Who gets addicted? What do addicts take? What does addiction do?
The author, who has written a book on this subject, explains what substance abuse is, what substances are misused by youngsters, how they affect the brain and behaviour, and what leads the young to such addiction. In the next issue, he will present ways of preventing addiction and of helping addicts to get healed.
Sandeep’s parents were software professionals. They provided him with all the comforts he desired, but could not spend time with him due to their professional commitments. Sandeep (14) began to feel lonely without the love and company of his parents. Mid-way through standard IX, Sandeep’s school counsellor called his parents to say that he had become addicted to sniffing whitener, due to which he was lost in his own world and unresponsive in class.
A 14-year old government school student was found lying unconscious after school hours on the school campus. Two of his close friends shared that he had consumed ganja, which he bought from another young boy with money he had stolen. When interrogated, the boy who supplied the drug said that he acted as an agent of a roadside store in the neighbourhood.
The following shocking words are of a young woman doing her college: “My boyfriend and I have been addicted to drugs and alcohol. He used to assault me for cash to fuel his habits. Once I borrowed Rs. 5,000/- from a friend. She suggested I get into prostitution to get more cash. I was desperate and agreed.” (Mid-Day, September 15, 2015, p. 6)
“How at all did we not notice all along that our child was addicted to substances?” was a common refrain of the parents. But by the time they did notice, the children were so steeped in the habit that it was difficult to rehabilitate them without sustained professional intervention. “Prevention is the best cure to this malaise” remarked an experienced counsellor. But to be able to prevent it, we need to notice it in the first place. This article helps readers notice when something is amiss with their wards. It also suggests measures to help children who are afflicted or at risk for addiction.
Students together with numerous school teachers and counsellors tell stories of school-going students experimenting with substances; and of the struggles of their parents to rehabilitate them. A survey conducted by the NGO Prayas in association with the Ministry of Child Welfare and Development in 2007 across thirteen states of India indicates that such instances are more common than one would expect. Their study revealed that 32.1% of the survey respondents below the age of 18 across twelve states of India, had ingested alcohol, bhang, ganja, heroin or some other narcotic substance. Of these, 70.3% were first introduced to these substances by their friends and relatives, and 11.7% were influenced by their parents[1].
The survey findings as well as the stories cited raise several questions: Almost 70% of young people refrain from using substances during their adolescent years. So, what kind of youngsters get drawn into experimenting with substances? What kind of substances do they ingest? How does addiction to substances affect users? Is there a way of identifying young people who are using substances? What can be done to prevent young persons from experimenting with substances? How can persons who are addicted to substances be helped? This article addresses key issues associated with these questions. However, at the outset, we need to clarify a few terms related to substance addiction.
What is “substance abuse”?
The terms ‘drugs’ and ‘substances’ are often used interchangeably. The term ‘drug’ commonly refers to naturally occurring substances or pharmaceutical preparations ranging from over-the-counter medications to illegal preparations that are considered to be psychotropic or narcotic; and which modify perception, mood, behaviour, physical or mental functioning. While including these preparations, the term ‘substance’ also refers to addictive products generally not referred to as ‘drugs’ such as inhalants, and those with tobacco or alcohol components. In this article I use the more overarching term ‘substance’ since I refer to a wide range of addictive and injurious substances.
The meaning of the terms ‘substance use’ and ‘substance abuse’ is much debated. In this article, the term ‘substance use’ refers to the ‘consumption’ of substances. ‘Substance abuse’ refers to inappropriate, frequent, excessive and prolonged use; addiction to, and dependence on substances that negatively impacts persons’ physiological, behavioural, mental, emotional, social and occupational functioning. Not all persons who ‘use’ substances ‘abuse’ or become dependent on them. However, children who begin using substances like tobacco and alcohol from a young age risk abusing and becoming dependent on them, and sometimes ‘graduating’ to using and becoming dependent on illegal psychotropic substances. Hence, apart from providing information to assist students who are abusing substances, this article also advocates protecting and preventing young children and persons from ‘using’ substances in the very first place.
What they start with—and when
Statistics provided by the National Commission for Protection of Child Rights (NCPCR, 2013)[2] have indicated that children switch from using tobacco, inhalants and alcohol—generally considered to be ‘gateway substances’—to ingesting illegal substances like cannabis, opioids, stimulants and hallucinogens.
When do they start?
- Tobacco and inhalants: 12 years
- Cannabis and alcohol: 13 years
- Opium, pharmaceutical opioids and heroin: 14 years
- Injectable substances: 15 years
Three types of substances:
- Tobacco (83%)
- Alcohol (68%)
- Cannabis and inhalants (35%)
Parents, teachers and caregivers might benefit from being able to differentiate between the kinds of substances that the NCPR reports to be commonly consumed by children and adolescents.
What substances do they take?
Indian children and youth generally consume a variety of substances such as tobacco, inhalants, alcohol, cannabis, opioids, simulants and hallucinogens. Each substance is ingested in different ways and has its own distinctive characteristics and effect.
In India, tobacco is widely used in a variety of ways such as smoking, chewing, applying, sucking and gargling. Tobacco is smoked in the form of beedis and cigarettes. Chewing betel leaves (paan) with tobacco is a major form of smokeless tobacco use. Nearly 3000 chemical constituents are present in smokeless tobacco, while close to 4000 are present in tobacco smoke. Most of these chemicals are harmful. Each cigarette contains about 0.1-2.8 milligrams of nicotine – a highly active ingredient.
Inhalants are chemical substances whose vapours are inhaled to produce psychoactive (mind altering) effects. Some of the commonly inhaled substances are spray paints, glues and cleaning fluids. Inhalant vapours are ingested through the nose or mouth in a variety of ways such as sniffing, snorting fumes from a container, spraying aerosols directly into the nose or mouth, or placing an inhalant-soaked rag in the mouth. They are rarely ingested by any other route. Since inhalant-induced intoxication lasts for only a few minutes, users try to extend the “high” by repeated inhalations over several hours. Lead-based components of inhalants can damage brain cells.
Alcohol is a generic term for many different chemical compounds, each with its own distinct properties. Ethyl alcohol (ethanol) is the active ingredient in alcohol. Its concentration varies across preparations such as beer, wine, whisky, gin, brandy, rum, rectified spirit and toddy. Alcohol is a brain depressant and alters a person’s mood in various ways. It heightens the mood one experiences prior to intake, be it sadness, happiness or anger. In small amounts, it relieves anxiety. When consumed in larger quantities, it may generate an exaggerated sense of strength, impair judgement and performance, and result in boisterous behaviour.
Cannabis is a psychotropic product derived from the plant cannabis sativa; and is believed to have been used for thousands of years for medical, religious and social purposes. The dried leaves, tops and resins of the cannabis plant are used in preparations like bhang, charas and ganja. Its potency varies with the concentration of its active ingredient delta-9 THC (tetra hydrocannabinol). Psychological dependency can be associated with frequent cannabis use.
Natural opioids are prepared from the milky juice of the seedpods of the opium poppy. Most opioid drugs are synthesized in the laboratory. Opioids are medications that relieve pain. They reduce the intensity of pain signals reaching the brain; and affect brain areas controlling our emotions. This helps diminish the effects of painful stimuli. Medications that fall within this class include morphine, codeine, hydrocodone and methadone. They also include the illegal drug heroin.
Stimulants (also referred to as psycho-stimulants) are psychoactive drugs that induce temporary improvement in either mental or physical functioning or both. They are sometimes called “uppers.” Caffeine, nicotine, amphetamines, cocaine, and methamphetamine are examples of stimulants. They may be swallowed, injected in liquid form, or crushed and snorted. Stimulants such as Adderall, Benzedrine, Concerta and Ritalin that are prescribed for medical purposes are available in the form of tablets or capsules.
Hallucinogens, also known as psychedelics, are drugs that cause hallucinations (profound distortions in a person’s perceptions of reality). Lysergic acid diethylamide (LSD) is the best known hallucinogen. It is synthesized from a dry fungus that grows on rye grass. Phencyclidine (PCP) and ketamine are other commonly used hallucinogens. Hallucinogens act on the central nervous system to induce profound sensory, mental and emotional changes such as: seeing images, hearing sounds, and feeling sensations that seem real but do not exist; distortions in the user’s sense of reality, time and emotions; and rapid, intense emotional swings.
Progression of Substance Use
The pattern of substance consumption moves from experimentation, to tolerance for higher doses, to dependence. Users’ pattern of behavior ‘degenerates’ as they spiral to ‘lower’ stages. Those who consistently consume high doses over extended periods of time experience withdrawal symptoms when they stop using substances.
Experimental use of a substance either for recreation or to de-stress, tends to turn to regular and risky use. Adolescents who use substances regularly often begin to tolerate higher doses; stay away from school, friends and family more often; and increasingly begin to bond with those who are regular substance users. Those who are at risk for becoming dependent on the substance tend to neglect regular school and work on account of abusing the substance.
Tolerance is the body’s craving for increasingly higher doses of a drug or substance in order to obtain the same effect as when the drug/ substance was first used. A user who begins to tolerate higher doses of a substance with repeated use tends to become dependent on it.
A person who is dependent on a substance chronically seeks and abuses it, and is unable to refrain from using it despite harmful consequences. Dependence weakens users’ physical, emotional and mental potential; cripples their relationships; and keeps them from attaining cherished personal, educational and career goals.
Withdrawal Symptoms
Persons begin to experience withdrawal symptoms when they reduce or stop using a substance they have been consuming in high doses for an extended period of time. Withdrawal symptoms usually peak between 48 and 72 hours after the last dose and subside after about a week depending upon the type and amount of the substance used. Withdrawal symptoms vary with the kind of drug/substance that is used. However, common withdrawal symptoms that develop in association with a number of drug/substance types include:
- Mood disturbances: mood swings, irritability and agitation
- Sleep disturbances: insomnia
- Physiological disturbances: chills, sweating, tremors, shaking of hands; flu-like symptoms including running nose, headache, and vomiting
- Craving: a strong desire to use the drug of choice in order to stop the withdrawal symptoms
When consumed in excess over long periods of time, substances begin to disrupt the normal functioning of the brain.
How substances affect the brain
The brain is made up of billions of nerve cells or neurons which receive messages from our sense organs and other parts of the body and relay messages back to these sources. Chemical agents called neurotransmitters assist networks of neurons to communicate with one another; and to thereby coordinate processes of sensation, movement, thought, emotion, and behaviour. Substances spoken about earlier interfere with the way these neural networks function and disrupt users’ naturally ‘wired’ physiological, cognitive (thinking, decision-making and planning), and emotional processes.
Substances of abuse affect three important sections of the human brain – the brain stem, the cerebral cortex and the limbic system (NIDA, 2014) (as illustrated in Figure of brain attached at the end of document).
- The brain stem regulates physiological processes such as our digestive, circulatory, and respiratory systems that our bodies need to stay alive. Substance abuse disrupts some of these life-sustaining systems.
- The cerebral cortex is divided into: (a) lobes that process and coordinate messages we receive through our senses; and (b) lobes that control our cognitive functions (thinking, decision-making and planning). Substances of abuse damage our thinking ability.
- The limbic system links together structures that regulate our ability to feel pleasure, as well as to experience positive or negative emotions. Substances of abuse disrupt our natural emotion- and pleasure-regulating systems by acting on the limbic system.
The pull of pleasure
The neurotransmitter dopamine operates in regions of the brain that regulate movement, emotion, motivation, and feelings of pleasure. Natural activities like eating, singing and dancing activate the pleasure circuits of the brain by triggering the release of dopamine. The resulting feeling of pleasure motivates us to repeat these life-sustaining behaviours. Substances of abuse trigger the release of unusually large quantities of dopamine (and other neurotransmitters). Thus, the resulting substance-induced feeling of pleasure is much more pronounced than that of natural pleasure-inducing behaviours like eating, singing and dancing. The quest to re-experience this artificially induced surge of pleasure motivates users to repeatedly consume substances (NIDA, 2014).
What happens to the brain?
The brain responds to the artificial substance-induced surge of dopamine either by producing less of it, or by blocking receptors onto which it binds. With the natural supply of dopamine reduced through this self-regulating activity of the brain, substance users’ ability to experience pleasure in response to normal activities is more diminished. Thus, when the effect of substance-induced pleasure fades, the user feels listless and depressed, and is unable to enjoy activities that were earlier felt to be pleasurable. The resulting dysphoric state drives users to once again consume substances in order to be able to function, as well as to re-experience surges of substance-induced pleasure. In addition, the person may need to ingest larger quantities of the substance to produce the familiar dopamine high giving rise to substance tolerance and dependence (NIDA, 2014).
Dangers of substance use
Using substances is dangerous not only because of the long-term physiological impact they have on the body, but also because a single high dose can diminish users’ awareness of the environment, of circumstances that may endanger their safety, and of their ability to set limits. Prolonged dependence on substances among older users has been associated with instances of self-inflicted harm, violent behaviour, stealing to obtain money to purchase more of the substance, driving under the influence of substances, and vulnerability to sexually transmitted diseases and sexual exploitation.
As the same Mid-Day article reported, a IX Standard drop-out said, “I wish I had listened to my parents and studied hard… then I wouldn’t have fallen in this trap. I would roam around with addicts, all boys, who would threaten me to bring cash from home. I would comply and we would spend all that money on drugs and smoke up.”
The words of the teenage daughter of a policeman are even sadder: “I smoked up all kinds of drugs, including marijuana and hashish… Because I didn’t want my parents to know what I was up to, I would go home only once in fifteen days, sleeping in a jaunt for hungover girls. We would all pass out and wake up the next day with no idea of what had happened to us the previous night.”
What are the risks?
Not all persons who ‘use’ or consume substances become dependent on them. However, research suggests that those who begin experimenting with substances during childhood or adolescence are at risk for becoming addicted to and dependent on substances during their adult years. Thus, it is important to identify and assist children and adolescents who are potentially at risk. Knowing individual, family, school and community-related factors that pre dispose children to abuse substances may help in this task.
Individual level
Children and adolescents most at risk for substance abuse are those who:
- Experience academic difficulties due to attention-deficit-hyperactivity-disorder, or learning difficulties such as dyslexia
- Experience psychological vulnerabilities such as anxiety, depression, and swings in mood from elation to depression (Bipolar disorder)
- Have poor study, interpersonal, coping and problem-solving skills; and therefore withdraw from peers and family due to low self-confidence and low self-esteem
- Are victims of physical, emotional, or sexual abuse
- Are either rebellious or aggressive
Family level
Children are at risk for experimenting with substances when their families:
- Have a history of substance abuse
- Adopt a favourable attitude towards the use of substances
- Are dysfunctional and conflict-ridden. Dysfunctional families have a history of marital discord and violence; chemical dependence; perfectionism, excessive or absent limit-setting; physical, emotional, and sexual abuse; neglect or abandonment. Children of dysfunctional families are often victims of neglect or abuse of various kinds. They often abuse substances to cope with the distress they experience.
School level
At school, children who are likely to experiment with substances:
- Have a history of academic failure
- Lack commitment to school
- Display behaviour such as violation of school and institutional norms, disrespect for elders, bullying, stealing, and destroying others’ property
- Associate with peers who abuse substances and view substance-use in a favourable manner
Community level
Children are at risk for abusing substances when the populations or communities to which they belong:
- Migrate frequently and do not develop attachment to any particular neighbourhood.
- Lack appropriate norms and laws for regulating antisocial behaviour and substance abuse.
- Easily access and consume alcohol and other substances.
Children who display a combination of characteristics across all four levels—individual, family, school and community—are most at risk for abusing substances. Thus, teachers and elders may want to attend to students who are shy or withdrawn, display poor attendance, a decline in academic achievement; defiant behaviour, bullying and gang activity, or involvement in crime; and those who hail from broken or tension-ridden families, and depressed communities. These characteristics may suggest that students are using substances when they also display other characteristic symptoms of substance abuse that are highlighted in the next sub-section.
How to spot addiction
Those addicted to substances often use effective strategies to cover up their addiction, and in addition, deny that they are gradually losing the ability to regulate their addictive behaviour. On the other hand, teachers and family members of students who are addicted may either not suspect that there is something amiss, or if they do, often attribute unusual behaviour to peer pressure or adolescent turbulence. The ability to identify that a student is ingesting substances is the first step towards referring an addicted student for help. Hence caregivers may want to familiarize themselves with specific characteristics clusters of behaviour described in this section that persons addicted to substances generally exhibit.
Looks and smell
Students who abuse substances tend to be shabby and unkempt in their dress and personal grooming. They exhibit features such as: poor hygiene; burns or soot on fingers or lips; and track marks on arms or legs (some wear long sleeves in warm weather to hide track marks). In addition, they may smell of smoke; exude unusual smells in their breath or on clothes; chew gum or mint to cover up the smell they exude through their breath; or use medications to reduce eye reddening, nasal irritation, or bad breath.
Slurred or angry speech
Those who abuse substances display marked changes in their patterns of communicating with others. They may be uncommunicative with family, teachers or peers; make excuses to explain away their negligence, lapses, or unusual behaviour; speak in a slurred, rapid, pressured or unintelligible manner, or in an angry and hostile manner; or lose inhibition and speak in a loud or obnoxious manner.
Changes in mood and sleep patterns
Those who abuse substances may display marked swings in attention, mood, or energy levels such as: being hyperactive or unable to focus on tasks; displaying sudden swings in mood from depression, to anger, to unusual elation; being tired, lethargic, sullen, withdrawn or depressed; exhibit periods of sleeplessness or high energy, followed by long periods of “catch up” sleep.
Signs at home
Substance users’ family members may observe the disappearance of money or valuables, over-the-counter pills and syrups, and home supply of alcohol or cigarettes. On the other hand they may find unusual supplies such as hidden stashes of alcohol; drug apparatus like pipes, needles, syringes, rolling papers, butane lighters, aluminium foils, small medicine bottles and eye drops; and inhalants of various kinds. Users may also demand unusually large amounts of pocket money; spend much time in their personal room, bathroom, or away from home.
Health problems
Persons who abuse substances display symptoms of ill-health unrelated to regular illness and ailments such as: headaches, unclear vision, redness of eyes and puffiness of face, nosebleeds, runny nose not caused by allergies or colds, sores and spots around the mouth, nausea and vomiting, seizures, sudden or dramatic weight loss or gain, skin abrasions or bruises, and accidents or injuries.
It is very likely that persons who show behaviours across several clusters mentioned above are addicted to substances. Thus parents and caregivers might want to make discreet enquiries and speak to the concerned person about it
Importance of identifying cues
Identifying students who are at risk may motivate caregivers to prevent them from falling prey to substance abuse. On the other hand, identifying those who are actively abusing substances is the first step towards rehabilitating them.
(In the next issue: How to prevent substance addiction. How to help addicts to quit.)
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[1] Cited in Prashant Mehta. “Evaluative trends of illicit drugs uses in India and analysis of Indian and international laws of prohibition of drugs of abuse.” Acta Chimica & Pharmaceutica Indica, 1(1), 2011, 32-43.
[2] National Commission for Protection of Child Rights. (2013). Assessment of pattern and profile of substance abuse among children in India. A Report. New Delhi: Government of India.
Fr. Ajoy Fernandes, S.D.B.
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