in the United States is excerpted from DrugFacts: Nationwide Trends, National Institute on Drug Abuse (NIDA), June 2015. Reviewed January 2019.

Chapter 2

Drugs: Abuse and Addiction

Chapter Contents

Section 2.1—What Is Drug Abuse?

Section 2.2—What Is Drug Addiction?

Section 2.1

What Is Drug Abuse?

This section contains text excerpted from the following sources: Text in this section begins with excerpts from Drug Abuse, MedlinePlus, National Institutes of Health (NIH), December 28, 2016; Text under the heading How Drug Abuse Starts and Progresses is excerpted from Preventing Drug Use among Children and Adolescents (In Brief), National Institute on Drug Abuse (NIDA), October 2003. Reviewed January 2019.

Drug abuse is a serious public-health problem that affects almost every community and family in some way. Each year drug abuse causes millions of serious illnesses or injuries among Americans. Abused drugs include:

Methamphetamine

Anabolic steroids

Club drugs

Cocaine

Heroin

Inhalants

Marijuana

Prescription drugs, including opioids

Drug abuse also plays a role in many major social problems, such as drugged driving, violence, stress, and child abuse. Drug abuse can lead to homelessness, crime, and missed work or problems with keeping a job. It harms unborn babies and destroys families. There are different types of treatment for drug abuse. But the best approach is to prevent drug abuse in the first place.

How Drug Abuse Starts and Progresses

Studies such as the National Survey on Drug Use and Health (NSDUH), formally called the National Household Survey on Drug Abuse (NHSDA), reported by the Substance Abuse and Mental Health Services Administration (SAMHSA), indicate that some children are already abusing drugs at age 12 or 13, which likely means that some begin even earlier. Early abuse often includes such substances as tobacco, alcohol, inhalants, marijuana, and prescription drugs such as sleeping pills and antianxiety medicines. If drug abuse persists into later adolescence, abusers typically become more heavily involved with marijuana and then advance to other drugs, while continuing their abuse of tobacco and alcohol. Studies have also shown that abuse of drugs in late childhood and early adolescence is associated with greater drug involvement. It is important to note that most youth, however, do not progress to abusing other drugs.

Scientists have proposed various explanations for why some individuals become involved with drugs and then escalate to abuse. One explanation points to a biological cause, such as having a family history of drug or alcohol abuse. Another explanation is that abusing drugs can lead to affiliation with drug-abusing peers, which, in turn, exposes the individual to other drugs.

Researchers have found that youth who rapidly increase their substance abuse have high levels of risk factors with low levels of protective factors. Gender, race, and geographic location can also play a role in how and when children begin abusing drugs.

Section 2.2

What Is Drug Addiction?

This section includes text excerpted from Drugs, Brains, and Behavior: The Science of Addiction, National Institute on Drug Abuse (NIDA), July 2018.

Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control, and those changes may last a long time after a person has stopped taking drugs.

Addiction is a lot like other diseases, such as heart disease. Both disrupt the normal, healthy functioning of an organ in the body, both have serious harmful effects, and both are, in many cases, preventable and treatable. If left untreated, they can last a lifetime and may lead to death.

Note: The term addiction as used in this section, is equivalent to a severe substance use as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013).

Why Do People Take Drugs?

In general, people take drugs for a few reasons:

To feel good. Drugs can produce intense feelings of pleasure. This initial euphoria is followed by other effects, which differ with the type of drug used. For example, with stimulants such as cocaine, the high is followed by feelings of power, self-confidence, and increased energy. In contrast, the euphoria caused by opioids such as heroin is followed by feelings of relaxation and satisfaction.

To feel better. Some people who suffer from social anxiety, stress, and depression start using drugs to try to feel less anxious. Stress can play a major role in starting and continuing drug use as well as relapse (a return to drug use) in patients recovering from addiction.

To do better. Some people feel pressure to improve their focus in school or at work or their abilities in sports. This can play a role in trying or continuing to use drugs, such as prescription stimulants or cocaine.

Curiosity and social pressure. In this respect, teens are particularly at risk because peer pressure can be very strong. Teens are more likely than adults to act in risky or daring ways in an effort to impress their friends and show their independence from parents and social rules.

If Taking Drugs Makes People Feel Good or Better, What’s the Problem?

When they first use a drug, people may perceive what seem to be positive effects. They also may believe they can control their use. But drugs can quickly take over a person’s life. Over time, if drug use continues, other pleasurable activities become less pleasurable, and the person has to take the drug just to feel normal. They have a hard time controlling their need to take drugs even though it causes many problems for themselves and their loved ones. Some people may start to feel the need to take more of a drug or take it more often, even in the early stages of their drug use. These are the tell-tale signs of an addiction.

Even relatively moderate drug use poses dangers. Consider how a social drinker can become intoxicated, get behind the wheel of a car, and quickly turn a pleasurable activity into a tragedy that affects many lives. Occasional drug use, such as misusing an opioid to get high, can have similarly disastrous effects, including overdose and dangerously impaired driving.

Do People Freely Choose to Keep Using Drugs?

The initial decision to take drugs is typically voluntary. But with continued use, a person’s ability to exert self-control can become seriously impaired; this impairment in self-control is the hallmark of addiction.

Brain-imaging studies of people with addiction show physical changes in areas of the brain that are critical to judgment, decision-making, learning and memory, and behavior control. These changes help explain the compulsive nature of addiction.

Why Do Some People Become Addicted to Drugs, While Others Do Not?

As with other diseases and disorders, the likelihood of developing an addiction differs from person to person, and no single factor determines whether a person will become addicted to drugs. In general, the more risk factors a person has, the greater the chance that taking drugs will lead to drug use and addiction. Protective factors, on the other hand, reduce a person’s risk. Risk and protective factors may be either environmental or biological.

Table 2.1. Risk and Protective Factors

Figure 2.1. Risk Factors for Drug Addiction

What Biological Factors Increase Risk of Addiction

Biological factors that can affect a person’s risk of addiction include their genes, stage of development, and even gender or ethnicity. Scientists estimate that genes, including the effects environmental factors have on a person’s gene expression, called epigenetics, account for between 40 and 60 percent of a person’s risk of addiction. Also, teens and people with mental disorders are at greater risk of drug use and addiction than others.

What Environmental Factors Increase the Risk of Addiction

Environmental factors are those related to the family, school, and neighborhood. Factors that can increase a person’s risk include the following:

Home and family. The home environment, especially during childhood, is a very important factor. Parents or older family members who use drugs or misuse alcohol, or who break the law, can increase children’s risk of future drug problems.

Peer and school. Friends and other peers can have an increasingly strong influence during the teen years. Teens who use drugs can sway even those without risk factors to try drugs for the first time. Struggling in school or having poor social skills can put a child at further risk for using or becoming addicted to drugs.

What Other Factors Increase the Risk of Addiction

Besides the factors mentioned above there are a few other factors too that increase the risk of addiction. They are:

Early use. Although taking drugs at any age can lead to addiction, research shows that the earlier a person begins to use drugs, the more likely he or she is to develop serious problems. This may be due to the harmful effect that drugs can have on the developing brain. It also may result from a mix of early social and biological risk factors, including lack of a stable home or family, exposure to physical or sexual abuse, genes, or mental illness. Still, the fact remains that early use is a strong indicator of problems ahead, including addiction.

How the drug is taken. Smoking a drug or injecting it into a vein increases its addictive potential. Both smoked and injected drugs enter the brain within seconds, producing a powerful rush of pleasure. However, this intense high can fade within a few minutes. Scientists believe this starkly felt contrast drives some people to repeated drug taking in an attempt to recapture the fleeting pleasurable state.

The Adolescent Brain

The brain continues to develop into adulthood and undergoes dramatic changes during adolescence. One of the brain areas still maturing during adolescence is the prefrontal cortex—the part of the brain that allows people to assess situations, make sound decisions, and keep emotions and desires under control. The fact that this critical part of a teen’s brain is still a work in progress puts them at increased risk for making poor decisions, such as trying drugs or continuing to take them. Introducing drugs during this period of development may cause brain changes that have profound and long-lasting consequences.

Chapter 3

How Drugs Impact 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. The brain regulates your body’s basic functions, enables you to interpret and respond to everything you experience, and shapes your behavior. In short, your brain is you—everything you think and feel, and who you are.

How Does the Brain Work?

The brain is often likened to an incredibly complex and intricate computer. Instead of electrical circuits on the silicon chips that control our electronic devices, the brain consists of billions of cells, called "neurons," which are organized into circuits and networks. Each neuron acts as a switch controlling the flow of information. If a neuron receives enough signals from other neurons connected to it, it fires, sending its own signal on to other neurons in the circuit.

The brain is made up of many parts with interconnected circuits that all work together as a team. Different brain circuits are responsible for coordinating and performing specific functions. Networks of neurons send signals back and forth to each other and among different parts of the brain, the spinal cord, and nerves in the rest of the body (the peripheral nervous system).

To send a message, a neuron releases a neurotransmitter into the gap (or synapse) between it and the next cell. The neurotransmitter crosses the synapse and attaches to receptors on the receiving neuron, like a key into a lock. This causes changes in the receiving cell. Other molecules, called transporters, recycle neurotransmitters (that is, bring them back into the neuron that released them), thereby limiting or shutting off the signal between neurons.

How Do Drugs Work in the Brain?

Drugs interfere with the way neurons send, receive, and process signals via neurotransmitters. Some drugs, such as marijuana and heroin, can activate neurons because their chemical structure mimics that of a natural neurotransmitter in the body. This allows the drugs to attach onto and activate the neurons. Although, these drugs mimic the brain’s own chemicals, they don’t activate neurons in the same way as a natural neurotransmitter, and they lead to abnormal messages being sent through the network.

Other drugs, such as amphetamine or cocaine, can cause the neurons to release abnormally large amounts of natural neurotransmitters or prevent the normal recycling of these brain chemicals by interfering with transporters. This too amplifies or disrupts the normal communication between neurons.

What Parts of the Brain Are Affected by Drug Use?

Drugs can alter important brain areas that are necessary for life-sustaining functions and can drive the compulsive drug use that marks addiction. Brain areas affected by drug use include:

The basal ganglia, which play an important role in positive forms of motivation, including the pleasurable effects of healthy activities like eating, socializing, and sex, and are also involved in the formation of habits and routines. These areas form a key node of what is sometimes called the brain’s reward circuit. Drugs overactivate this circuit, producing the euphoria of the drug high; but with repeated exposure, the circuit adapts to the presence of the drug, diminishing its sensitivity and making it hard to feel pleasure from anything besides the drug.

The extended amygdala plays a role in stressful feelings like anxiety, irritability, and unease, which characterize withdrawal after the drug high fades and thus motivates the person to seek the drug again. This circuit becomes increasingly sensitive with increased drug use. Over time, a person with substance-use disorder uses drugs to get temporary relief from this discomfort rather than to get high.

The prefrontal cortex powers the ability to think, plan, solve problems, make decisions, and exert self-control over impulses. This is also the last part of the brain to mature, making teens most vulnerable. Shifting balance between this circuit and the reward and stress circuits of the basal ganglia and extended amygdala makes a person with a substance-use disorder seek the drug compulsively with reduced impulse control.

Some drugs, such as opioids, also affect other parts of the brain, such as the brain stem, which control basic functions critical to life, such as heart rate, breathing, and sleeping, which helps explain why overdoses can cause depressed breathing and death.

Figure 3.1. Parts of the Brain (Source: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health)

How Do Drugs Produce Pleasure?

Pleasure or euphoria—the high from drugs—is still poorly understood, but probably involves surges of chemical signaling compounds including the body’s natural opioids (endorphins) and other neurotransmitters in parts of the basal ganglia (the reward circuit). When some drugs are taken, they can cause surges of these neurotransmitters much greater than the smaller bursts, naturally produced in association with healthy rewards like eating, music, creative pursuits, or social interaction.

It was once thought that surges of the neurotransmitter dopamine produced by drugs directly caused the euphoria, but scientists now think dopamine has more to do with getting us to repeat pleasurable activities (reinforcement) than with producing pleasure directly.

How Does Dopamine Reinforce Drug Use?

Our brains are wired to increase the odds that we will repeat pleasurable activities. The neurotransmitter dopamine is central to this. Whenever the reward circuit is activated by a healthy,

A pleasurable experience, a burst of dopamine signals that something important is happening that needs to be remembered. This dopamine signal causes changes in neural connectivity that make it easier to repeat the activity again and again without thinking about it, leading to the formation of habits.

Just as drugs produce intense euphoria, they also produce much larger surges of dopamine, powerfully reinforcing the connection between consumption of the drug, the resulting pleasure, and all the external cues linked to the experience. Large surges of dopamine teach the brain to seek drugs at the expense of other, healthier goals and activities.

Cues in a person’s daily routine or environment that have become linked with drug use because of changes to the reward circuit can trigger uncontrollable cravings whenever the person is exposed to these cues, even if the drug itself is not available. This learned reflex can last a long time, even in people who haven’t used drugs in many years. For example, people who have been drug-free for a decade can experience cravings when returning to an old neighborhood or house where they used drugs. As with riding a bike, the brain remembers.

Why Are Drugs More Addictive than Natural Rewards?

For the brain, the difference between normal rewards and drug rewards can be likened to the difference between someone whispering into your ear and someone shouting into a microphone. Just as we turn down the volume on a radio that is too loud, the brain of someone who misuses drugs adjusts by producing fewer neurotransmitters in the reward circuit, or by reducing the number of receptors that can receive signals. As a result, the person’s ability to experience pleasure from naturally rewarding (i.e., reinforcing) activities is also reduced.

This is why a person who misuses drugs eventually feels flat, without motivation, lifeless, and/or depressed, and is unable to enjoy things that were previously pleasurable. Now, the person needs to keep taking drugs to experience even a normal level of reward—which only makes the problem worse, like a vicious cycle. Also, the person will often need to take larger amounts of the drug to produce the familiar high—an effect known as tolerance.

Figure 3.2. Some Drugs Target the Brain’s Pleasure Center

_____________

This chapter includes text excerpted from Drugs, Brains, and Behavior: The Science of Addiction, National Institute on Drug Abuse (NIDA), July 2018.

Chapter 4

Genetics and Epigenetics of Addiction

Why do some people become addicted while others don’t?

Family studies that include identical twins, fraternal twins, adoptees, and siblings suggest that as much as half of a person’s risk of becoming addicted to nicotine, alcohol, or other drugs depends on his or her genetic makeup. Pinning down the biological basis for this risk is an important avenue of research for scientists trying to solve the problem of drug addiction.

Genes—functional units of deoxyribonucleic acid (DNA) that make up the human genome—provide the information that directs a body’s basic cellular activities. Research on the human genome has shown that, on average, the DNA sequences of any two people are 99.9 percent the same. However, that 0.1 percent variation is profoundly important—it’s still three million differences in the nearly three billion base pairs of DNA sequence! These differences contribute to visible variations, such as height and hair color, and invisible traits, such as increased risk for or protection from certain diseases such as heart attack, stroke, diabetes, and addiction.

Some diseases, such as sickle cell anemia (SCA) or cystic fibrosis (CF), are caused by an error, known as a mutation, in a single gene. Some mutations, such as the BRCA1 and 2 mutations that are linked to a much higher risk of breast and ovarian cancer, have become critical medical tools in evaluating a patient’s risk for serious diseases. Medical researchers have had striking success at unraveling the genetics of these single-gene disorders, though finding treatments or cures have not been as simple. Most diseases, including addiction, are complex, and variations in many different genes contribute to a person’s overall level of risk or protection. The good news is that scientists are actively pursuing many more paths to treatment and prevention of these more complex illnesses.

Linking Genes to Health: Genome-Wide Association Studies

The advances in DNA analysis are helping researchers untangle complex genetic interactions by examining a person’s entire genome all at once. Technologies such as genome-wide association studies (GWAS), whole genome sequencing, and exome sequencing (looking at just the protein-coding genes) identify subtle variations in DNA sequence called single-nucleotide polymorphisms (SNPs). SNPs are differences in just a single letter of the genetic code from one person to another. If an SNP appears more often in people with a disease than those without, it is thought to either directly affect susceptibility to that disease or be a marker for another variation that does.

GWAS and sequencing are extremely powerful tools because they can find a connection between a known gene or genes and a disorder, and can identify genes that may have been overlooked or were previously unknown.

Through these methods, scientists can gather more evidence from affected families or use animal models and biochemical experiments to verify and understand the link between a gene and the risk of addiction. These findings would then be the basis for developing new treatment and intervention approaches.

The Role of the Environment in Diseases Such as Addiction

That old saying nature or nurture might be better phrased nature and nurture because research shows that a person’s health is the result of dynamic interactions between genes and the environment. For example, both genetics and lifestyle factors—such as diet, physical activity, and stress—affect high blood pressure risk. National Institute on Drug Abuse (NIDA) research has led to discoveries about how a person’s surroundings affect drug use in particular.

For example, a community that provides healthy after-school activities has been shown to reduce vulnerability to drug addiction, and available data show that access to exercise can discourage drug-seeking behavior, an effect that is more pronounced in males than in females.

In addition, studies suggest that an animal’s drug use can be affected by that of its cage mate, showing that some social influences can enhance risk or protection. In addition, exposure to drugs or stress in a person’s social or cultural environment can alter both gene expression and gene function, which, in some cases, may persist throughout a person’s life. Research also suggests that genes can play a part in how a person responds to his or her environment, placing some people at higher risk for disease than others.

Epigenetics: Where Genes Meet the Environment

Epigenetics is the study of functional, and sometimes inherited, changes in the regulation of gene activity and expression that are not dependent on gene sequence. Epi- itself means above or in addition to. Environmental exposures or choices people make can actually mark—or remodel—the structure of DNA at the cell level or even at the level of the whole organism. So, although each cell type in the human body effectively contains the same genetic information, epigenetic regulatory systems enable the development of different cell types (e.g., skin, liver, or nerve cells) in response to the environment. These epigenetic marks can affect health and even the expression of the traits passed to children. For example, when a person uses cocaine, it can mark the DNA, increasing the production of proteins common in addiction. Increased levels of these altered proteins correspond with drug-seeking behaviors in animals.

Histones, as another example, are like protein spools that provide an organizational structure for genes. Genes coil around histones, tightening or loosening to control gene expression. Drug exposure can affect specific histones, modifying gene expression in localized brain regions. Science has shown that manipulation of histone-modifying enzymes and binding proteins may have promise in treating substance-use disorders.

The development of multidimensional data sets that include and integrate genetic and epigenetic information provides unique insights into the molecular genetic processes underlying the causes and consequences of drug addiction. Studying and using these data types to identify biological factors involved in substance abuse is increasingly important because technologic advances have improved the ability of researchers to single out individual genes or brain processes that may inform new prevention and treatment interventions.

Genetics and Precision Medicine

Clinicians often find substantial variability in how individual patients respond to treatment. Part of that variability is due to genetics. Genes influence the numbers and types of receptors in people’s brain, how quickly their bodies metabolize drugs, and how well they respond to different medications. Learning more about the genetic, epigenetic, and neurobiological bases of addiction will eventually advance the science of addiction.

Scientists will be able to translate this knowledge into new treatments directed at specific targets in the brain or to treatment approaches that can be customized for each patient—called pharmacogenomics. This emerging science, often called precision medicine, promises to harness the power of genomic information to improve treatments for addiction by tailoring the treatment to the person’s specific genetic makeup. By knowing a person’s genomic information, healthcare providers will be better equipped to match patients with the most suitable treatments and medication dosages, and to avoid or minimize adverse reactions.

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This chapter includes text excerpted from Genetics and Epigenetics of Addiction, National Institute on Drug Abuse (NIDA), February 2016.

Chapter 5

Drug Abuse and Related Hospitalization Costs

Chapter Contents

Section 5.1—Substance Abuse Cost to Society

Section 5.2—Drug-Related Hospital Emergency Room Visits

Section 5.3—Increase in Emergency Room Visits Related to Ecstasy

Section 5.4—Deaths from Drug Overdoses

Section 5.1

Substance Abuse Cost to Society

This section contains text excerpted from the following sources: Text under the heading Costs of Substance Abuse is excerpted from Trends and Statistics, National Institute on Drug Abuse (NIDA), April 2017; Text under the heading Overview of Study Findings is excerpted from Excessive Drinking Is Draining the U.S. Economy, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), July 13, 2018.

Costs of Substance Abuse

Abuse of tobacco, alcohol, and illicit drugs is costly to the nation, exacting more than $740 billion annually in costs related to crime, lost work productivity, and healthcare.

Table 5.1. Costs of Substance Abuse