INTRODUCTION

Substance abuse has become a major health problem in and

around the world. Substance abuse permeates all levels of

society. Substance use, misuse, and dependence are among the

most prevalent causes of adolescent morbidity and mortality in

most countries. Substance of all types is being widely used or

misused by teens and emerging adults in the United States

(Steve Sussman, 2008). Among older teens, some studies have

found alarmingly high substance use and dependence rates.

Adolescent substance misusers experience numerous social,

economic, physical, and legal consequences, for example,

truncated development. Substance use-related disorders are

associated with such problems as poor academic performance,

job instability, teen pregnancy, and the transmission of

sexually transmitted disease. Crime such as stealing,

vandalism, and violence are associated with “heavy drug use”

in adolescence. Adverse consequences occur like overdose and

accidents. In fact, the incidence of drinking and driving

among older adolescents and emerging adults is double that of

general populations. Drug using individuals are more likely to

develop disorganize thinking and unusual beliefs that may

interfere with problem-solving abilities and emotional

functioning and may lead to greater social isolation and

depression. Substance dependent adolescents (Sussman S, 2001)

endure consequences of additional problems such as drug

tolerance effects, withdrawal symptoms, and preoccupation with

using a drug to the exclusion of other activities.

Using substances by injection can cause serious health

problems no matter which substance is injected. Injecting any

drug is significant risk factor for contracting blood-borne

diseases such as HIV and Hepatitis B and C (WHO, 2003). People

who inject drugs have a higher risk of dependence and are

likely to have more severe dependence than those who do not

inject.

Newcomb and Bentler (1989) provide information on the

etiology, or cause, of substance use and abuse. These authors

note that use is prompted most by peer influence, whereas

abuse stems from internal psychological distress. They also

identify risk factors associated with substance use and abuse,

including a personal history of drug use, use by peers, a

lower socioeconomic level, family dysfunction, a family

history of abuse, poor school performance, low self-esteem,

lack of abidance with law, need for excitement, stress life

events, and anxiety and depression.

Substance abuse refers to the harmful or hazardous use of

psychoactive substance, including alcohol and illicit drugs.

Psychoactive substance (Organization, 2001) use can lead to

dependence syndrome – a cluster of behavioural, cognitive, and

physiological phenomena that develop after repeated substance

use and that typically include a strong desire to take the

drug, difficulties in controlling its use, persisting in its

use despite harmful consequences, a higher priority given to

drug use than to other activities and obligations, increased

tolerance, and sometimes a physical withdrawal state.

The reasons people use drugs include obtaining pleasure, joy

and euphoria; meeting social expectations, giving in to peer

pressure, dealing with or escaping stress, anxiety, and

tension, avoiding pain and achieving altered states of

consciousness.

Psychoactive drugs (Plotnik, 2008) are chemicals that affect

our nervous systems and, as a result, may alter consciousness

and awareness, influence how we sense and perceive things, and

modify our moods, feelings, emotions, and thoughts.

Psychoactive drugs are both licit (legal) such as tobacco,

coffee, and alcohol and illicit (illegal) such as marijuana,

heroin, cocaine and LSD. Although all psychoactive drugs

affect our nervous systems, how they affect our behaviours

depends on our psychological state and other social factors.

Etiology Of Drug Dependency

Addiction or dependency (Sherry Wasilow - Mueller, 2001) may

be viewed as a subset of brain and behaviour disorders, which

include all psychiatric diagnosis (such as schizophrenia,

bipolar disorder, major depressive disorder, and obsessive-

compulsive disorder). Current recognition of addiction,

acceptance of it as a medical disorder by the public, and

treatment options for it roughly mirror conditions for

schizophrenia, bipolar disorder, and major depressive disorder

some 20 years ago.

Although addiction usually (but not always) begins with a

conscious decision to use a drug, changes that occur in the

brain at some point can turn drug use and then abuse into a

chronic, relapsing illness. Some genetically predisposed

individual, however become “addicted” almost immediately, with

very little progression from use to abuse to dependency. Two

events must occur for the addictive process to be initiated.

First, there is an addictive process to be initiated. First,

there is an activation of the brain’s “pleasure pathway”. This

occurs in the medical forebrain bundle, which runs from the

brain stem and midbrain through the hypothalamus to a variety

of sites in the forebrain that are concerned with emotion,

motivation, reward, and decision making.

Second, for the addictive response to be initiated, the neural

response to the drug exposure must have a rapid onset and must

also rebound below the initial baseline of neural activity

before returning to it.

Content

Early Use

An individual uses drugs freely in order to feel better.

First-time drug users often are just experimenting or

succumbing to peer pressure to try a substance. Others are

thrill-seekers who try any new option that comes along. Other

people are looking for a way to deal with stress or mental

disorders and seek relief through self-medication.

Drugs primary influence the pleasure centre in the brain,

which are responsible for the feeling of being high. Many

chemicals mimic the neurotransmitter in the brain and serve to

help people feel better and achieve a sense of well-being.

Dopamine levels are increased by most illegal chemicals and

add to the pleasurable sensations. In doing so, the physical

neurotransmitters in the brain become altered. Human evolution

created the dopamine structures to reward humans for survival

behaviour, such as sex and eating. Following the initial burst

of dopamine and the unnatural release of additional dopamine,

drugs continue to create the pleasurable sensation much longer

than natural behaviours. Those levels of well-being are

difficult, if not impossible, to reach without the use of

drugs, setting up the brain to seek more of the pleasurable

sensations.

Risks

Studies by the NIDA (Ray, 2009) show that 67 percent of people

who try marijuana for the first time are teenagers between the

ages of 12 and 17. Between the peer pressure, undeveloped

decision-making skills and immature brain development of this

group, prevention can be difficult for educators and parents.

While environmental pressures play a big role in causing

substance abuse, researchers believe that genetics play a

larger role. The NIDA found that 40 to 60 percent of the

reasons a person will become addicted is attributable to

heredity. Additional risks associated with probability that

someone will become addicted after trying dope include mental

illnesses, drug availability, past traumatic stress and

personality.

Diagnosis

Substance abuse problems can be diagnosed by using DSM-IV-TR

which recognizes two mental disorders associated with

substance abuse, substance abuse and substance dependence. A

diagnosis of substance abuse applies to a client with an

impairment in social or occupational functioning. ( continue

from page 441 counselling book )

Exploring Adolescent and Emerging Adult Problems

The Bio-Psycho-Social Approach

Biological, psychological, and social factors have been

proposed as cause of problems that adolescents, emerging

adults, and others can develop. The bio-psychological approach

emphasizes that problems develop through an interaction of

biological, psychological, and social factors.

The Development Psychopathology Approach

In the developmental psychopathology approach, the emphasis is

on describing and exploring developmental pathways of

problems. One way of classifying adolescent and emerging adult

problems is an internalizing (for example, depression and

anxiety) or externalizing (for example, juvenile delinquency).

Resilience

Three sets of characteristics are reflected in the lives of

adolescents and emerging adults who show resilience in the

face of adversity and disadvantage: (1) individual factors –

such as good intellectual functioning; (2) family factors –

such as a close relationship with a caring parent figure, and

(3) extrafamilial factors – bonds to prosocial adults outside

the family. Resilience in adolescence is linked to continuing

to be resilient in emerging adulthood, but resilience can

develop in emerging adulthood.

Problems and Disorder

Drug Use

Understanding drug use requires an understanding of physical

dependence and psychological dependence. Alcohol (Santrock,

2010) acts as a depressant and is the drug most widely used by

U.S adolescents and emerging adults. Alcohol abuse is a major

problem, although its use in adolescence has begun to decline.

There is an increase in alcohol use and binge drinking during

emerging adulthood. Binge drinking by college students is a

continuing concern. Use of alcohol and drugs typically

declines by the mid-twenties. Risk factors for alcohol use

include heredity and negative family and peer influences.

Other drugs that can be harmful to adolescents include

hallucinogens (LSD and marijuana), stimulants (such as

nicotine, cocaine, and amphetamines), and depressants (such as

barbiturates, tranquilizers, and alcohol). A special concern

is cigarette use by adolescents.

An alarming trend has recently occurred in the increase use of

prescription painkillers by adolescents. Use of anabolic

steroids has been linked with strength training, smoking, and

heavy use of alcohol. Parents and peers can provide important

supportive roles in preventing adolescent drug use. Being born

in a high-risk family, having conduct problems at school, and

being rejected by peers were factors related to drug use by

12-years-olds (Santrock, 2010). Early educational achievement

by adolescents have positive influence in reducing the

likelihood of developing problems with drug and alcohol abuse.

Diagnostic and Statistical Manual of Mental Disorders

The classification of substance-related disorders in DSM

system is not based on whether a drug is legal or not, but

rather on how drug use impairs the person’s physiological and

psychological functioning.

Substance use disorders are patterns of maladaptive use of

psychoactive substances. These disorders, include substance

abuse and substance dependence.

Substance abuse – concept and process as opposed to misuse

involves accumulation of negative consequences. Substance

abuse as defined by the Diagnostic and Statistical Manual of

Mental Disorders, fourth edition, text revision (DSM-IV-TR)

(APA, 2000), is a maladaptive pattern of substance use leading

to clinically significant impairment or distress as manifested

in a 12-month period by at least one of four criteria : (1)

recurrent substance use resulting in failure to fulfil major

obligations at work, school, or home such as poor performance

at work or school, neglect of children or young siblings; (2)

recurrent substance use in hazardous situations such as

driving while intoxicated; (3) recurrent substance-related

legal problems and (4) continued substance use despite having

recurrent interpersonal problem related to substance use such

as arguments with family members about consequences of

intoxication. These criteria were primary conceptualized for

application to adult population.

Physiological and psychological effects of drugs

Substance dependence (Derigne, 2010) has been defined by the

DSM-IV-TR as being a severer disorder, consisting of a

maladaptive pattern of substance use leading to clinically

significant impairment or distress as manifested in a 12-month

period by three or more of the following :

1. Tolerance means that with repeated use, a person will no

longer achieve the same degree of pleasurable effect

experienced in the past and the person has to use

increasing amounts of the substance to get the same

pleasurable effect.

2. Withdrawal symptoms mean when physically dependent on a

substance, individuals will develop withdrawal symptoms,

which cause distress or impairment when use stops or the

amount is cut down; the person will continue to use the

substance to avoid the withdrawal symptoms.

3. The substance is taken in larger amounts or over a longer

period of time then intended.

4. The person experiences a persistent desire or

unsuccessful efforts to cut down or control substance

use.

5. A great deal of time is spent in activities necessary to

obtain the substance, use it, or recover from its

effects.

6. Important social, occupational, or recreational

activities are given up or reduced because of substance

use.

7. Substance use is continued despite knowledge or having a

persistent physical or psychological problem that is

likely to have been caused or exacerbated by the

substance.

Psychological Dependency – occurs when the user feels and

behaves as if the substance is necessary for their

wellbeing. Use of the drug is continued despite knowledge of

its negative health or social consequences, despite efforts

to reduce consumption, and even despite remission of

physical dependency (it thus provokes relapse).

Relapse – when substance use begins again after a

period of abstinence or remission.

While these criteria also were created primarily for an

adult population, one may speculate that dependence symptoms

encompass people at any developmental period.

Theoretical Perspectives

People began using psychoactive substances for various

reasons. Some adolescents start using drugs because of peer

pressure or because they believe drugs make them seem more

sophisticated or grown up. Some use drugs as a way of

rebelling against their parents or society at large. People

continue to use drugs because drugs give them pleasurable

effects or people find it difficult to stop. Most

adolescents drink alcohol to “get high”, not to establish

that they are adults. Many people smoke cigarettes for the

pleasure they provide. Some people smoke cigarettes to help

them to relaxed when they are tense and paradoxically, to

give them a kick or lift when they are tired in which all

these leads to addiction. Some may want to quit this

addiction but find it difficult to break their addiction.

People who are anxious about their jobs or social lives may

be drawn to the calming effects of alcohol, marijuana,

tranquilizers and sedatives. People with low self confidence

and self-esteem may be drawn to the ego-bolstering effects

of amphetamines and cocaine. Many poor people attempt to

escape the poverty, anguish, and tedium of inner-city life

through using heroin and similar drugs. More well to do

adults may rely on drugs to manage the transition from

dependence to independence and major life changes concerning

jobs, and lifestyles.

Biological Perspectives

Many drugs of abuse, including nicotine, alcohol, heroin,

marijuana, and especially cocaine and amphetamines, produce

pleasurable effects by increasing the availability of the

neurotransmitter dopamine, a key brain chemical involved in

activating the brain’s reward or pleasure circuits.

Neurotransmitters (APA, APA Concise Dictionary Of

Psychology, 2009) are any of a large number of chemicals

that released by neurons to mediate transmission or

inhibition of nerve signals across the junctions between

neurons. Neurotransmitters include amines, such as

acetylcholine, norepinephrine, dopamine, and serotonin, and

amino acids, such as gamma-aminobutyric acid, glutamate, and

glycine.

For addicts, the steady influx of dopamine from using drugs

makes it difficult for them to focus on anything other than

attaining and using drugs, even if the drugs no longer

produce feelings of pleasure. Over time, regular use of

drugs such as cocaine, alcohol and heroin may sap the

brain’s own production of dopamine. Consequently, the

brain’s natural reward system, the “feel good” circuitry

that produces states of pleasure associated with the

ordinarily rewarding activities of life, such as consuming a

satisfying meal or engaging in pleasant activities. Without

drugs, an addict life may not seem worth living.

Changes in the dopamine system may help to explain the

intense cravings and anxiety that accompany drug withdrawal

and the difficulty people have in maintaining abstinence,

refraining from the use of drugs.

Genetic factors (Doweiko, 1993) are link to various forms of

substance use and abuse, including abuse / dependence on

alcohol, amphetamines, heroin, and even tobacco in the form

of cigarette smoking. Environment factors, such as family

influences and peer pressure, play a more important role in

accounting for the initiation of drug use in early

adolescence, whereas genetic factors play an increasing role

in explaining continuation of drug use through early and

middle adulthood.

Alcoholism tends to run in the families. The closer the

genetic relationship (Ray, 2009), the greater the risk.

Familial patterns provide only suggestive evidence of

genetic factors, because family share a common environment

as well as common genes. More definitive evidence comes from

twin and adoptee studies. For example, a twin is twice as

likely to become an alcoholic if an identical rather than

non-identical twin is one, and adopted children are around

four times more likely to become problem drinkers than other

adoptees if their biological parents were alcoholics,

regardless of the drinking habits of their adoptive parents.

Alcoholism, nicotine dependence, and opioid addiction are

linked to genes that determine the structure of dopamine

receptors in the brain. In effect, good parenting can reduce

the influence of bad genes. Multiple genes act together with

environment and psychological factors in contributing to the

development of substance-related disorders.

Learning Perspectives

Learning theorists (Hill, 2001)propose that substance-

related behaviour are largely learned and can in principle,

be unlearned. Learning theory can be applied to addiction in

many ways, which focus on the roles of operant and classical

conditioning and observational learning. Substance abuse

problems are not regarded as symptoms of disease but rather

a problem habits. Even though genetic and biological factors

may increase susceptibility abuse problems, the role of

learning in development and maintenance of these problem

behaviours are the main concern in learning perspectives.

Emotional stress, such as anxiety or depression, often sets

the stage for the development of substance abuse.

Drug use may become habitual because of the pleasure

(positive reinforcement) or temporary relief (negative

reinforcement) from negative emotions, such as anxiety and

depression, which drugs can produce. With drugs like

cocaine, which appear capable of directly stimulating

pleasure mechanisms in the brain, the positive reinforcement

is direct and powerful.

Classical conditioning present in the environment during

drug taking may become associated with the pleasure and

physiological changes caused by substance (e.g a bar may be

associated with the pleasure from alcohol). These cues may

thereafter act as prompts by creating a craving for the drug

in its absence and are key factors in psychological

dependence and relapse (e.g walking back into familiar bar

or seeing a friend with cigarette after giving up alcohol or

nicotine).

In operant conditioning situation, once drugs are taken, the

short term pleasure they provide is obviously a major

positive reinforce of drug seeking and taking behaviour,

compared to the longer-term negative effects (punishment).

Avoidance of unpleasant withdrawal symptoms act as potent

source of negative reinforcement for these behaviours. In

terms of more psychological negative reinforcement, drugs

may help escape stress or fear arousal (e.g of social

situations by reducing inhibitions).

In social learning theory, children may see many influential

role models in parents, peers and media celebrities taking

drugs like alcohol and, because they often selectively see

the positive consequences of enjoyment rather than negative

ones, they develop positive expectations and wish to use

them too.

Cognitive Perspectives

Cognitive perspectives focus on roles of attitudes, beliefs

and expectancies in accounting for substance use and abuse.

Expectancies support the role of cognitive factors in

substance abuse and dependence. Holding positive

expectancies about drug use, such as believing that drinking

alcohol will make one popular or outgoing, increases the

likelihood of using these substances. Outcome expectancies

in teens in what they expect a drug’s effects will be, are

strongly influenced by the beliefs held by others in their

social environment, including friends and parents. Alcohol

or other drug use may also boost self-efficacy expectation,

personal expectancies we hold about our ability to

successfully perform tasks. If we believe we need a drink or

two (or more) to “get out of our shell” and relate socially

to others, we may come to depend on alcohol in social

situations.

Effective Treatment of Substance Abuse and Dependence

Treatment has often been a frustrating endeavour. There is a

vast array of nonprofessional, biological, and psychological

approaches to substance abuse and dependence. In many and

perhaps most cases, drug-dependent people may not be ready

or motivated to change their drug use behaviour or may not

seek treatment on their own. Motivational interviewing may

be used by substance abuse counsellors to first increase the

clients readiness to make changes in their lives. In a

supportive manner rather than confrontation manner,

counsellors help clients recognize the problems caused by

their drug use and risks they face in continuing to use

drugs. Counsellors focus on raising client’s awareness of

the differences between their present circumstances and how

they want their lives to be and the steps they need to take

to make these changes.

When drug-dependent people are ready to break free of drugs,

the process of helping them through the withdrawal syndrome

is usually straight forward. Helping them pursue a life

devoid of their preferred substances is more problematic.

Treatment taking place in a setting such as the therapist’s

office, a support group, a residential center or a hospital

is where abstinence is valued and encouraged. The individual

returns to work, family, or street settings in which abuse

and dependence were instigated and maintained. The problem

of relapse can be more troublesome than problems involved in

initial treatment.

Another complication is that many people with substance

abuse problems have other psychological disorders as well.

Most clinics and treatment programs focus on the drug or

alcohol problem, this narrow focus results in poorer

treatment outcomes including more frequent rehospitalisation

among those with these dual diagnoses.

Specific treatment for substance abuse / chemical dependency

will be determined by the physician based on the age of the

patient/ abuser, overall health, medical history, the extend

of the symptoms and of the dependency. Type of substance

abused, the tolerance for specific medications, procedures,

or therapies, the expectations for the course of condition

and the opinion or preference of the patient.

A variety of treatment programs (Psychiatry, 2004) for

substance abuse are available on an inpatient or outpatient

basis. Programs considered are usually based on the type of

substance abused. Detoxification and long-term follow-up

management are important features of successful treatment.

Long-term follow-up management usually includes formalized

group meetings and developmentally age-appropriate

psychosocial support systems, as well as continued medical

supervision. Individual and family psychotherapy are often

recommended to address the developmental, psychosocial, and

family issues that may have contributed to and resulted from

development of a substance abuse disorder.

Conclusion

Our society (Plotnik, 2008) is flooded with psychoactive

substances that alter the mood and twist perceptions.

Substances that lift us up, calm us down, and turn us upside

down. Many young people start using these substances because

of peer pressure or because their parents and other

authority figures tell them not to. For many others who

become addicted to drugs, the pursuit and use of drugs take

center stage in their lives and become even more important

than family, work, or their own welfare.

Changing our behaviours, including substance use, can seem

scary or difficult but it is possible. If adolescent or an

individual wants to change his substance use problem, they

should look at the risk that they have put on their health,

social, legal, psychological, work and family. They must

look at ideas to change.

Whether legal or illegal, psychoactive drugs alter one’s

consciousness, emotions, and thoughts by affecting the

brain’s communication network.

A low to moderate consumption of alcohol has benefits,

including improved cholesterol profiles, improved platelet

and clotting function, and improved sensitivity to insulin

according to Dr Milton Lum (Lum, 2013). Moderate alcohol

consumption may also protect against cerebrovascular disease

with the antioxidants in wine. However heavy and long-term

alcohol consumption leads to alcohol abuse and dependence,

impaired memory, contributes to neurodegerative disease, and

hinders psychosocial functioning. The Food and Drug

Administration of the United States has defined “moderate

alcohol consumption” as up to one drink for women, and up to

two drinks for men daily.

The Future of Treatment for Substance Abuse

The need to develop additional modalities (Bukstein, 1995),

particularly in the inpatient programs where the trend is

towards much more severely affected youth, has resulted in

more behavioural-focused treatment, an increased emphasis on

family issues (including parent management training), and

more attention to psychopathology and the specific treatment

of coexisting psychiatric disorders when indicated. The

future of substance abuse treatment is uncertain. Severe

restrictions in the type and length of treatment may

significantly limit the efficacy of treatment. Ultimately,

treatment planning will have to be backed by research

demonstrating the effectiveness of various type of treatment

for various populations of adolescents who differ on a

variety of demographic, social, behavioural, and

psychological characteristics.

There are the differential effects of various modalities,

either alone or together when administrating treatment. At

times it is very difficult to know the effects of certain

types of treatment on certain subgroup who vary on racial or

ethnic status or some special characteristic such as

hopelessness, pregnancy, or HIV-positive. Treatment should

be proceed with caution, asking questions of what type of

treatment will apply for which group and the effects of the

treatment whether it will lead to positive or negative

results for substance abuse patients that is being treated.

Prevention treatment can work, provided a comprehensive

study is done and the important and impact of socioeconomic

conditions. Prevention does not involve doing a little, but

doing a lot to produce the greatest effect possible on the

many risk factors for adolescent substance use or abuse.

Adolescents are training to be adult. They copy adults and

reflect the choices that adults must also make. It is hardly

(Amy Wachholtz, 2011) surprising that both culturally

sanctioned substance use in the forms of alcohol and tobacco

and illicit use of other substances is prevalent in adults,

as well as youth. Our society is struggling to deal with the

negative consequences of our involvement with psychoactive

substances. Asking clients and patients to break through

their denial, all counsellor and psychiatrist must identify

what the problem of substance abuse patient is and how it

can best be dealt with.

We can also look at some complementary and alternative

treatments such as acupuncture to treat chronic pain and

substance abuse patients to help overcome their needs for

addiction and abuse. Integrating spirituality (Arnold R. M,

2002) into treatment as an additional therapeutic resource

is common in addiction treatment program particularly those

that use the 12 step approach for the treatment of

addiction. The majority of participants in addiction

treatment programs report that they view spirituality as a

positive coping mechanism and they appreciate the inclusion

of spirituality into treatment.

Meditation techniques (Amy Wachholtz, 2011) vary widely in

their form and function. Still or sitting meditations may

include mantram, transcendental, loving-kindness, but we

should also include moving meditation techniques such as

yoga and tai chi. Meditation has been shown to be effective

to treat chronic pain and opioid addiction.