Main Treating Addiction: A Guide for Professionals

Treating Addiction: A Guide for Professionals

, , ,

An indispensable practitioner reference and text, this engaging book focuses on how to provide effective help to clients with substance use disorders. The authors, leading authorities on addiction treatment, present a state-of-the-art framework for assessment and treatment (updated for DSM-5). They describe and illustrate evidence-based treatment methods, including cognitive-behavioral, 12-step, motivational, pharmacological, and family approaches. Also addressed are such crucial clinical issues as resistance, maintenance of change, treating co-occurring disorders, and spirituality. Reproducible clinical tools can be photocopied from the book or downloaded and printed in a convenient 8 1/2" x 11" size. Of special utility, the companion website features more than 25 widely used, ready-to-download assessment tools, assembled in one place for the first time, together with the authors' guidance for using them throughout the process of treatment.

Categories: Psychology
Year: 2011
Edition: 1
Publisher: The Guilford Press
Language: english
Pages: 464 / 481
ISBN 10: 1609186389
ISBN 13: 9781609186388
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Treating Addiction

Treating Addiction
A Guide for Professionals

William R. Miller
Alyssa A. Forcehimes
Allen Zweben
Postscript by A. Thomas McLellan

New York   London

© 2011 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
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These materials are intended for use only by qualified professionals.
With the exception of some materials that are in the public domain, the publisher grants
to individual purchasers of this book nonassignable permission to reproduce all materials for which photocopying permission is specifically granted in a footnote. This license
is limited to you, the individual purchaser, for personal use or use with individual clients. This license does not grant the right to reproduce these materials for resale, redistribution, electronic display, or any other purposes (including but not limited to books,
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Library of Congress Cataloging-in-­P ublication Data
Miller, William R. (William Richard)
Treating addiction: a guide for professionals / by William R. Miller,
Alyssa Forcehimes, and Allen Zweben
   p. cm.
Includes bibliographical references and index.
ISBN 978-1-60918-638-8 (hardback)
1. Substance abuse—Treatment. 2. Drug abuse—Treatment.
I. Forcehimes, Alyssa. II. Zweben, Allen, 1940– III. Title.
RC564.M546 2011

To Robert G. Hall, PhD,
who in 1973 persuaded me that I ought to learn something
about addiction treatment
W. R. M.
To my sister,
who showed me that lasting change from addiction
can and does occur
A. A. F.
To my wife, Aviva,
who has always been there for me
A. Z.

About the Authors

William R. Miller, PhD, is Emeritus Distinguished Professor of Psychology
and Psychiatry at the University of New Mexico in Albuquerque. Throughout his career he has developed and evaluated various methods for addiction treatment, including motivational interviewing, behavior therapies,
and pharmacotherapies. More generally interested in the psychology of
change, Dr. Miller has also focused on the interface of spirituality and
psychotherapy. Having authored more than 40 books and 400 professional
and scientific articles and chapters, Dr. Miller is listed by the Institute for
Scientific Information as one of the world’s most cited scientists.
Alyssa A. Forcehimes, PhD, is a clinical psychologist on the faculty of
Psychiatry at the University of New Mexico Health Sciences Center. She
coordinates the Southwest Node of the National Institute on Drug Abuse
Clinical Trials Network, which is located at the University’s Center on
Alcoholism, Substance Abuse, and Addictions. Dr. Forcehimes’s research
focuses on processes of motivation for change and on effective methods
for disseminating and teaching evidence-based behavioral treatments for
addiction to mental health, substance abuse, and health care providers.
Allen Zweben, PhD, is Professor and Associate Dean for Research and Academic Affairs at the Columbia University School of Social Work in New
York. Dr. Zweben has been a principal investigator on numerous federally and privately funded behavioral and medication trials, including two
landmark studies funded by the National Institute on Alcohol Abuse and
Alcoholism: Project MATCH, a patient–­treatment matching study, and the
COMBINE study, a project examining the efficacy of combining pharmacotherapy and psychotherapy interventions for alcohol problems.




or me, this book represents a retrospective of what I have learned during
37 years of work in addiction treatment and research. There is no way to
adequately thank the hundreds of colleagues, students, research staff, and
clients who have helped me to learn along the way, but I do want to name
just a few. First of all, there is Robert G. Hall, named in the dedication.
He invited a totally green summer intern into the world of addiction treatment and set me on a path that would fascinate me throughout my career.
I have had the privilege of sharing the hard work of conducting many clinical research projects and discussing their implications with several long­standing colleagues, among them Drs. Reid Hester, Dick Longabaugh, Bob
Meyers, Terri Moyers, Steve Rollnick, Scott Tonigan, Paula Wilbourne, and
Carolina Yahne. I owe so much to two of the finest administrative assistants anyone could have, Dee Ann Quintana and Delilah Yao, who looked
after me through two lively and impossibly busy decades. The last two
decades of my academic career were continuously and generously funded
by grants from the National Institute on Alcohol Abuse and Alcoholism
and the National Institute on Drug Abuse. I spent my entire professional
career at the University of New Mexico (UNM), and I can’t imagine a better place to have worked. The amazing staff of UNM’s Center on Alcoholism, Substance Abuse, and Addictions (CASAA) were a fine community
of friends and colleagues without whom I could not have undertaken half
of what I’ve managed to squeeze into these years. After working with 20
publishing companies throughout my career, I have settled into a happy
relationship with The Guilford Press, appreciating the unusual quality of



attention to detail, editing, and collaboration with authors that is reflected
again in this book. Finally, I am ever grateful to my wife of 39 years, Kathy
Jackson, and to our family for giving and sharing with me a life outside the
frenzied world of treating addictions.
—W. R. M.
Writing a book of this size is a complex process that draws not only on the
knowledge of its authors, but also on the specialized expertise of colleagues
and the moral support of friends and loved ones. I deeply thank the following people, each of whom helped me in a variety of ways: my sister—whose
personal experience of recovery from addiction inspired my career—and
three mentors—co­author William R. Miller, who saw the writer in me and
has continued to nurture and develop that skill, and Dr. Scott Tonigan
and Dr. Michael Bogenschutz, for guiding my early career development. I
would also like to thank the staff with whom I work at CASAA. They are
an outstanding group of scientists, program coordinators, and administrators, and I feel lucky to be affiliated with a center committed to excellent
research on the treatment of addiction. Finally, I would like to thank my
family—the one I came from, full of people who have loved me unconditionally and supported me throughout my life, and the one I was fortunate
enough to gain through marriage and have the happiness of going home to
each night. I am especially grateful to my husband, Augustine Chavez, for
sharing our first year of marriage during which I was wedded, in part, to
my work on this book, and for his encouragement, knowledge, and love
along the way.
—A. A. F.
I am grateful to Dr. David Ockert and Armin Baier, who provided me with
valuable feedback on pharmacological adjuncts. Their comments were
based on having extensive knowledge and experience using pharmacotherapies in a specialty treatment setting. I am also appreciative of the help
given to me by Jessica Troiano, who assisted with gathering references and
other materials related to producing this book.
—A. Z.



hose of us who work in health and social services are bound to encounter
substance use disorders, no matter what our specialty or setting is. The
average North American has about a 15% chance of developing an addictive disorder in the course of his or her lifetime, and at any given time the
prevalence rate of substance use disorders is about 8% of the population
(Kessler et al., 2005; Somers, Goldner, Waraich, & Hsu, 2004). In health
care and social service populations the percentage is higher still (Rose,
Brondino, & Barnack, 2009; Weisner, 2002), and many more people are
directly affected by a loved one with alcohol and/or drug problems. If you
treat people for health, mental health, or social problems, you will see quite
a few of them with addictions.
Yet, many professionals receive relatively little training or encouragement to treat this common family of problems. Though some professionals
specialize in addiction treatment, little time is typically devoted to this field
in generalist training for social work, psychology, counseling, medicine,
and nursing. The lack of training is unfortunate because, as we discuss
in the opening chapter, alcohol and drug addictions are intertwined with
many other behavioral health and medical problems, and those working in
health and social service settings are well positioned to identify and address
them. The primary obstacle has been a lack of specific preparation to do
We have written this book for both generalists and specialists to provide an up-to-date foundation for helping people with addictive disorders.
Together we have had nearly a century of experience in this field, in clinical



psychology (W. R. M. and A. A. F.) and social work (A. Z.), and we have
had the privilege to work with many dedicated counselors, nurses, physicians, and other professionals over the years who help people escape from
addictive behaviors. It is rewarding work and, whether you are a generalist
or an addiction specialist, we hope this book will help you gain the knowledge, confidence, and passion to address this common and significant disorder among those you serve.
Throughout this book we have sought to ground our recommendations in the best science available. “Evidence-based treatment” has become
a strong emphasis in this field, and as we write this more than half of U.S.
states already require the use of evidence-based practices in order to receive
reimbursement for addiction treatment (Miller, Zweben, & Johnson, 2005).
There is a long and fascinating history of evidence-based treatment, with
more than a thousand published clinical trials of addiction treatment methods. New research appears at a dizzying rate, and we have had the privilege
of being able to keep up with and translate it for clinicians whose days
are filled with providing treatment. Some findings that we present may be
surprising or even disturbing. They certainly were to us when we initially
encountered them, sometimes as unexpected findings in our own clinical
research. We cite both new and old research throughout the book; many
important studies and findings were published in the latter half of the 20th
century. The National Institute on Drug Abuse Clinical Trials Network
alone has conducted more than 30 multisite trials since 2000. Blessed with
such a large science base in addiction treatment, we owe it to those we serve
to make good use of it.
That science base also includes many studies showing that relationship
matters; it makes a difference not just what treatment is delivered, but who
provides it and how. The importance of a therapist’s approach is not unique
to this field, but it seems to be particularly crucial to success in treating
addictions, which have been so stigmatized. It makes a difference when a
therapist practices with profound respect, loving compassion, and accurate
empathy; some believe the quality of the relationship is the most important
and powerful aspect of treatment. Thus, you will find an emphasis on relationship and style interwoven throughout this book.
What we wish to offer you, then, is an up-to-date professional resource
that combines both clinical and scientific perspectives. We hope this book
will be helpful to professionals who are already treating addictive disorders and for people who are just learning how to treat addictions. We also
encourage health professionals more generally to think of addictions as
falling within their scope of work and have kept this in mind in our writing. In addiction treatment, it makes a difference what you do and how you
do it, and it is far easier to develop evidence-based practice from the outset
than to change already established habits.



A Word about Words
In writing this book, we had to make many decisions about terminology.
The addiction field has been replete with stigmatizing and moralistic language like “clean” and “dirty.” Since 1980, the American Psychiatric Association in its Diagnostic and Statistical Manual has recommended that
diagnostic terms be used to describe disorders (“depression”) rather than
people (“depressives”). Although language that describes disorders is now
the professional norm in most of behavioral health, in the addiction field
it is still common to hear labels being applied to people (e.g., “abuser,”
“addict,” “alcoholic”). Terminology makes a difference. In a recent survey, health professionals were much more likely to blame and recommend
punishment when a person was described as a “substance abuser” rather
than as “having a substance use disorder” (Kelly & Westerhoff, 2010). This
detail was the only change in the case description, and yet it yielded significantly more negative perceptions and recommendations. Throughout
this book we have been careful to describe conditions rather than labeling
A wide variety of terms are applied to people who are under professional care, among them “patient,” “client,” “resident,” “participant,”
“consumer,” and, at a Navajo treatment center in New Mexico, “relative.”
Because most treatment for substance use disorders is provided in non­medical settings, we have most often used “clients” or “people” as the
generic term and “patients” when the context is medical.
Similarly, people who provide treatment for substance use disorders
encompass a wide range of professions and titles. We have used “counselor,” “clinician,” and “practitioner” as generics for people who provide
In describing conditions, we have adhered to the current, albeit somewhat awkward, terms “substance use disorder” as well as “alcohol/drug
problems” or “alcohol and other drug problems,” the latter being the traditional reminder that ethyl alcohol is itself a drug. As a shorthand generic,
we have preferred the term “addiction,” which is the title of the oldest
scientific journal in the field. We use the term to refer to the full continuum
of substance use disorders, much as Jellinek (1960) used the term “alcoholism,” and we refer to more severe forms as “dependence” (see Chapter 2).
Another decision that we made in writing is to avoid using the word
“relapse,” even though it is popular and widely used. Our reasoning is that
“relapse” communicates that there are only two possible states: using problematically or not using at all. Ironically, use of the term “relapse” itself
implies and promotes what Marlatt has described as the “abstinence violation effect” and thus can become a self-­fulfilling prophecy (Marlatt &
Donovan, 2005). “Relapse” also has rather pejorative overtones and is not



typically used in describing other chronic health conditions. A person with
diabetes who comes into the emergency room in hypoglycemic shock is not
typically said to have relapsed. Neither is a person with a recurrence of
problems related to asthma or heart disease. What language, then, might
one use instead? Euphemisms still retain the assumption of a binary onor-off state, whereas treatment outcomes tend to be much more variable
(Miller, 1996b; Miller, Walters, & Bennett, 2001). The clearest solution,
we believe, is simply to describe the behavior (e.g., drinking, drug use)
without adding moralistic baggage. This is the approach we have taken,
using “relapse” when necessary to describe the concept. In lieu of “relapse
prevention,” we focus positively on maintaining change (see Chapter 19). It
is a challenging discipline to write in this way, precisely because it involves
shedding some old habits and assumptions.


Part I. An Invitation to Addiction Treatment


Chapter 1.

Why Treat Addiction?

Chapter 2.

What Is Addiction?


Chapter 3.

How Do Drugs Work?


Part II. A Context for Addiction Treatment



Chapter 4.

A Client-­Centered Foundation


Chapter 5.

Screening, Evaluation, and Diagnosis


Chapter 6.

Detoxification and Health Care Needs


Chapter 7.

Matching: Individualizing Treatment Plans


Chapter 8.

Case Management


Part III. A Menu of Evidence-Based Options
for Addiction Treatment
Chapter 9.

Brief Interventions


Chapter 10. Enhancing Motivation for Change


Chapter 11. A Community Reinforcement Approach


Chapter 12. Strengthening Coping Skills




Chapter 13. Involving and Working with Family


Chapter 14. Mutual Help Groups


Chapter 15. Pharmacological Adjuncts


Part IV. Issues That Arise in Addiction Treatment


Chapter 16. Responding to Resistance


Chapter 17. Enhancing Adherence


Chapter 18. Treating Co-­Occurring Disorders


Chapter 19. Promoting Maintenance


Chapter 20. Working with Groups


Chapter 21. Addressing the Spiritual Side


Chapter 22. Professional Ethics


Chapter 23. Promoting Prevention


Postscript: Looking Forward


A. Thomas McLellan





A variety of screening and assessment measures relevant to addiction treatment are available at For clinicians’ use and
­convenience, they are provided in downloadable form with the authors’

Part I

An Invitation to Addiction Treatment


hy would you choose to treat addictions as a part of your professional career? For many who specialize in this area it comes down
to a matter of the heart, a special caring and commitment for those
whose lives have been torn apart by alcohol and other drugs. Decades
ago, just about the only people treating addictions were those who had
a personal commitment to alleviating this particular form of human
suffering, often by virtue of their own recovery. The need today is much
broader than specialists can address. Professionals who work in any
sector of health and social services are bound to encounter many people
with alcohol/drug problems and are ideally situated to help them. This
book offers an integrated approach, with particular emphasis on the
practical things you need to know and do. Chapter 1 offers a rationale
for learning about and treating addictions. Chapter 2 clarifies some key
terminology in this field, including diagnostic concepts. Because it is
also important for the clinician to know something about how drugs
of abuse work in the human body, Chapter 3 offers some basics of psychopharmacology.


Chapter 1

Why Treat Addiction?


here are several good reasons why treating addictions should be of vital
concern, not just for specialists in this area, but to all professionals who
work in health care, behavioral health, and social services (Miller & Weisner, 2002). One of these is how common addiction problems are. In the
United States, for example, current alcohol use disorders alone are diagnosable in about 7% of the general adult population (Secretary of Health and
Human Services, 2000). An overlapping 15% of the population remains
addicted to nicotine (Hughes, Helzer, & Lindberg, 2006), and about 2%
meet diagnostic criteria for an illicit drug use disorder (Compton, Thomas,
Stinson, & Grant, 2007). Still others have significant problems with addictive behaviors that do not involve a drug, such as pathological gambling,
which afflicts up to 5% of the population, particularly in areas with a
high concentration of legalized gaming (Petry & Armentano, 1999). Thus
the sheer prevalence of these problems and the suffering they cause to the
afflicted and those around them are reason enough to attend to them.
A second reason is that addictions are closely intertwined with the
problems that bring people into the offices of medical, mental health, social
service, and correctional workers. In most populations seen by such professionals, the prevalence of substance use disorders can be much higher than
in the general population. If 1 out of every
12 people in the general population has Aware of it or not, most health and
an alcohol/drug problem (without even social service professionals are
counting their family members and oth- already treating the sequelae of
ers they affect), the proportion is greater addictions without directly addressing
still among health care and mental health a significant source of the problems.
patients, as high as 20 to 50% depending



on the setting (Weisner, 2002). Thus, aware of it or not, most health and
social service professionals are already treating the sequelae of addictions
without directly addressing a significant source of the problems.
Why not just refer people with addictions to specialist programs? There
is a role, of course, for specialist treatment of addictions, particularly when
it is closely integrated with other needed services. Yet there is a downside to
regarding clients’ disorders as separable, to be treated by different specialists. A majority of people with alcohol or other drug dependence also have
concomitant mental and/or physical disorders that need attention. The
presence of concomitant disorders complicates the treatment of addictions,
and vice versa. Furthermore, if addictions are chronic conditions, there is
wisdom in continuous care and not just acute specialist treatment. People
often get lost in the referral process, and there are well-known problems
with the coordination of care when various parts of the person are being
treated in separate services (Shavelson, 2001). For all these reasons, there
is a trend toward integrating the treatment of addictions within a larger
spectrum of health and social services.
By the time people accept specialist addiction treatment (or are compelled to do so), their problems have often reached a severe level. Often
they had been seen earlier in health care, mental health, social service, or
legal and correctional systems for conditions directly or indirectly related
to their substance use. Yet their alcohol/drug problems were either not recognized or not addressed effectively at these times. It is clearly possible to
recognize and treat alcohol/drug problems in more general practice settings. It may even be easier to treat them there because people tend to turn
up in health care and social services at earlier stages of problem development, long before they may accept referral to a specialist addiction treatment program.
Perhaps the most persuasive reason for addressing addictions, however,
is the one that attracted and has held each of us in this field over the years:
addictions are highly treatable, and a variety of effective treatment methods
are available. When people who have developed alcohol/drug dependence
recover, they really get better. You don’t need subtle psychological measures to see the change. They look better. They feel better. Their family and
social functioning tends to improve. They are healthier and happier. They
fare better at work, school, and play. And, contrary to public opinion, most
of them do recover. With the array of effective treatments now available, it
is rewarding indeed to treat addictions in practice. Furthermore, substance
use disorders—­particularly tobacco and
alcohol—are by far the leading preventable
Treating addictions is quite literally
cause of death in the Western world. Treata matter of life and death.
ing addictions is quite literally a matter of
life and death.

Why Treat Addiction?


Why Not Treat Addictions?
So why, then, have so many professionals chosen not to address this very
common, life-­threatening, and highly treatable class of disorders that are
so intertwined with other problems? The answer lies, in part, in several
First, some practitioners believe treating addictions requires a mysterious and highly specialized expertise that is entirely separate from their
own. In fact, as will become clear in the chapters that follow, the psychosocial treatment methods with strongest
evidence of efficacy are often familiar to The psychosocial treatment
behavioral health professionals who treat methods with strongest evidence
other disorders, and are commonly part of of efficacy are often familiar to
the ordinary training and practice of many behavioral health professionals
professionals: client-­centered listening skills, who treat other disorders.
behavior therapies, relationship counseling,
good case management, and motivational
interviewing. Effective medications are available to aid in treatment and
long-term management of these chronic conditions. The major professional
health disciplines have already contributed and will continue to contribute much in understanding and treating addictions (e.g., Miller & Brown,
1997). To be sure, there are some facts and particular skills you need to
know when addressing alcohol/drug problems. Providing that background
is one primary purpose of this book.
A second challenge is time. Counselors and psychotherapists may
have 50-minute hours, but health care appointments are often brief, with
many other tasks to be accomplished. Those who work in contexts such
as primary health care, family medicine, and dentistry may understandably see substance use disorders as “not my job”—falling outside the realm
of possibility within time constraints. Yet many other chronic conditions
are followed and treated within the scope of routine care, and it’s possible
to do what you can within the time that you have. Medical professionals
may have only a few minutes to address substance use concerns, but it is
clear that even this amount of time when used well can make a difference
(see Chapter 9). Similarly, those who work in mental health or probation
services have other issues to address and may view addictions as beyond
their professional responsibility or expertise, but alcohol/drug problems are
intertwined with mental health and correctional concerns.
A third possible obstacle is the belief that in order to be effective in
treating addictions, one must be in recovery oneself. Although a substantial
minority of professionals who treat addictions are themselves in recovery,
ample evidence indicates that therapeutic effectiveness is simply unrelated
to one’s own history of addiction. Those who are in recovery are neither



more nor less effective than other professionals in treating addictions, even
when delivering 12-step-­related treatments (Project MATCH Research
Group, 1998d). Rather, effectiveness is related to other factors of therapeutic style (see Chapter 4).
Then there is, for some, a social stigma associated with addictive disorders, sometimes linked to pessimism (among the public, professionals, and
clients themselves) about the possibility of change (Moyers & Miller, 1993;
Schomerus, Corrigan, et al., 2011; Schomerus, Lucht, et al., 2011). This
was exacerbated by writings in the mid-20th century suggesting that people
with substance dependence are pathological liars, sociopaths, and highly
defended by chronic immature defense mechanisms. We also see moralizing and blaming related to the perception that these disorders are self­inflicted (overlooking that other chronic health problems are also closely
linked to personal behavior and lifestyle). In truth, people with substance
use disorders represent a full spectrum of personality, socioeconomic status, intelligence, and character. Research provides no support for the belief
that these individuals differ from others in overusing certain defenses, and
they surely have no corner on dishonesty. One reason we, the authors, have

Box 1.1. Personal Reflection: Why Addictions?
What draws people into the field of addiction treatment? Often it is firsthand experience, and that was certainly the case for me. I departed for college at the same
time my younger sister entered an inpatient substance abuse treatment program.
The anxious feeling of being on my own for the first time was compounded by the
heartache of knowing that my sister was also living away from home and struggling to overcome addiction. When I visited her a few months into treatment, I saw
in her a profoundly changed life: her values had shifted and she had found peace
with herself.
But how did she change, I wondered? When I asked my sister this question,
she shrugged and responded that it was hard to explain—­something just happened. No one, including my sister, seemed overly concerned with exploring this
question, with understanding why. They were content to simply appreciate the
results of this change. But I remained curious: What had caused this significant and
sudden change that allowed her to overcome addiction?
In my clinical work now, as I hear each client’s story and watch changes occur
throughout our work together, I continue to wonder how it is that people change.
How can I work with people most effectively to help them enact and maintain
change? Why is it that some clients like my sister do change profoundly, while
others do not, at least during the time in which our lives intersect? It’s a privilege
to be a companion and witness to such important life changes, and fascinating to
continue pondering questions like these along the way.
—A. A. F.

Why Treat Addiction?


remained in this field is that we have genuinely enjoyed treating people who
are struggling with addictions, and also working with their loved ones. It is
rewarding, lifesaving work.

An Integrative Approach
The approach we describe in this book is integrative in at least four ways.
As the chapters to follow reveal, this approach is (1) comprehensive and
evidence-based, (2) multidisciplinary, (3) holistic, and (4) collaborative.

Comprehensive and Evidence‑Based
Our integrated approach is first of all grounded in available clinical science. Professional and public opinions abound regarding addictions. Such
opinions, including our own, have often proved inaccurate when carefully
examined in well-­designed scientific research. In this book we have sought
as much as possible to differentiate opinion from science, and given primary emphasis to the substantial base of scientific evidence that is now
available to guide practice.
The approach we describe is also comprehensive in that it places treatment within a larger context of scientific knowledge about the nature of
addictions, motivation for change, assessment and diagnosis, mutual help
groups, case management, and prevention (McCrady & Epstein, 1999;
Miller & Carroll, 2006). We address the full spectrum of addiction treatment, from crucial aspects of the first contact to long-term maintenance, as
befits the management of a complex and often chronic condition.

Second, we draw upon a range of professional perspectives including those
from counseling and family therapy, medicine and nursing, pastoral care,
psychology, and social work. In an ideal world, treatment might be delivered by a collaborative team of professionals representing these differing
areas of professional expertise. In reality, treatment often relies upon a single or primary therapist whose role includes providing or serving as liaison
with this range of services.

Third, we seek in our integrated approach to consider the whole person:
biological, psychological, social, and spiritual. Some think of going to a
specialist for treatment of addiction, much as one goes to a dentist for care
of one’s teeth. Yet addictions involve and affect the whole person and those



around him or her. They are biological and psychological and social and
spiritual. By nature of disciplinary training, you may be prepared to deal
best with one of these dimensions. Those who treat addictions, however,
will meet all of these aspects of the person, and treatment will not be optimally effective if it is limited to only one of them.

Collaborative Care
Finally, we advocate the integration and coordination of addiction care
with the broader range of health and social services. Sequestering addiction
treatment in isolated programs has served in some ways to sustain stigma
and discourage treatment. We favor involving a broad range of professionals
in direct care for people with alcohol/drug problems. In truth, most health
and social service professionals are already seeing people with addiction
problems, though they may be unaware of it or regard such problems as
someone else’s concern. In complex disorders like addictions, where attention is needed in so many spheres, care can begin with almost any area.
Taken together, the 23 chapters of this book represent pieces of a puzzle, the building blocks of an integrative approach to addiction treatment.
They describe a system of care that is comprehensive, evidence-based, multidisciplinary, holistic, and collaborative. That’s a tall order for us in writing this book, and for you in practice. Taking the attitude of “My way or
the highway” and offering only one brand of treatment is much simpler, but
does a disservice to clients in failing to make use of the vast amount that
has been learned about how to help people with addictions. An integrative
approach is a challenging goal, a direction in which you can keep growing
throughout your professional career. That has certainly been our continuing experience, and we are grateful for this opportunity to pass on, for your
consideration, what we have learned along the way.

Key Points

ÍÍSubstance use disorders are prevalent in the general population,

and even more so among people seen in health care, social service,
and correctional settings.

ÍÍSubstance use disorders are highly treatable. A majority of
affected people recover.

ÍÍAn encouraging armamentarium of effective, evidence-based
treatment methods is available, no one of which is best for
everyone with addiction problems.

Why Treat Addiction?


ÍÍPeople with alcohol/drug problems commonly have other

significant psychological, medical, and social problems, and
coordinated treatment of these problems is needed.

ÍÍTreating addictions should be a normal part of general health care
and social service systems and not limited to specialist programs.

R e fl e c t i o n Q u e st i o n s
Of the people you normally serve (or anticipate serving), what
percentage would you estimate have alcohol or other drug problems?
What most encourages or motivates you to work with people whose
lives are affected by addiction, and with their family members?
In your community, where are people with alcohol/drug problems most
likely to turn up seeking help or services? (Hint: It’s not in addiction
treatment programs.)

Chapter 2

What Is Addiction?


ust about everyone has some notion of what addiction is. The website offers this general definition: “The condition of
being habitually or compulsively occupied with or involved in something.”
This definition concisely reflects three aspects of the term that are found in
most popular conceptions of addiction: (1) it is something done regularly,
repeatedly, habitually; (2) there is a compulsive quality to it that seems at
least partly beyond the individual’s conscious control; and (3) it does not
necessarily involve a drug, although that is the most common association.
In everyday speech, people are said to be “addicted” when they relentlessly pursue any sensation or activity, be it sex, gambling, alcohol or other
drugs, work, food, shopping, or love. Peele (2000) argued that the concept
of addiction has expanded to describe so many behaviors that it has almost
lost its meaning. Something becomes an addiction when it increasingly
dominates a person’s life and, as a result, harms or detracts from other
aspects of life. In this broad colloquial sense, addiction is not unusual.
For purposes of science and health care, however, a more precise meaning is needed. This meaning is usually expressed in the form of a diagnosis
that is defined by a particular pattern of signs and symptoms. Diagnostic
criteria are typically developed by consensus within a professional organization such as the World Health Organization, which is responsible for
the International Classification of Diseases (ICD). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders
(DSM) has been the standard for classification by behavioral health professionals in North America. The DSM is revised every decade or so, which
means that the names and criteria for diagnosing addictions have evolved
over time.

What Is Addiction?


Understanding Diagnoses
A formal classification system such as the ICD or DSM is a way to help
health professionals mean the same thing when making diagnoses. It is a bit
like the biological taxonomy of life forms classified by genus and species.
Such classification systems tend to become larger and more complex over
time as new species and subspecies are recognized, and this has certainly
happened with the DSM. What was once a single diagnosis of “alcoholism”
or “drug addiction” has been differentiated into dozens of more specific
It is also true that formal diagnoses often differ from popular conceptions. For example, schizophrenia is often mistakenly associated with a
“split personality.” When most people think of depression, they envision
someone who is sad. One might imagine a woman in a housecoat, bent over
on the couch with shoulders hunched and her head in her hands, weeping.
These are the images used in television programming and commercials for
prescription medications. Actual clinical presentations often vary widely
and can depart substantially from popular stereotypes. For instance, sadness is only one possible dimension that can be present or absent in a diagnosis of depression. Common conceptions of schizophrenia focus on positive symptoms such as hallucinations and delusions rather than negative
symptoms such as catatonic behavior and flat affect. Part of the skill of a
behavioral health diagnostician is recognizing the variability as well as the
commonality of individual clinical pictures.
The same is true with addiction, which involves multiple dimensions
that are variously present or absent in an individual. Popular conceptions
often focus on certain manifestations. One might imagine a disheveled man
slumped on a sidewalk, surrounded by cans and bottles, having lost his
family, job, and home. Classic stereotypes also tend to involve the most
severe levels of use and consequences.
For professional purposes within this book, we use addiction as the
most generic term for substance use disorders (as well as other addictive
behaviors), encompassing a broad range of severity. Addiction is not currently a diagnosis in itself. As discussed in this chapter, diagnoses have
become more differentiated and precise. Addiction is, however, the title of
the oldest scientific journal of this field which covers a range of interrelated
clinical problems. As an umbrella concept, addiction encompasses a wide
variety of individual presentations such as:
•• A 37-year-old man who drinks heavily enough most nights to still be
legally intoxicated the next morning, and whose wife is threatening
to leave him because of his drinking, but who appears to be in good
physical health, has a good job, and has never suffered obvious negative social consequences.



•• A skeletal 22-year-old who steals and trades sex to support a daily
habit injecting methamphetamine.
•• A successful businesswoman who began taking her daughter’s prescribed methylphenidate periodically as a way to be alert and accomplish more during the day, then started needing higher doses, buying
stimulants illegally and using them more regularly.
•• A college student who drinks 8–12 beers three or four nights a
week to feel “buzzed” and has a drink the next morning to calm
his nerves.
•• A 50-year-old woman who goes to the casino daily to play the quarter slot machines for 6 hours while her husband is at work and has
built up $40,000 in credit card debt.
•• A single parent who smokes two packs of cigarettes daily and has
unsuccessfully tried several times to quit.
In short, people with addiction look and act in many different ways.
This is one reason why questionnaires that purport to detect the presence or absence of addiction are problematic. Such “dipstick” tests were
once popular, an easy list of questions that would yield a plus or minus sign
to tell whether the person had “a problem.” Brief screening questions are
useful to indicate whether more evaluation is called for, but do not themselves make a diagnosis (see Chapter 5). For now, we focus on how to think
more broadly about addiction and its causes.

Seven Dimensions of Addiction
There are at least seven dimensions of addiction that, though interrelated,
are also surprisingly independent of each other. All of them occur along a
continuum, and knowing where an individual is on one particular dimension does not reliably tell you his or her location on the others. This is one
reason why definitions and diagnostic criteria for addiction are so challenging.

A first dimension to consider is the extent and pattern of the person’s use of
psychoactive substances. This is most often described in terms of quantity
(how much?), frequency (how often?), and variability (steady vs. periodic
patterns of use). Other addictive behaviors such as gambling can, of course,
be measured along the same dimensions.
How do quantity, frequency, and variability differ?

What Is Addiction?


How much do you drink/use on a typical day when you are using?
10 or more
How often do you drink/use in a typical week?
Every day
What is your typical pattern of use?


Just knowing how much a person is using does not in itself tell you about
its effects on the person’s life (though there certainly is a relationship). A
second dimension to consider is the extent to which alcohol/drug use has
resulted in adverse consequences for the individual and those around him
or her. The term “problem drinking” historically refers to using alcohol
in a way that causes negative psychosocial consequences (Cahalan, 1970).
These might include, for example, problems in work, school, family and
other relationships, mood, finances, and legal problems.
What kind of consequences is the person experiencing? What areas


Physical Adaptation
One characteristic of many psychoactive drugs is that the body adapts as
a person uses them. One such adaptation is drug tolerance: a reduction in
the effect of a particular dose of the drug. Over time a person may require
increasingly larger doses to experience the same high as before (chronic
tolerance), or even to feel “normal.” Having even one drink diminishes the
additive impact of the next one (acute tolerance). Another way in which the
body adapts over time is physiological dependence. With some drugs, the
body becomes accustomed to their presence and adjusts normal functioning
accordingly. Then when the drug is withdrawn, there is a physical rebound
effect that is usually unpleasant, and opposite to the effects of intoxication.
Alcohol intoxication depresses many physical functions, whereas alcohol
withdrawal involves heightened arousal and sensitivity to stimuli (rang-



ing in intensity from a hangover to severe and life-­threatening withdrawal
syndrome). Conversely, stimulant intoxication increases physical arousal
whereas withdrawal from stimulants involves a depressing rebound.

Physiological Dependence



Behavioral Dependence
Physical adaptation to a drug is not the
only form of dependence. A more general
pattern of behavioral dependence is that
the drug gradually assumes a more central place in the person’s life, displacing
other activities, relationships, and social roles that once had greater priority (American Psychiatric Association, 1994; Edwards & Gross, 1976).
Increasing amounts of the person’s time, energy, and resources are devoted
to obtaining, using, and recovering from the effects of the drug. People
can also come to rely on a drug for certain coping functions. If the use of a
drug is the only or primary way that someone has to cope with a particular
feeling or situation, the person is psychologically dependent on the drug for
that purpose (see Chapter 7).
Physical adaptation to a drug is not
the only form of dependence.

Behavioral Dependence
No signs of


Cognitive Impairment
Psychoactive drugs can also have acute (temporary) or chronic (long-term)
effects on cognitive functioning, adaptive abilities, and intelligence. Depressant drugs (like alcohol, tranquilizers, and sedatives) can impair memory,
attention, reaction time, and learning abilities during the period of intoxication. This is an important reason why driving under the influence is illegal. With long-term use, alcohol and certain other psychoactive drugs can
also produce chronic, even irreversible, mental impairment.
Cognitive Impairment


What Is Addiction?


Medical Harm
Many psychoactive drugs also have the potential to damage physical health.
Some harm is due to the acute effects of intoxication, such as risk taking, aggression, and overdose. Other forms of medical harm are related to
chronic use. There are well-­documented links of smoking to heart disease
and cancer. Heavy drinking is associated with increased rates of various
cancers, heart disease, and damage to the liver and other organ systems.
Alcohol/drug use can also damage health indirectly by diminishing normal self-care, displacing nutrition, and compromising the management of
chronic conditions such as diabetes.
Medical Harm:
Acute Effects
risk taking

risk taking
Medical Harm:
Chronic Use



Motivation for Change
Finally, motivation for change is commonly recognized as an important
dimension of addiction and recovery. Reluctance to recognize the need for
change and take action is a common problem in addiction. Historically it
was believed that a person with addiction had to “hit bottom” and experience sufficient suffering before being ready to change, but there are now
many tools to help enhance motivation for change (see Chapter 10).
How important is it to this person to make a change?











Studying addiction is in a way like the fabled blind men encountering
an elephant. One touches the trunk and concludes that an elephant is like a
firehose. Another touching the elephant’s side says that it is like a wall. One
who holds the tail finds elephants to be like snakes. Another hugs a leg and
reports that an elephant is much like a tree. An elephant is none of these
and all of these. A complete understanding requires combining different
perspectives; any one part reveals only a little about other aspects or about
the whole elephant.



Box 2.1. Applying Your Knowledge: Thinking about the Different
Dimensions of Addiction
In the previous section, we described seven different dimensions of addiction. Consider the following case example and think about where this individual would fall
on the seven dimensions of addiction:
Steven is a 28-year-old male who comes in to your clinic because he tested
positive for cocaine on a random drug test at work and is required by his employer
to get drug counseling. He reported using cocaine twice in the past 12 months,
both times while at parties with old college buddies. He reported that he snorted
one line on both occasions and woke up the next morning without any side effects
of withdrawal. He is a marathon runner and is training for a triathalon, with a “clean
bill of health” from his primary care physician. When asked about some of the not
so good things about using cocaine, he reported concern about possibly losing his
job as a result of this positive drug test and some fears about what cocaine use
might do to his body, specifically how it might impact his marathon time. Steven
told you, “I’m done with using cocaine. I won’t ever be using it again. This event
made me realize that I need to grow up and start acting my age. I’m not some
dumb college kid any more, and I want to be successful in my career and continue
to improve my marathon times in order to qualify to run in the Boston marathon. I
know cocaine isn’t going to help me do either of those things.”
Where would you say Steven is on each of the seven dimensions, given what
you know so far? What else would you want to know?



Physical Adaptation


Behavioral Dependence


Medical Harm


Cognitive Impairment


Motivation for Change



What Is Addiction?


History of the DSM
Technically speaking, there was no alcoholism prior to 1849. That is
when the Swedish physician Magnus Huss coined the term “alcoholism”
to describe adverse consequences of excessive drinking (Sournia, 1990).
There was drunkenness, inebriety, and intemperance, but no alcoholism.
Since then, society has struggled to define what constitutes addiction and
to puzzle over its causes.
The history of diagnoses in the DSM illustrates the evolving concept
of addiction. Each DSM has offered criteria for deciding whether specific
diagnoses fit a particular person’s case. The diagnostic decision is binary—­
present or absent—even though reality may be more of a continuum. To
make a yes/no diagnostic decision, then, often means drawing a somewhat
arbitrary cutoff point along a continuum of severity. In the DSM this is
typically done according to the number of symptoms present.
In the early 1950s, the first edition of the DSM grouped both alcoholism and drug addiction with sociopathic personality disturbances, indicating that people with addiction suffered from “deep seated personality
disturbance” (DSM-I; American Psychiatric Association, 1952, p. 34). The
sociopathic personality category also included sexual deviations and antisocial behavior, suggesting that individuals with addiction were a threat
to societal order. Unlike the detailed lists of criteria that are used to classify disorders today, the first edition contained only a brief paragraph that
focused almost entirely on the presumed etiology of the disorder. According to the DSM-I, addiction was likely a symptom of an underlying brain or
personality disorder and was a clear departure from culturally acceptable
behavior. The signs and symptoms displayed by someone with an addiction
to drugs or alcohol were not clearly described.
In the second edition (DSM-II; American Psychiatric Association,
1968), several new terms were proposed as types of alcoholism, including episodic excessive drinking, habitual excessive drinking, and alcohol
addiction. This reflected conceptions from a classic book by E. M. Jellinek (1960), The Disease Concept of Alcoholism, that used “alcoholism”
as a broad and generic term for alcohol-­related disorders (as Magnus Huss
had done), and hypothesized various subtypes. Similarly, drug dependence
was expanded in DSM-II to include subcategories by specific drug class.
Physiological signs of dependence, such as withdrawal and tolerance, were
described as signs and symptoms of these conditions. As in DSM-I, however, these disorders remained as subcategories of “personality disorders
and certain other nonpsychotic mental disorders.” The placement of these
conditions implied once again that addiction represented a disorder of the
personality that caused the individual to use alcohol or other drugs excessively.



During the 1970s, clinical research indicated a need to further differentiate substance use disorders. The Feighner criteria were developed in
an effort to diagnose alcoholism on research-based decision rules (Feighner et al., 1972). This trend toward differential diagnosis was reflected in
the third edition of the DSM (DSM-III; American Psychiatric Association,
DSM-III was the first to identify substance abuse and dependence as
separate pathological conditions. This differentiation was based, in part,
on findings from longitudinal research indicating that many people with
a history of alcohol problems never progressed to dependence (Cahalan,
1970; cf. Hasin, Grant, & Endicott, 1990), suggesting the possibility of
two separate disorders. As of DSM-III, “alcoholism” was no longer used
as a formal diagnosis. Another significant change in DSM-III was the creation of a separate category for substance use disorders, removing the prior
implication that they represented underlying personality disorders.
DSM-III more generally avoided tying disorders to specific etiologies.
With regard to addiction, DSM-III suggested that social and cultural factors were important contributors to the onset and continuation of abuse
and dependence. This suggestion further underlined the shift away from
thinking of addiction as personal pathology, toward something more akin
to a public health model that considered environmental factors. Substance
abuse was defined as problematic use with social or occupational impairment, but with the absence of significant tolerance and/or withdrawal. The
DSM-III definition of substance dependence emphasized the physiological symptoms of tolerance (needing to take much higher doses of the substance to obtain the same effect) and withdrawal (having a distinct pattern
of physiological changes after stopping or reducing use), and required the
presence of one or both of these criteria in order to make a dependence
diagnosis. In both disorders, impairment in social and occupational function was a prominent aspect of the definitions, creating a significant overlap between the criteria for substance abuse and dependence. In essence,
“abuse” was the presence of drug-­related problems in the absence of a history of significant physiological adaptation.
Meanwhile, a changing conception of substance dependence was
already emerging, a shift away from strictly physiological symptoms toward
a broader behavioral syndrome. This shift was strongly influenced by the
work of Griffith Edwards (1986; Edwards & Gross, 1976) who conceptualized alcohol dependence as a cluster of interrelated behavioral, psychological, and physiological elements, all varying in severity. Common
elements of the dependence syndrome included a narrowing of the drinking
repertoire (increasingly patterned and predictable), drink-­seeking behavior,
tolerance, withdrawal, drinking to relieve or avoid withdrawal symptoms,
subjective awareness of the compulsion to drink, and a return to drinking
after a period of abstinence. Also contributing to a shift toward emphasis

What Is Addiction?


Box 2.2. Is There an Addictive Personality?
In the mid-20th century it was believed that people with substance use disorders
had a particular predisposing personality, with high levels of immature defense
mechanisms such as denial. Treatment programs were designed to confront and
“break down” these pathological defenses since they were seen as a primary cause
of addiction. Yet decades of research have revealed few commonalities in the personality of people with addiction problems. People with substance use disorders
vary widely on other dimensions, and when their defenses have been measured
specifically they appear no different from other people (Donovan, Hague, & O’Leary,
1975). In other words, many different kinds of people succumb to addiction. There
are some developmental factors related to risk of subsequent addiction—­difficult
temperament, childhood conflicts with the law and authorities, and impaired self­control—but no characteristic abnormal personality.
So if people do not walk through the door of addiction treatment programs
all with the same personality, what behaviors caused counselors to perceive their
clients as in denial? Often it came down to disagreement with the counselor over
a diagnosis or label, and the client showing (from the counselor’s perspective)
insufficient distress, acceptance of help, compliance with particular treatment prescriptions, and change—­factors that tend to get clients labeled as “unmotivated.”
Treatment providers tended to perceive clients as “motivated” when they agreed
with the provider, accepted the provider’s diagnosis or label, expressed a desire
for help, showed appropriate distress, voiced a need for the provider’s assistance,
complied with treatment prescriptions, and succeeded in changing. Clients’ resistance and defensiveness, which often were attributed to their difficult personalities,
are highly responsive to counseling style (see Chapter 16). A suspicious, authoritarian, confrontational style substantially increases resistance and defensiveness,
not only in people with addictions but in most human beings. This creates a self­fulfilling prophecy, with clients who are initially ambivalent digging in their heels
and becoming adamant about not changing. In contrast, a respectful, listening,
and compassionate therapeutic style (see Chapter 4) tends to reduce resistance
and promote change.

on behavioral aspects of dependence was classic work by Brady and Lucas
(1984) showing that laboratory animals can be taught to self-­administer
psychoactive drugs. Once animals learned to self-­administer an addictive
substance, most would expend enormous amounts of time and effort to
obtain additional doses. This drug-­seeking behavior also proved difficult to
extinguish, particular when the administered substance was one with high
abuse liability in humans (such as stimulants or opiates).
In 1987, DSM-III was revised (DSM-III-R; American Psychiatric Association, 1987) in a way that gave the behavioral aspects of substance use
disorders equal weight to the physiological components. The DSM-III-R
category of psychoactive substance abuse was defined as a pattern of use



that continues despite knowledge of adverse consequences or by drug use
in situations in which it is physically dangerous. As before, the “abuse”
diagnosis was a residual category for people who had never met criteria for
DSM-IV (American Psychiatric Association, 1994) largely continued
the definitions of DSM-III, now defining over 100 different substance­related disorders for 12 different classes of drugs (see Chapter 3). In
addition to abuse and dependence, there were diagnoses for drug-­related
intoxication, withdrawal, delirium, dementia, amnestic disorder, psychotic
disorders, mood disorders, anxiety disorders, sexual dysfunction, and sleep
disorders. Unlike its predecessors, DSM-IV clearly separated the criteria for
dependence from those of abuse. Dependence in DSM-IV was a syndrome
involving compulsive use, with or without tolerance and withdrawal.
Abuse was defined as problematic use without compulsive use, tolerance,
or withdrawal. A transitional text revision (DSM, 4th ed., text rev.; American Psychiatric Association, 2000) defined substance abuse as meeting any
one of four criteria revolving around recurrent problems related to the substance, and dependence as meeting three or more of seven physiological or
behavioral criteria. This created a problem of “diagnostic orphans” who,
for example, evidence none of the criteria for abuse and only one or two
symptoms in the dependence category.
The fifth edition of the DSM, planned for release in 2013, revisits
this terminology yet again. Under consideration is a transition from the
abuse/dependence terminology and back to a general term of “addiction”
with categories of severity (e.g., mild, moderate, and severe), similar to the
approach we have taken in this book. Factor analyses found that the abuse
and dependence criteria actually loaded on a single factor and are interrelated with each other (Martin, Chung, & Langenbucher, 2008; Mewton,
Slade, McBride, Grove, & Teesson, 2011). This transition marks further
recognition that addiction occurs along a continuum of severity, and that
“abuse” is not separate from or necessarily antecedent to dependence.
Moving away from the separate categories of dependence and abuse is
something that we support. The terms “abuse” and “abusers” have always
been moralistic and pejorative in tone. (A colleague once quipped that
“alcohol abuse” is mixing a single-malt scotch with root beer.) And while
the term “dependence” has served to broaden thinking, it has also been
confusing because of its changing meanings. Many providers, particularly
those in medical settings, still equate dependence with physiological adaptation, as was the case in DSM-III. (Of course the same can be said of
“addiction” as a generic.) Another reason we favor abolishing these separate categories is that the change in nomenclature more accurately represents the continuum of severity, and eliminates the problem of diagnostic
orphans who don’t meet prior categories yet still have significant problems
related to substance use.

What Is Addiction?


Where Is the Line for Addiction?
Diagnosis historically has focused on a binary, black-or-white decision:
Does the person “have” a particular condition or not? Sometimes it’s vital
to know that. Presence or absence matters with regard to a brain tumor or
the human immunodeficiency virus (HIV). Many other conditions, however, involve shades of gray, a gradual continuum of severity, and addiction
is one of those. How much is too much? When has a person who drinks or
uses other drugs crossed “over the line” to addiction? As illustrated by the
evolving DSM, the answers change over time.
The idea that there is a black-or-white
line has itself been a source of problems in The idea that there is a black-orpersonal and social response to alcohol/ white line has itself been a source
drug use. At the time of DSM-II, the pre- of problems in personal and social
vailing belief was that alcoholism was a response to alcohol/drug use.
binary, present-or-­absent condition, like
pregnancy. One could not be “a little”
alcoholic—­either you were or you weren’t. In this view, alcoholics were
unable to handle alcohol, whereas normal people could drink with impunity. It thus became a source of significant argument whether a particular
person was or wasn’t alcoholic. In the common situation where a professional (or relative) diagnosed someone as being over the line, a person who
disavowed the diagnosis was said to be “in denial” (Carr, 2011). Because
alcoholism was then believed to be a personality disorder, and denial a
characteristic defense mechanism of the disorder, this often was seen as
confirming the diagnosis. A complementary belief was that only alcoholics had problems with alcohol, a view that discouraged social controls on
alcohol or caution in its use by those presumed to be nonalcoholics. Within
this perspective, the main approach to prevention would be to identify and
educate those unfortunates who have the condition.
The recognition of addiction as a continuum has led to a different
approach. Certainly people with severe dependence deserve humane and
effective care. It is also clear that alcohol is a hazardous substance that
warrants special social controls (Babor, 2010). A majority of those who are
harmed or endangered by alcohol use are not dependent drinkers (Institute
of Medicine, 1990). Arguing about whether a person is on one side or the
other of a diagnostic line misses the point. We find that it is common for
clients to balk at a diagnostic label or the idea of “having a problem.” Yet
if we ask them to tell us about ways in which alcohol or other drugs have
caused problems or hassles for them, there is usually a list, sometimes a
long one. The more important issue is to understand how substance use is
affecting people’s lives, and what they need or want to do about it.
A clear current reflection of this broader conception is the recommendation of “safe drinking limits” by the World Health Organization, the



U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA), and
other bodies. Working from epidemiological data, such guidelines inform
people about levels of consumption that are linked to increased risk of illness and injury. Regardless of diagnosis, there are levels of alcohol use that
are simply risky in terms of short- and long-term health consequences. In
a “Rethinking Drinking” website, the NIAAA defined at-risk drinking as
consuming more than four drinks on any day or 14 drinks per week for
men, or more than three drinks on any day or seven drinks per week for
women ( as of May 2011).
This change in thinking toward a continuum of severity is also occurring in general medicine with regard to chronic conditions such as diabetes,
heart disease, and asthma. The arbitrary cutoff points for “normal” versus “elevated” blood pressure, glucose, or cholesterol have been decreasing
over the years, with earlier intervention indicated. In the past, diabetes was
not treated until the patient became symptomatic. This has shifted toward
identifying those who are prediabetic so that physicians can intervene prior
to organ damage. For patients with identified risk factors, such as being
overweight or having a family history of diabetes, the routine procedure is
to regularly assess fasting glucose or HbA1c levels and encourage lifestyle
changes to prevent the development of diabetes.
The idea of intervening prior to someone developing more severe consequences also parallels trends in mental health. For example, there are
good reasons to prevent a first occurrence of depression. Once a person
experiences one episode of major depression, there is an increased likelihood of having another, suggesting the idea of biological kindling: the
first episode makes that person more vulnerable to future episodes. This
finding has increased efforts to intervene early (Muñoz, Le, Clarke, Barrera, & Torres, 2009). For those at high genetic risk of developing depression, there are effective strategies to prevent the first episode. There are
also treatment guidelines based on the number of depressive episodes a
person has experienced. For example, if someone has three or more episodes, prophylactic maintenance on antidepressant medications is often
It is common, therefore, to use different
strategies depending on the level of
It is common to use different
for hypertension, diabetreatment strategies depending
many other medical and
on the level of severity.
psychological conditions varies depending on
where the individual is on a continuum. The
parallels to addiction are straightforward. Yet addiction has often been
treated as though it could be cured through acute care. If addiction at least
resembles a chronic illness, then one should not expect the problem to be
resolved by an episode of treatment, and ongoing care is as important as it
would be with asthma or diabetes.

What Is Addiction?


Historically people seldom received addiction treatment before substantial problems and dependence had developed. In the 21st century, there
is a trend toward recognizing, treating, and preventing both alcohol and
other drug problems at an earlier stage, through screening and intervention
within more general health and social service settings (Miller & Weisner,
2002). The efficacy of even relatively brief opportunistic counseling is well
documented (Bernstein et al., 2007; Monti et al., 1999; Spirito, 2004), even
though these individuals were not actively seeking addiction treatment and
may not even have been thinking about making a change in their drinking
or drug use. Prevention is discussed in more detail in Chapter 23, and brief
intervention is discussed in more detail in Chapter 9.
Another important reason for addressing addiction within primary
health care, mental health, and social service settings is the high rate of co-­
occurrence with other health and social problems (see Chapter 18). Whether
or not they know it, professionals in such settings most likely are regularly
treating people with addiction problems. In children and adolescents, alcohol/drug use is a common element in clusters of problem behaviors (Jessor
& Jessor, 1977). In adults, addiction seldom occurs in isolation. In people
with serious mental illnesses, addiction is the most frequently coexisting
disorder, occurring at three times the general population rate (Substance
Abuse and Mental Health Services Administration, 2009).
Before moving on to consider causes of
addiction, we add one more practical rec- Don’t waste time and effort
ommendation. Don’t waste time and effort arguing with people about whether
arguing with people about whether they they warrant a diagnostic label.
warrant a diagnostic label. Great emphasis has sometimes been placed on making
clients “accept” or “admit” an identity such as “alcoholic” or “addict.”
There is no good evidence that this is a prerequisite to change. Plenty of
people recover without ever accepting a diagnosis or receiving treatment.
Clinicians also know that there are many who readily accept a diagnostic
label and yet continue to struggle. Don’t get stuck trying to impose a label.
Within the original 12-step philosophy, one never imposes the label “alcoholic” on someone else; it is for each individual to decide whether this identification fits and is helpful (Alcoholics Anonymous [AA] World Services,
2001). The writings of Bill W., cofounder of AA, reflect great patience to
work with people wherever they are at present (Miller & Kurtz, 1994).

Etiologies of Addiction
The etiology of a condition is its cause or origin. We turn now to consider
the etiologies of addiction, those factors that influence its onset, severity,
and course. Identifying and understanding these factors is different from



diagnosing addiction. Beginning with the third edition in 1980, the DSM
has separated diagnosis from etiology.
So what causes addiction? Is it a shortcoming of character or will?
Can anyone become addicted? Can the blame be placed on the drugs themselves, as addictive substances? Is the fault in our genes or personality, with
some people more prone to addiction, in the same manner that they are
predisposed to diabetes or depression? Should we look to the social environment for causes? To some extent, the answer to all of these questions is
“Yes.” There is a certain amount of truth to each.

Personal Responsibility Models
In most societies, problems with alcohol and other drugs have been regarded
to some extent as a failure of self-­control, a violation of moral, ethical, or
religious standards. Most religions have prohibitions regarding the use of
certain psychoactive substances. In Jewish and Christian Scriptures, for
example, alcohol is not proscribed, but drinking in a way that risks or
causes harm is described as sinful. The remedies suggested by this model
include legislation, education, repentance, punishment, and social sanctions. This perspective is still very much evident in social responses to and
sometimes even in treatment of addictions. Underlying these models in general is the assumption that alcohol/drug use is a voluntary, chosen behavior,
and that the person could have done otherwise. This is exemplified in social
views and practices with regard to driving under the influence. Few would
accept a defense that someone just couldn’t help but use drugs or drink
before driving. Intoxication is rarely a defense or mitigating factor in crime.
Substance use is still regarded as a choice for which one is responsible.
Some models place particular emphasis on spiritual factors. Prominent
among these is the 12-step approach begun in 1935 from the experience of
its cofounders Bill W. and Dr. Bob when, “in the kinship of common suffering, one alcoholic had been talking to another” (Kurtz, 1979, p. 8). The
12-step programs, which do not endorse any particular model of etiology,
nevertheless place considerable emphasis on character flaws as a contributor to addiction. The importance of spirituality is even more central in the
12-step program for recovery. In this perspective, people are powerless to
resolve addiction on their own, and the help of a higher power is essential.
AA and other 12-step programs (see Chapter 14) provide recommendations
for a program of spiritual awakening and personal recovery. This spiritual
awakening is understood as the means to move from destructive independence to proper dependence on God and others (Kurtz, 1991). A spiritual
path to recovery was also emphasized in Moral Rearmament, another
international program that, like AA, had its roots in Rev. Frank Buchman’s
Oxford Groups in the 1930s (Lean, 1985).

What Is Addiction?


Agent Models
Agent models place primary emphasis on the strong effects of the agent
(the drug) itself. In this view, anyone who is exposed to the drug is at risk
because of its addictive and destructive properties. The U.S. temperance
movement, which originally promoted caution and moderation (temperance) in the use of alcohol, became a prohibition movement, placing primary blame on the drug itself. In 1919, the 18th Amendment to the U.S.
Constitution was ratified, making it illegal to manufacture, sell, transport,
or import “intoxicating liquor,” only to be repealed by the 21st Amendment in 1933. To be sure, the hazardous qualities of alcohol and tobacco
are well documented, and if they were to be introduced as new drugs today,
knowing what we know, they would be unlikely to be legalized. An agent
model was implicit in the “war on drugs” of the late 20th century. The
primary remedy it implies is to rid society of the drug itself.

Dispositional Models
Dispositional models, in contrast, place the primary cause of addiction
within the person. They share this emphasis with moral models, but typically construe the cause as constitutional and beyond the individual’s
willful control. Among these is a disease model that regards people with
addiction as constitutionally different from others and incapable of controlling their own use. In this view, the person is not responsible for having
the condition. Disease models did much to argue for humane treatment
rather than punishment of addiction. Of relevance to dispositional models,
various genetic risk factors have been documented that increase the likelihood of developing addiction to particular substances. Other dispositional
models have emphasized stable and perhaps irreversible changes that occur
in the brain with chronic use and that compromise self-­control. While a
dispositional model may absolve people of blame for their condition, the
responsibility for recovery necessarily remains with the individual, who is
typically counseled to adopt permanent abstinence as the only sure way to
prevent further progression and harm.

Social Learning Models
Other models emphasize the role of experience in shaping addiction. The
use of alcohol and other psychoactive drugs is clearly responsive to both
classical (stimulus–­response) and operant conditioning (contingent reinforcement and punishment). Even highly dependent individuals modify
their choices and use of substances in response to changes in the social
environment. Drinking and drug use practices are also clearly influenced
by modeling (learning by observing others), particularly from family and



peers. As the psychology of learning embraced human thought processes
in the late 20th century, the role of cognition in addiction was also examined. An important factor highlighted by this research is drug expectancies, beliefs and expectations about the likely positive or negative effects of
drug use (Brown, Christiansen, & Goldman, 1987; Goldman, Del Boca,
& Darkes, 1999). Interventions from a social learning perspective focus on
changing the individual’s relationship to the social environment: changing
patterns of reinforcement for drug use and nonuse (Chapter 11), social support, family interactions, high-risk situations, expectancies, and cognitive­behavioral coping skills (Chapter 12).

Sociocultural Models
A still broader viewpoint emphasizes the influence of societal and cultural
factors. The ease of availability and the price of alcohol, tobacco, and other
drugs clearly affect the level of use in a community. Social environments
with high levels of use (such as drinking in the military or in college fraternities) tend to increase consumption levels in new and continuing members. Advertising and media programming also influence expectancies and
perceived norms. Interventions within this perspective typically focus on
alcohol/drug policy. Examples include the licensing and regulation of sales
outlets, training of alcohol servers to prevent intoxication and impaired
driving, and taxation to increase the price of legal substances.

A Public Health Perspective
In seeking to prevent, treat, and contain threats to health, the most common approach is a broad one that takes into account all of the above influences. Usually called a public health perspective, it groups causal factors
into three categories: those involving the agent (in this case, the drug itself),
the host (personal characteristics of an individual), and the environment. In
containing a flu epidemic, for example, one would consider the particular
virus family involved (agent), personal factors that increase or decrease an
individual’s risk of infection (host), and environmental factors that promote
or diminish spread of the disease. The history
of addiction treatment has often been characA public health perspective
terized by passionate debates about which of
takes all important factors into
these factors is most important, which model
account and considers their
is “correct.” A public health perspective takes
interactions with each other.
all important factors into account and considers their interactions with each other.
The agent dimension was discussed above, focusing on characteristics
of the drugs themselves. Substances have addictive properties, including
rapidity of onset, tolerance, and interaction with neurotransmitter systems.

What Is Addiction?


The faster a drug reaches the brain, the more reinforcing its use tends to
be. Once in the brain, psychoactive drugs mimic or influence neurotransmitters (see Chapter 3). Many, for example, increase the release of dopamine, which is one of the primary neurotransmitters in the experience of
pleasure. Substance-­induced dopamine transmission is three to five times
greater than that of natural reinforcers, like food or sex. It is sensible, then,
that drugs may be preferred over natural rewards because of this rapid and
intense pleasure. It is possible to classify drugs according to their potential
to produce addiction. Toxic side effects of drugs like alcohol and tobacco
are also well documented. The effects of drugs also pose particular risks
in certain situations (e.g., when driving, during pregnancy). Thus the drugs
themselves deserve attention in social policy.
Much is also known about host factors in addiction, where attention
is focused on characteristics of individuals that place them at risk. Propensity for addiction is related to gender, family history of addiction, age, and
temperament (Substance Abuse and Mental Health Services Administration, 2009). Tarter’s construct of neurobehavioral disinhibition comprises
a cluster of emotional tendencies, behavioral symptoms, and problems in
cognitive function that indicate that a child has not adequately developed
psychological self-­regulation (Tarter et al., 2003). The construct includes
many symptoms that characterize attention-­deficit/hyperactivity disorder
(ADHD), conduct disorder, and oppositional defiant disorder. Escalating
psychosocial problems in youth, particularly conduct problems, have long
been identified as a predictor for later alcohol/drug problems (Jones, 1968;
Sartor, Lynskey, Heath, Jacob, & True, 2007). Temperament is, of course,
itself partially inherited. It is estimated that genetic risk factors explain
about 50% of the vulnerabilities leading to heavy drinking (Schuckit, 2009)
but the picture is less clear for genetic predispositions to other drug addiction (Buckland, 2008).
The environmental dimension includes factors outside of the individual.
The environment includes the broader community, such as the legal environment (alcoholic beverage control laws, laws regarding driving under the
influence, minimum purchase age laws, zoning), the economic environment
(pricing, tax rate, promotions), and the normative environment (social attitudes and beliefs regarding substances). The environment also includes the
physical aspects of the person’s environment, such as the setting or context
in which drinking and other drug-using behavior occurs. Another environmental influence is a person’s associates, including their family, friends,
coworkers, and other peers, who in turn carry ethnic, religious, and educational influences. Environmental or cultural stress levels may also influence
substance use. Certain religious group affiliations may increase or decrease
risk for alcohol/drug use and addiction (Gorsuch, 1995).
These agent, host, and environment factors also interact with each
other. A child who inherits a difficult temperament and risk for poor self-



r­ egulation may be protected by intensive parenting (Diaz & Fruhauf, 1991).
An individual who lives and works in a hard-­drinking environment may be
protected by religious affiliation. People differ in the inherited extent to
which their brains “light up” in response to particular drugs. Explanations
that focus on a single cause or model are clearly too simplistic. Effective
treatment and prevention efforts consider the range of factors involved and
address those most likely to yield benefit for the particular person or community.

Key Points

ÍÍAddiction occurs along a continuum of severity, or rather along

at least seven continuous dimensions of use, problems, physical
adaptation, behavioral dependence, cognitive impairment, medical
harm, and motivation for change.

ÍÍKnowing where an individual falls on one of these dimensions tells
little about the rest of the clinical picture.

ÍÍDiagnosis is about classification according to decision rules, which
have changed markedly over time.

ÍÍExplanatory models of addiction have also evolved over time,

often emphasizing one causal factor to the exclusion of others.

ÍÍA public health view of addiction embraces host, agent, and

environmental factors and their interactions, providing a more
comprehensive perspective for guiding treatment and prevention.

R e fl e c t i o n Q u e st i o n s
Of the various etiological models described in this chapter, which one(s)
have you most strongly embraced in your own views of addiction?
Which one(s) most closely match your own current perspective?
In your own mind, when does a behavior cross the line and become an
To what extent do you think people are responsible for developing their
own addiction(s)?

Chapter 3

How Do Drugs Work?


n Chapter 1 we explained why addiction treatment is a matter not only
for specialists in this area, but also for health and social service professionals in general. The training and experience of behavioral health professionals in particular provides excellent background for helping people
overcome alcohol/drug problems.
Yet even in the 21st century, the training of such professionals still seldom provides sufficient background and encouragement to treat addictions.
Although generalist professional training may provide 80% of the competence needed to help people with substance use disorders, the remaining 20%
of information and skills are important. Lacking this preparation, clinicians
may overlook addiction problems or refer them elsewhere for treatment. One
of our main goals in writing this book is to fill in that remaining 20%.
One important core competence, of course, is at least a basic working knowledge of psychoactive drugs and their effects. That is the primary
focus of this chapter. Let us say at the outset, however, that nonmedical
practitioners need not have memorized all of the chemical and street names
or understand in detail the psychopharmacology of each and every drug.
Medical colleagues are available for consultation on such issues, and much
of what you don’t know about street savvy, your clients can teach you.
Compared to clinicians, clients often have much more firsthand knowledge
about the drugs they use, although of course street information can also be
dangerously inaccurate. Drug users’ practical knowledge might be thought
of as a daunting disadvantage for the health professional, but it also means
that clients are a constant source of learning about lives and cultures that
may at first be quite alien to those who have survived the rigors of postgraduate training. We, the authors of this book, have learned much about
addictions from our clients. Of course we also constantly examine such



learning, as well as our own hunches and beliefs, in the light of the best
science available.

Routes of Administration
A good starting point, before considering major classes of drugs, is to
understand the various and sometimes surprising routes by which people
self-­administer psychoactive drugs. They fall into four major categories, all
of which begin with “in”: (1) ingestion, (2) inhalation, (3) intranasal, and
(4) injection. These do not encompass all possible routes of administration
that have been devised (such as placement under the eyelid, insertion into
the rectum or vagina, or absorption through the skin as by “patches”), but
they do encompass about 99.9% of drug misuse.

By far the most common way to self-­administer a psychoactive drug is by
mouth: to eat it, drink it, chew it, swallow it, or let it dissolve under the lips
or tongue. Drinking is the exclusive route for the most common problem
drug: ethyl alcohol. Prescription and other drugs in pill form are swallowed. Hairspray can be sprayed into a jug of water, shaken, and allowed to
settle—a preparation known as ocean because of its frothy appearance—
that is then drunk. Teas are brewed from various substances including khat
and valerian root. The original active ingredient in Coca-Cola was cocaine,
from which it derived its name.
Other drugs are chewed, absorbed through the gums, or placed under the
tongue in solid or liquid form. Coca leaves, khat root, tobacco, and nicotine
gum can be chewed, and their active ingredients absorbed through saliva and
the rich supply of blood vessels in the mouth. Some drugs can be introduced
through foods that are eaten and then absorbed through the stomach, such as
marijuana in brownies, alcohol-­injected fruit, or rum-­saturated cake.
Psychoactive drugs ingested by mouth pass into the gastrointestinal
system, where they are absorbed into the bloodstream through the lining
of the stomach and large intestine. Drugs in liquid form (such as alcohol)
tend to be absorbed more rapidly. Absorption is usually slowed by the presence of food in the stomach, which is why drinking on an empty stomach
produces faster intoxication. It can take from one to several hours to absorb
most of a drug dosage taken by mouth.

The second most common way to administer psychoactive drugs is to inhale
them as smoke or vapor, absorbing them primarily through the lungs. The
lungs have a rich blood supply, and drugs that are inhaled can be in the

How Do Drugs Work?


bloodstream within seconds. This is, of course, the usual route of administration for tobacco and marijuana. Cocaine in its usual hydrochloride salt
form is destroyed by burning, but it can be reduced by various methods to
a concentrated base form (such as “crack”) that is smokable to deliver very
high doses. Other misused drugs are termed inhalants because they are self­administered by breathing them in through the nose or mouth as a gas (such
as nitrous oxide) or a vapor (such as “sniffing” glue or “huffing” gasoline).

A third common route of administration is by snorting a drug into the nose,
which also has an extremely rich supply of blood vessels in the mucous membranes. Snuff is a preparation of tobacco that can be drawn up into the nose
in this manner. Snorting is a common method for self-­administering “lines”
of cocaine hydrochloride. Heroin is also sometimes taken intranasally.

Finally, drugs of abuse can be introduced into the body by shooting them
via syringe into a vein (intravenous), a muscle (intramuscular), or beneath
the skin (subcutaneous). Intravenous injection is the most common route
of administration for heroin and certain other opiates. It is also a popular
method for taking methamphetamine (“crank”), which may be combined
with heroin. Intravenous injection is, of course, the most rapid method for
getting a drug into the bloodstream, producing the fastest and most intense
effects. It is also the most dangerous. When used regularly for injection,
veins begin to collapse. As veins in the arms become unusable, injection
drug users may make use of blood vessels in the hands, feet, legs, and neck.
Bacterial infections and abscesses can occur if sterile procedures are not
used. The sharing of syringes by drug users is a major cause of the spread
of blood-borne infections such as HIV and the various forms of hepatitis.
Containing the spread of such diseases is a principal purpose of needle
exchange programs where users can obtain new sterile syringes and safely
dispose of used needles free of charge. Injection is also the most common
route of fatal overdoses of illicit drugs, precisely because the drug effects
are so immediate, intense, and often difficult to reverse.

Drug Distribution and Elimination
After a drug has been introduced, it moves through the body in more or less
predictable ways (pharmacokinetics) until finally it is eliminated. Drugs
first travel from the point of entry into the bloodstream, as by absorption through membranes, unless it has already been placed directly into
the circulatory system by intravenous injection. Once a drug enters the



bloodstream it is circulated throughout the
body within about a minute. To reach its
principal site of action in the central nervous system, however, a psychoactive drug
must further cross from the bloodstream
through the blood–brain barrier and into the brain, where it interacts with
nerve cells (neurons) to produce its effects.
Most psychoactive drugs do not circulate in the bloodstream for long.
They are gradually eliminated through the body’s filtering systems. They
are broken down or metabolized by the liver, excreted through the kidneys
in urine, even expelled in air from the lungs, in sweat through the skin, or
in breast milk. Drug testing makes use of this by analyzing expelled air (as
in alcohol breath tests) or urine for the presence of psychoactive drugs or
their metabolites.
The speed with which a given drug is eliminated from the body is usually expressed in terms of its half-life, which is the length of time required
for the body to reduce the drug level by half. Within one half-life, the level
of a drug would be reduced to 50% of its starting level. It takes two half-life
periods to eliminate 75%, and after three half-life periods the amount of
drug in the body would be down to about 12% of its original level. Drugs
vary dramatically in their half-life. Ethyl alcohol, for example, is cleared
from the body far faster than is methyl alcohol. Methadone has a longer halflife than heroin, making it a better substitution drug* because its effects are
distributed across 1–2 days instead of an hour or two (for heroin). Speed of
elimination can also be influenced by factors including age, gender, health
of the liver, interactions with other drugs, and hereditary traits.
Once a drug enters the bloodstream
it is circulated throughout the body
within about a minute.

Percentage of Drug Remaining after Each Half-Life

Percent Remaining








* Substitution medications are used to replace illicit drugs that the person has been
using. They may be used both for detoxification (see Chapter 6) and as longer term
maintenance medications (see Chapter 15).

How Do Drugs Work?


Drug Effects
Once they reach the brain, psychoactive drugs interact with particular neural systems to produce their characteristic effects. The brain’s communication system relies upon tiny electrical currents transmitted through chains
of neurons. Each neuron fires in response to particular chemicals known as
neurotransmitters. When one of these chemicals comes into contact with
a nerve cell to which it is related (by virtue of the cell having receptors for
it), the molecule fits like a key into a lock. By fitting into the receptor, it can
increase or decrease the cell’s ability to transmit electrical signals to other
nerve cells farther along in the chain.
A neuron consists of the cell body, dendrites that receive chemical messages from previous neurons in the chain, and a tail-like fiber called an axon
that communicates with subsequent neurons in the chain. Many axons have
a myelin sheath that speeds up the transmission of information. When a
neuron fires, it releases one or more special neurotransmitters from its axon
into a synapse, the fluid space between nerve cells. The released chemical
comes into contact with the dendrites of other neurons and may cause them
to fire. The neurotransmitter is then normally re­absorbed from the synapse
by the neurons from which it was released, a process known as reuptake.


From National Institute on Drug Abuse (2005)



The human body was not designed to respond to most drugs that are
misused. Some psychoactive drugs work because they closely resemble
molecules that occur naturally within the body. For example, the central
nervous system includes a remarkable capacity to reduce pain through the
release of natural neurotransmitters known as endorphins. Opioid drugs
such as heroin closely resemble these natural molecules. They stimulate the
endorphin (opiate) receptors, artificially activating the body’s system for
relieving suffering and inducing a pervasive sense of well-being. A drug that
can thus mimic the effects of a natural neurotransmitter is called an agonist
for that system. Most drugs of abuse are agonists, activating or amplifying



transmitter systems in the brain, usually in a way that is much more intense
than normal experience.
One problem with artificial activation, however, is the phenomenon
of drug tolerance, discussed in Chapter 2. Heroin-­dependent people often
report that the most intensely pleasant rush of their lives happened during
their first exposure to heroin, and that they have spent the rest of their lives
chasing that same high. For a variety of reasons, psychoactive drugs tend to
lose their potency with repeated use, so that in order to experience the same
high the person must use ever larger doses. The system becomes saturated,
and natural neurotransmitter activity is reduced in response to artificial
activation. Eventually the person uses the drug just to feel normal.
Just as some drugs serve as agonists, others serve as antagonists for specific neurotransmitters. An antagonist molecule binds to the receptor and
blocks it, reducing activation by either the natural neurotransmitter or by its
artificial agonists. Some drugs can serve both agonist and antagonist functions; they are partial agonists stimulating activity in a specific neurotransmitter system, while also blocking further stimulation by other agonists. We
discuss agonists, partial agonists, and antagonists further when we consider
therapeutic medications that are used to treat drug dependence (Chapter 15).
Resembling a natural neurotransmitter is not the only way in which
drugs can influence the central nervous system. Some drugs exert effects not
by mimicking neurotransmitter molecules, but by acting on neurons in other
ways. Alcohol is a prime example. Although some of alcohol’s many effects
do seem to involve activation of receptor systems, alcohol also impacts the
entire brain by altering nerve cell membranes in ways that are only partially
understood at present. Other drugs exert their effects by blocking reuptake,
causing a neurotransmitter to remain longer than normal in the synaptic
space and thus continuing to act on postsynaptic neurons.

Major Drug Classes and Their Acute Effects
This section outlines major classes of drugs that are used illicitly and how
they affect the central nervous system. For each drug class we describe the
common sought-after effects of intoxication (“the peak”) and the rebound
period that follows use (“the valley”). These descriptions are necessarily
brief. Several classic resources are available that describe in more detail the
pharmacokinetics, pharmacodynamics, and specific effects of psychoactive
drugs (Hart, Ksir, & Ray, 2008; Julian, Advokat, & Comaty, 2007; Preston & Johnson, 2009; Stahl, 2009).
Some common street names for major drug classes are listed in Box
3.1. There are hundreds of such street names, which vary among geographic
areas, with new slang names appearing regularly. Box 3.2 on page 37 summarizes the neurotransmitter systems particularly affected by the various
classes of drugs discussed below.

How Do Drugs Work?


Box 3.1. Some Street Names for Drugs

Booze, hooch, juice, sauce


Speed, crystal, ice, crank, chalk, crystal, glass, meth,
uppers, bennies


Barbs, downers, reds, ludes, goofballs




Pot, dope, grass, weed, herb, hemp, rope, Mary Jane, hash,
ganja, tea


Coke, C, crack, snow, crystal, rocks, toot, cola, nose candy,
heaven, white


Horse, shit, smack, junk, H, skag, fix, China white, whack,


Acid, 25, tabs, sugar, blotter, microdots, paper mushrooms

Mescaline, peyote Buttons, mesc, mess, cactus

Angel dust, PCP, elephant, hog


Mushroom, shroom, sacred mushrooms, magic mushrooms

Stimulants can be ingested, taken intranasally, or injected intravenously.
By reducing them to a base form, stimulants can also be inhaled in smoke.
As a class of drugs, stimulants exert their psychological effects by increasing activity in three key neurotransmitter systems: dopamine, norepinephrine, and serotonin. Cocaine does so by blocking the reuptake of these
chemicals from synapses. Amphetamines resemble the neurotransmitter
epinephrine (adrenalin), and exert their stimulant effect primarily by the
dumping of increased amounts of dopamine and norepinephrine into neural synapses. Stimulants activate the brain’s positive reinforcement system,
which normally rewards activities that promote survival and well-being. In
essence they directly and intensely trigger the brain system that says “Do
that again!” It is no mystery, therefore, why these drugs have such a high
capacity for habitual use and dependence.

The Peak
Stimulants have been called “power drugs” because they induce euphoria
and a grandiose sense of personal power and achievement. They can be
used to remain awake and alert, promote persistence, and suppress fatigue
and hunger—­effects that historically made these drugs useful to soldiers
and to others like students and truck drivers wanting to stay awake and



alert. In general they speed up functioning: the person thinks faster, talks
faster, moves faster. With higher or repeated doses, the user may develop
paranoia or other delusions.

The Valley
As with many drugs of abuse, the stimulant high is followed by a low, a
“crash.” The rebound from stimulant use is substantial, and not surprisingly involves the opposite of the drug’s acute effects. During the postdrug
valley the user may experience anxiety, depression, fatigue and drowsiness,
increased appetite, and persisting paranoia.
Two other widely used stimulants are nicotine (primarily in tobacco)
and caffeine (in