The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.

Can Children and Adolescents Have Bipolar Disorder?

Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness.

Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day. 5  Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.

·As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

Other Treatments

·In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or suicidality, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes. The possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT, and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, where appropriate, with family or friends.19

·Herbal or natural supplements, such as St. John's wort (Hypericum perforatum), have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient. Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John's wort can reduce the effectiveness of certain medications.20  In addition, like prescription antidepressants, St. John's wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken.21

Even though episodes of mania and depression naturally come and go, it is important to understand that bipolar disorder is a long-term illness that currently has no cure. Staying on treatment, even during well times, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes.

Do Other Illnesses Co-occur with Bipolar Disorder?

Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance use disorders.23 Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.

Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, also may be common in people with bipolar disorder.24,25 Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate treatment. For more information on anxiety disorders, contact NIMH (see below).

How Can Individuals and Families Get Help for Bipolar Disorder?

Anyone with bipolar disorder should be under the care of a psychiatrist skilled in the diagnosis and treatment of this disease. Other mental health professionals, such as psychologists, psychiatric social workers, and psychiatric nurses, can assist in providing the person and family with additional approaches to treatment.

Help can be found at:

• University-or medical school-affiliated programs
• Hospital departments of psychiatry
• Private psychiatric offices and clinics
• Health maintenance organizations (HMOs)
• Offices of family physicians, internists, and pediatricians
• Public community mental health centers
• People with bipolar disorder may need help to get help.
• Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.
• A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing referral to a mental health professional.
• Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.
• A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.
• Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for each individual.
• In some cases, individuals with bipolar disorder may agree, when the disorder is under good control, to a preferred course of action in the event of a future manic or depressive relapse.
• Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
• Family members of someone with bipolar disorder often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.
• Many people with bipolar disorder benefit from joining support groups such as those sponsored by the National Depressive and Manic Depressive Association (NDMDA), the National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association (NMHA). Families and friends can also benefit from support groups offered by these organizations. For contact information, see the "For More Information" section at the back of this booklet.

What About Clinical Studies for Bipolar Disorder?

Some people with bipolar disorder receive medication and/or psychosocial therapy by volunteering to participate in clinical studies (clinical trials). Clinical studies involve the scientific investigation of illness and treatment of illness in humans. Clinical studies in mental health can yield information about the efficacy of a medication or a combination of treatments, the usefulness of a behavioral intervention or type of psychotherapy, the reliability of a diagnostic procedure, or the success of a prevention method. Clinical studies also guide scientists in learning how illness develops, progresses, lessens, and affects both mind and body. Millions of Americans diagnosed with mental illness lead healthy, productive lives because of information discovered through clinical studies. These studies are not always right for everyone, however. It is important for each individual to consider carefully the possible risks and benefits of a clinical study before making a decision to participate.

In recent years, NIMH has introduced a new generation of "real-world" clinical studies. They are called "real-world" studies for several reasons. Unlike traditional clinical trials, they offer multiple different treatments and treatment combinations. In addition, they aim to include large numbers of people with mental disorders living in communities throughout the U.S. and receiving treatment across a wide variety of settings. Individuals with more than one mental disorder, as well as those with co-occurring physical illnesses, are encouraged to consider participating in these new studies. The main goal of the real-world studies is to improve treatment strategies and outcomes for all people with these disorders. In addition to measuring improvement in illness symptoms, the studies will evaluate how treatments influence other important, real-world issues such as quality of life, ability to work, and social functioning. They also will assess the cost-effectiveness of different treatments and factors that affect how well people stay on their treatment plans.

The National Institute of Mental Health (NIMH) is part of the National Institutes of Health (NIH), a component of the U.S. Department of Health and Human Services.

Marijuana

Marijuana is the most commonly abused illicit drug in the United States. A dry, shredded green/brown mix of flowers, stems, seeds, and leaves of the hemp plant Cannabis sativa, it usually is smoked as a cigarette (joint, nail), or in a pipe (bong). It also is smoked in blunts, which are cigars that have been emptied of tobacco and refilled with marijuana, often in combination with another drug. It might also be mixed in food or brewed as a tea. As a more concentrated, resinous form it is called hashish and, as a sticky black liquid, hash oil. Marijuana smoke has a pungent and distinctive, usually sweet-andsour odor. There are countless street terms for marijuana including pot, herb, weed, grass, widow, ganja, and hash, as well as terms derived from trademarked varieties of cannabis, such as Bubble Gum, Northern Lights, Fruity Juice, Afghani #1, and a number of Skunk varieties.

The main active chemical in marijuana is THC (delta-9-tetrahydrocannabinol). The membranes of certain nerve cells in the brain contain protein receptors that bind to THC. Once securely in place, THC kicks off a series of cellular reactions that ultimately lead to the high that users experience when they smoke marijuana.

Extent of Use —

In 2004, 14.6 million Americans age 12 and older used marijuana at least once in the month prior to being surveyed. About 6,000 people a day in 2004 used marijuana for the first time—

2.1 million Americans. Of these, 63.8 percent were under age 18(1). In the last half of 2003, marijuana was the third most commonly abused drug mentioned in drug-related hospital emergency department (ED) visits in the continental United States, at 12.6 percent, following cocaine (20 percent) and alcohol (48.7 percent)(2). Percentage of 8th-Graders Who Have Used Marijuana Monitoring the Future Survey, 2005 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Lifetime 23.1% 22.6% 22.2% 22.0% 20.3% 20.4% 19.2% 17.5% 16.3% 16.5% Annual 18.3 17.7 16.9 16.5 15.6 15.4 14.6 12.8 11.8 12.2 30-day 11.3 10.2 9.7 9.7 9.1 9.2 8.3 7.5 6.4 6.6 Daily 1.5 1.1 1.1 1.4 1.3 1.3 1.2 1.0 0.8 1.0

Percentage of 10th-Graders Who Have Used Marijuana Monitoring the Future Survey, 2005 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Lifetime 39.8% 42.3% 39.6% 40.9% 40.3% 40.1% 38.7% 36.4% 35.1% 34.1% Annual 33.6 34.8 31.1 32.1 32.2 32.7 30.3 28.2 27.5 26.6 30-day 20.4 20.5 18.7 19.4 19.7 19.8 17.8 17.0 15.9 15.2 Daily 3.5 3.7 3.6 3.8 3.8 4.5 3.9 3.6 3.2 3.1

Percentage of 12th-Graders Who Have Used Marijuana Monitoring the Future Survey, 2005 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Lifetime 44.9% 49.6% 49.1% 49.7% 48.8% 49.0% 47.8% 46.1% 45.7% 44.8% Annual 35.8 38.5 37.5 37.8 36.5 37.0 36.2 34.9 34.3 33.6 30-day 21.9 23.7 22.8 23.1 21.6 22.4 21.5 21.2 19.9 19.8 Daily 4.9 5.8 5.6 6.0 6.0 5.8 6.0 6.0 5.6 5.0

*“Lifetime” refers to use at least once during a respondent’s lifetime. “Annual” refers to use at least once during the year preceding an individual’s response to the survey. “30-day” refers to use at least once during the 30 days preceding an individual’s response to the survey.

Prevalence of lifetime,* annual, and use within the last 30 days for marijuana remained stable among 10th- and 12thgraders surveyed between 2003 and 2004. However, 8th-graders reported a significant decline in 30-day use and a significant increase in perceived harmfulness of smoking marijuana once or twice and regularly(3). Trends in disapproval of using marijuana once or twice and occasionally rose among 8th-graders as well, and 10th-graders reported an increase in disapproval of occasional and regular use for the same period(3).

Effects on the Brain

Scientists have learned a great deal about how THC acts in the brain to produce its many effects. When someone smokes marijuana, THC rapidly passes from the lungs into the bloodstream, which carries the chemical to organs throughout the body, including the brain.

In the brain, THC connects to specific sites called cannabinoid receptors on nerve cells and influences the activity of those cells. Some brain areas have many cannabinoid receptors; others have few or none. Many cannabinoid receptors are found in the parts of the brain that influence pleasure, memory, thought, concentration, sensory and time perception, and coordinated movement(4).

The short-term effects of marijuana can include problems with memory and learning; distorted perception; difficulty in thinking and problem solving; loss of coordination; and increased heart rate. Research findings for long-term marijuana abuse indicate some changes in the brain similar to those seen after long- term abuse of other major drugs. For example, cannabinoid (THC or synthetic forms of THC) withdrawal in chronically exposed animals leads to an increase in the activation of the stress-response system(5) and changes in the activity of nerve cells containing dopamine(6). Dopamine neurons are involved in the regulation of motivation and reward, and are directly or indirectly affected by all drugs of abuse.

Effects on the Heart

One study has indicated that an abuser’s risk of heart attack more than quadruples in the first hour after smoking marijuana(7). The researchers suggest that such an effect might occur from marijuana’s effects on blood pressure and heart rate and reduced oxygen-carrying capacity of blood.

Effects on the Lungs

A study of 450 individuals found that people who smoke marijuana frequently but do not smoke tobacco have more health problems and miss more days of work than nonsmokers(8). Many of the extra sick days among the marijuana smokers in the study were for respiratory illnesses.

Even infrequent abuse can cause burning and stinging of the mouth and throat, often accompanied by a heavy cough. Someone who smokes marijuana regularly may have many of the same respiratory problems that tobacco smokers do, such as daily cough and phlegm production, more frequent acute chest illness, a heightened risk of lung infections, and a greater tendency to obstructed airways(9). Smoking marijuana possibly increases the likelihood of developing cancer of the head or neck. A study comparing 173 cancer patients and 176 healthy individuals produced evidence that marijuana smoking doubled or tripled the risk of these cancers(10).

Marijuana abuse also has the potential to promote cancer of the lungs and other parts of the respiratory tract because it contains irritants and carcinogens(9, 11). In fact, marijuana smoke contains 50 to 70 percent more carcinogenic hydrocarbons than does tobacco smoke(12). It also induces high levels of an enzyme that converts certain hydrocarbons into their carcinogenic form—levels that may accelerate the changes that ultimately produce malignant cells(13). Marijuana users usually inhale more deeply and hold their breath longer than tobacco smokers do, which increases the lungs’ exposure to carcinogenic smoke. These facts suggest that, puff for puff, smoking marijuana may be more harmful to the lungs than smoking tobacco.

Other Health Effects

Some of marijuana’s adverse health effects may occur because THC impairs the immune system’s ability to fight disease. In laboratory experiments that exposed animal and human cells to THC or other marijuana ingredients, the normal disease-preventing reactions of many of the key types of immune cells were inhibited(14). In other studies, mice exposed to THC or related substances were more likely than unexposed mice to develop bacterial infections and tumors(15, 16).

Effects of Heavy Marijuana Use on Learning and Social Behavior

Research clearly demonstrates that marijuana has the potential to cause problems in daily life or make a person’s existing problems worse. Depression(17), anxiety(17), and personality disturbances(18) have been associated with chronic marijuana use. Because marijuana compromises the ability to learn and remember information, the more a person uses marijuana the more he or she is likely to fall behind in accumulating intellectual, job, or social skills. Moreover, research has shown that marijuana’s adverse impact on memory and learning can last for days or weeks after the acute effects of the drug wear off(19, 20, 25).

Students who smoke marijuana get lower grades and are less likely to graduate from high school, compared with their nonsmoking peers(21, 22, 23, 24). A study of 129 college students found that, among those who smoked the drug at least 27 of the 30 days prior to being surveyed, critical skills related to attention, memory, and learning were significantly impaired, even after the students had not taken the drug for at least 24 hours(20). These “heavy” marijuana abusers had more trouble sustaining and shifting their attention and in registering, organizing, and using information than did the study participants who had abused marijuana no more than 3 of the previous 30 days. As a result, someone who smokes marijuana every day may be functioning at a reduced intellectual level all of the time.

More recently, the same researchers showed that the ability of a group of long-term heavy marijuana abusers to recall words from a list remained impaired for a week after quitting, but returned to normal within 4 weeks(25). Thus, some cognitive abilities may be restored in individuals who quit smoking marijuana, even after long-term heavy use.

Workers who smoke marijuana are more likely than their coworkers to have problems on the job. Several studies associate workers’ marijuana smoking with increased absences, tardiness, accidents, workers’ compensation claims, and job turnover. A study among postal workers found that employees who tested positive for marijuana on a preemployment urine drug test had 55 percent more industrial accidents, 85 percent more injuries, and a 75-percent increase in absenteeism compared with those who tested negative for marijuana use(26). In another study, heavy marijuana abusers reported that the drug impaired several important measures of life achievement including cognitive abilities, career status, social life, and physical and mental health(27).

Effects of Exposure During Pregnancy

Research has shown that some babies born to women who abused marijuana during their pregnancies display altered responses to visual stimuli(28), increased tremulousness, and a high-pitched cry, which may indicate neurological problems in development(29). During the preschool years, marijuana-exposed children have been observed to perform tasks involving sustained attention and memory more poorly than nonexposed children do(30, 31). In the school years, these children are more likely to exhibit deficits in problem-solving skills, memory, and the ability to remain attentive(30).

Addictive Potential

Long-term marijuana abuse can lead to addiction for some people; that is, they abuse the drug compulsively even though it interferes with family, school, work, and recreational activities. Drug craving and withdrawal symptoms can make it hard for long-term marijuana smokers to stop abusing the drug. People trying to quit report irritability, sleeplessness, and anxiety(32). They also display increased aggression on psychological tests, peaking approximately one week after the last use of the drug(33).

Genetic Vulnerability

Scientists have found that whether an individual has positive or negative sensations after smoking marijuana can be influenced by heredity. A 1997 study demonstrated that identical male twins were more likely than nonidentical male twins to report similar responses to marijuana abuse, indicating a genetic basis for their response to the drug(34). (Identical twins share all of their genes.)

It also was discovered that the twins’ shared or family environment before age 18 had no detectable influence on their response to marijuana. Certain environmental factors, however, such as the availability of marijuana, expectations about how the drug would affect them, the influence of friends and social contacts, and other factors that differentiate experiences of identical twins were found to have an important effect.(34)

Treating Marijuana Problems

The latest treatment data indicate that, in 2002, marijuana was the primary drug of abuse in about 15 percent (289,532) of all admissions to treatment facilities in the United States. Marijuana admissions were primarily male (75 percent), White (55 percent), and young (40 percent were in the 15–19 age range). Those in treatment for primary marijuana abuse had begun use at an early age; 56 percent had abused it by age 14 and 92 percent had abused it by 18(35).

One study of adult marijuana abusers found comparable benefits from a 14session cognitive-behavioral group treatment and a 2-session individual treatment that included motivational interviewing and advice on ways to reduce marijuana use. Participants were mostly men in their early thirties who had smoked marijuana daily for more than 10 years. By increasing patients’ awareness of what triggers their marijuana abuse, both treatments sought to help patients devise avoidance strategies. Abuse, dependence symptoms, and psychosocial problems decreased for at least 1 year following both treatments; about 30 percent of the patients were abstinent during the last 3-month followup period(36).

Another study suggests that giving patients vouchers that they can redeem for goods—such as movie passes, sporting equipment, or vocational training— may further improve outcomes(37).

Although no medications are currently available for treating marijuana abuse, recent discoveries about the workings of the THC receptors have raised the possibility of eventually developing a medication that will block the intoxicating effects of THC. Such a medication might be used to prevent relapse to marijuana abuse by lessening or eliminating its appeal.

References

1 Results from the 2004 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H–27, DHHS Publication No. SMA 05–4061). Rockville, MD, 2004. NSDUH is an annual survey conducted by the Substance Abuse and Mental Health Services Administration. Copies of the latest survey are available from the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.

2 These data are from the annual Drug Abuse Warning Network, funded by the Substance Abuse and Mental Health Services Administration, DHHS. The survey provides information about emergency department visits that are induced by or related to the use of an illicit drug or the nonmedical use of a legal drug. The latest data are available at 800729-6686 or online at www.samhsa.gov.

3 These data are from the 2005 Monitoring the Future Survey, funded by the National Institute on Drug Abuse, National Institutes of Health, DHHS, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are online at www.drugabuse.gov.

4 Herkenham M, Lynn A, Little MD, Johnson MR, et al. Cannabinoid receptor localization in the brain. Proc Natl Acad Sci, USA 87(5):1932–1936, 1990.

5 Rodriguez de Fonseca F, et al. Activation of cortocotropin-releasing factor in the limbic system during cannabinoid withdrawal. Science 276(5321):2050–2054, 1997.

6 Diana M, Melis M, Muntoni AL, et al. Mesolimbic dopaminergic decline after cannabinoid withdrawal. Proc Natl Acad Sci 95(17):10269–10273, 1998.

7 Mittleman MA, Lewis RA, Maclure M, et al. Triggering myocardial infarction by marijuana. Circulation 103(23):2805–2809, 2001.

8 Polen MR, Sidney S, Tekawa IS, et al. Health care use by frequent marijuana smokers who do not smoke tobacco. West J Med 158(6):596–601, 1993.

9 Tashkin DP. Pulmonary complications of smoked substance abuse. West J Med 152(5):525–530, 1990.

10 Zhang ZF, Morgenstern H, Spitz MR, et al. Marijuana use and increased risk of squamous cell carcinoma of the head and neck. Cancer Epidemiology, Biomarkers & Prevention 8(12):1071–1078, 1999.

11 Sridhar KS, Raub WA, Weatherby, NL Jr., et al. Possible role of marijuana smoking as a carcinogen in the development of lung cancer at a young age. Journal of Psychoactive Drugs 26(3):285–288, 1994.

12 Hoffman D, Brunnemann KD, Gori GB, et al. On the carcinogenicity of marijuana smoke. In: VC Runeckles, ed, Recent Advances in Phytochemistry. New York. Plenum, 1975.

13 Cohen S. Adverse effects of marijuana: Selected issues. Annals of the New York Academy of Sciences 362:119–124, 1981.

14 Adams IB, Martin BR: Cannabis: pharmacology and toxicology in animals and humans. Addiction 91(11):1585–1614, 1996.

15 Friedman H, Newton C, Klein TW. Microbial infections, immunomodulation, and drugs of abuse. Clin Microbiol Rev 16(2):209–219, 2003.

16 Zhu LX, Sharma M, Stolina S, et al. Delta-9-tetrahydrocannabinol inhibits antitumor immunity by a CB2 receptor- mediated, cytokine-dependent pathway. J Immunology 165(1):373–380, 2000.

17 Brook JS, Rosen Z, Brook DW. The effect of early marijuana use on later anxiety and depressive symptoms. NYS Psychologist 35–39, January 2001.

18 Brook JS, Cohen P, Brook DW. Longitudinal study of co-occurring psychiatric disorders and substance use. J Acad Child and Adolescent Psych 37(3):322–330, 1998.

19 Pope HG, Yurgelun-Todd D. The residual cognitive effects of heavy marijuana use in college students. JAMA 275(7):521–527, 1996.

20 Block RI, Ghoneim MM. Effects of chronic marijuana use on human cognition. Psychopharmacology 100(1–2):219–228, 1993.

21 Lynskey M, Hall W. The effects of adolescent cannabis use on educational attainment: A review. Addiction 95(11):1621–1630, 2000.

22 Kandel DB, Davies M. High school students who use crack and other drugs. Arch Gen Psychiatry 53(1):71–80, 1996.

23 Rob M, Reynolds I, Finlayson PF. Adolescent marijuana use: Risk factors and implications. Aust NZ J Psychiatry 24(1):45–56, 1990.

24 Brook JS, Balka EB, Whiteman M. The risks for late adolescence of early adolescent marijuana use. Am J Public Health 89(10):1549–1554, 1999.

25 Pope HG, Gruber AJ, Hudson JI, et al. Neuropsychological performance in long-term cannabis users. Arch Gen Psychiatry 58(10):909–915, 2001.

26 Zwerling C, Ryan J, Orav EJ. The efficacy of pre-employment drug screening for marijuana and cocaine in predicting employment outcome.

27 Gruber AJ, Pope HG, Hudson JI, et al. Attributes of long-term heavy cannabis users: A case control study. Psychological Medicine 33(8):1415–1422, 2003.

28 Fried PA, Makin JE. Neonatal behavioural correlates of prenatal exposure to marihuana, cigarettes and alcohol in a low risk population. Neurotoxicology and Teratology 9(1):1–7, 1987.

29 Lester BM, Dreher M. Effects of marijuana use during pregnancy on newborn crying. Child Development 60(23/24):764–771, 1989.

30 Fried PA. The Ottawa prenatal prospective study (OPPS): Methodological issues and findings. It’s easy to throw the baby out with the bath water. Life Sciences 56(23–24):2159–2168, 1995.

31 Fried PA, Smith AM. A literature review of the consequences of prenatal marihuana exposure: An emerging theme of a deficiency in aspects of executive function. Neurotoxicology and Teratology 23(1):1–11, 2001.

32 Kouri EM, Pope HG, Lukas SE. Changes in aggressive behavior during withdrawal from long-term marijuana use. Psychopharmacology 143(3):302–308, 1999.

33 Haney M, Ward AS, Comer SD, et al. Abstinence symptoms following smoked marijuana in humans. Psychopharmacology 141(4):395–404, 1999.

34 Lyons MJ, Toomey R, Meyer JM, et al. How do genes influence marijuana use? The role of subjective effects. Addiction 92(4):409–417, 1997.

35 These data from the Treatment Episode Data Set (TEDS) 2003: Substance Abuse Treatment Admissions by Primary Substance of Abuse, According to Sex, Age Group, Race, and Ethnicity, funded by the Substance Abuse and Mental Health Services Administration, DHHS. The latest data are available at 800-729-6686 or online at www.samhsa.gov.

36 Stephens RS, Roffman RA, Curtin L. Comparison of extended versus brief treatments for marijuana use. J Consult Clin Psychol 68(5):898–908, 2000.

37 Budney AJ, Higgins ST, Radonovich KJ, et al. Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. J Consult Clin Psychol 68(6):1051–1061, 2000.

National Institutes of Health – U.S. Department of Health and Human Services

This material may be used or reproduced without permission from NIDA. Citation of the source is appreciated.

Prescription Medications

Brief Description:
Prescription drugs that are abused or used for nonmedical reasons can alter brain activity and lead to dependence. Commonly abused classes of prescription drugs include opioids (often prescribed to treat pain), central nervous system depressants (often prescribed to treat anxiety and sleep disorders), and stimulants (prescribed to treat narcolepsy, ADHD, and obesity).

Street Names:
Commonly used opioids include oxycodone (OxyContin), propoxyphene (Darvon), hydrocodone (Vicodin), hydromorphone (Dilaudid), meperidine (Demerol), and diphenoxylate (Lomotil). Common central nervous system depressants include barbiturates such as pentobarbital sodium (Nembutal), and benzodiazepines such as diazepam (Valium) and alprazolam (Xanax). Stimulants include dextroamphetamine (Dexedrine) and methylphenidate (Ritalin).

Effects:

  Long-term use of opioids or central nervous system depressants can lead to physical dependence and addiction. Taken in high doses, stimulants can lead to compulsive use, paranoia, dangerously high body temperatures, and irregular heartbeat.

Statistics and Trends:

  According to NIDA's 2005 Monitoring the Future study, 9.5% of high school seniors used hydrocodone (Vicodin) in the past year. Source: NIDA Infofacts: High School and Youth Trends.

Methamphetamine is a very addictive stimulant drug that activates certain systems in the brain. It is chemically related to amphetamine but, at comparable doses, the effects of methamphetamine are much more potent, longer lasting, and more harmful to the central nervous system (CNS).

Methamphetamine is a Schedule II stimulant, which means it has a high potential for abuse and is available only through a prescription that cannot be refilled. It can be made in small, illegal laboratories, where its production endangers the people in the labs, neighbors, and the environment. Street methamphetamine is referred to by many names, such as ?speed,? ?meth,? and ?chalk.? Methamphetamine hydrochloride, clear chunky crystals resembling ice, which can be inhaled by smoking, is referred to as ?ice,? ?crystal,? ?glass,? and ?tina.? 1

Methamphetamine is taken orally, intranasally (snorting the powder), by needle injection, or by smoking. Abusers may become addicted quickly, needing higher doses and more often. At this time, the most effective treatments for methamphetamine addiction are behavioral therapies such as cognitive behavioral and contingency management interventions.

Health Hazards
Methamphetamine increases the release of very high levels of the neurotransmitter dopamine, which stimulates brain cells, enhancing mood and body movement. Chronic methamphetamine abuse significantly changes how the brain functions. Animal research going back more than 30 years shows that high doses of methamphetamine damage neuron cell endings. Dopamine- and serotonin-containing neurons do not die after methamphetamine use, but their nerve endings (?terminals?) are cut back, and regrowth appears to be limited. Noninvasive human brain imaging studies have shown alterations in the activity of the dopamine system. These alterations are associated with reduced motor speed and impaired verbal learning. Recent studies in chronic methamphetamine abusers have also revealed severe structural and functional changes in areas of the brain associated with emotion and memory, which may account for many of the emotional and cognitive problems observed in chronic methamphetamine abusers.

Taking even small amounts of methamphetamine can result in increased wakefulness, increased physical activity, decreased appetite, increased respiration, rapid heart rate, irregular heartbeat, increased blood pressure, and hyperthermia. Other effects of methamphetamine abuse may include irritability, anxiety, insomnia, confusion, tremors, convulsions, and cardiovascular collapse and death. Long-term effects may include paranoia, aggressiveness, extreme anorexia, memory loss, visual and auditory hallucinations, delusions, and severe dental problems.

Also, transmission of HIV and hepatitis B and C can be a consequence of methamphetamine abuse. Among abusers who inject the drug, infection with HIV and other infectious diseases is spread mainly through the re-use of contaminated syringes, needles, and other injection equipment by more than one person. The intoxicating effects of methamphetamine, however, whether it is injected or taken other ways, can alter judgment and inhibition and lead people to engage in unsafe behaviors. Methamphetamine abuse actually may worsen the progression of HIV and its consequences; studies with methamphetamine abusers who have HIV indicate that the HIV causes greater neuronal injury and cognitive impairment compared with HIV-positive people who do not use drugs.

Extent of Use
Monitoring the Future Study (MTF)*
Past year** methamphetamine use in 2006 was reported by 1.8 percent of 8th-graders, 1.8 percent of 10th-graders (which represents a statistically significant decline from 2.9 percent in 2005), and 2.5 percent of 12th-graders. Perceived risk of harm from trying crystal methamphetamine, collected only for 12th-graders, increased from 54.6 percent in 2005 to 59.1 percent in 2006.

Methamphetamine Prevalence of Abuse
Monitoring the Future Survey, 2006

8th Grade 10th Grade 12th Grade
Lifetime 2.7% 3.2% 4.4%
Past Year 1.8 1.8 2.5
Past Month 0.6 0.7 0.9

Community Epidemiology Work Group (CEWG)***
In eight areas with data available from 2002 to 2005, sizable increases in primary methamphetamine treatment admissions as a proportion of total treatment admission, excluding alcohol, occurred in six; the increases were greatest in Arizona, Minneapolis/St. Paul, Los Angeles County, Denver, and Atlanta. Trend data show decreases in lab incidents from 2002 to 2005 in all CEWG States except Florida (up from 157 to 273), Michigan (from 225 to 341), and Pennsylvania (up from 30 to 79).

In the 2005 reporting period, primary treatment admissions for methamphetamine abuse as a proportion of all admissions, excluding alcohol, continued to be highest in Hawaii (56.3 percent) and San Diego (49.4 percent). Trend data from 2004 to 2005 show increases in methamphetamine treatment admissions as a proportion of all admissions, excluding alcohol, of between 4.1 and 4.7 percentage points in Atlanta, Los Angeles, and San Diego. The proportion of primary methamphetamine treatment admissions declined 5 percentage points in Arizona.

Demographic data available from seven CEWG areas suggest that, compared with cocaine and heroin admissions, primary methamphetamine admissions are more likely to be female, White, and younger than 25.

Unweighted DAWN Live! data for 2005 show that methamphetamine emergency department reports exceeded those for all other illicit drugs, excluding alcohol, in Phoenix and San Diego, and accounted for the second highest number of reports in San Francisco.

National Survey on Drug Use and Health (NSDUH)****
According to the 2005 NSDUH, 10.4 million Americans age 12 and older had tried methamphetamine at least once in their lifetimes. The rates for past month and past year methamphetamine use did not change between 2004 and 2005, but the lifetime rate declined from 4.9 percent to 4.3 percent. From 2002 to 2005, decreases were seen in lifetime (5.3 percent to 4.3 percent) and past year (0.7 percent to 0.5 percent) use, but not past month use.

Rates of past year methamphetamine use among persons aged 12 or older were among the highest in Nevada (2.0 percent), Montana (1.5 percent), and Wyoming (1.5 percent). Young adults aged 18 to 25 were more likely to use methamphetamine in the past year than youths aged 12 or 17 and adults aged 26 or older.

Other Information Resources
For more information on the effects of methamphetamine abuse and addiction, visit www.drugabuse.gov/drugpages/methamphetamine.html.

To find publicly-funded treatment facilities by state, visit www.findtreatment.samhsa.gov.

Stress and Substance Abuse

In the aftermath of the terrorist attacks on New York City and Washington, D.C., people across the country and abroad are struggling with the emotional impact of large-scale damage and loss of life, as well as the uncertainty of what will happen next. These are stressful times for all and may be particularly difficult times for people who are more vulnerable to substance abuse or may be recovering from an addiction. For example, we know that stress is one of the most powerful triggers for relapse in addicted individuals, even after long periods of abstinence. NIDA-supported ethnographers are already reporting increases in street sales of various drugs. Given that individuals may turn to drugs to cope with life's stressors, it is more important than ever that NIDA supports a comprehensive research portfolio that better informs how we prevent and treat drug abuse and addiction.

Stress and Drug Abuse; Stress and Relapse to Drug Abuse
Many clinicians and addiction medicine specialists suggest that stress is the number one cause of relapse to drug abuse, including smoking. Now, research is elucidating a scientific basis for these clinical observations. In both people and animals, stress leads to an increase in the brain levels of a peptide known as corticotropin releasing factor (CRF). The increased CRF levels in turn triggers a cascade of biological responses. Animal and human research has implicated this cascade in the pathophysiology of both substance use disorders and Posttraumatic Stress Disorder (PTSD) (Jacobsen, et al. Am J Psychiatry 2001). Research also has shown that administering CRF or a chemical that mimics the action of CRF in animals produces increases in stress-related behaviors (Koob, Heinrichs. Brain Research 1999; Jones, et al. Psychopharmacology 1998). And, mice that lack a receptor for CRF (CRF1) have impaired stress responses and express less anxiety-related behavior (Smith, et al. Neuron 1998; Timpl, et al. Nature Genetics 1998). Furthermore, people subjected to chronic stress or those who show symptoms of PTSD often have hormonal responses that are not properly regulated and do not return to normal when the stress is over. This may make these individuals more prone to stress-related illnesses and may prompt patients to relapse to drug use.

Selected Research Findings on Stress and Drug Abuse; Stress and Relapse to Drug Abuse.
Studies have reported that individuals exposed to stress are more likely to abuse alcohol and other drugs or undergo relapse.

Kosten TR, Rounsaville BJ, Kleber HD: A 2.5 year follow-up of depressions, life crises, and treatment effects on abstinence among opioid addicts. Arch Gen Psychiatry 1986; 43:733-739.
Dawes MA, Antelman SM, Vanyukov MM, Giancola P, Tarter RE, Susman EJ, Mezzich A, Clark DB: Developmental sources of variation in liability to adolescent substance use disorders. Drug and Alcohol Dependence 2000; 61(1): 3-14.
Sinha R, Fuse T, Aubin LR, O'Malley SS: Psychological stress, drug-related cues, and cocaine craving. Psychopharmacology 2000; 152:140-148.

In an analysis of studies regarding factors that can lead to continued drug use among opiate addicts, high stress was found to predict continued drug use.

Brewer DD, Catalano RF, Haggerty K, Gainey RR, Fleming CB: A meta-analysis of predictors of continued drug use during and after treatment for opiate addiction. Addiction 1998; 93:73-92.

Research has shown that in animals not previously exposed to illicit substances, stressors increase vulnerability for drug self-administration.

Piazza PV, Deminiere JM, Le Moal M, Simon H: Stress- and pharmacologically-induced behavioral sensitization increases vulnerability to acquisition of amphetamine self-administration. Brain Research 1990; 514:22-26.

Acute stress can improve memory, whereas chronic stress can impair memory and may impair cognitive function.

McEwan BS, Sapolsky RM: Stress and Cognitive Function. Current Opinion in Neurobiology 1995; 5:205-216.

Research has shown that there is overlap between neurocircuits that respond to drugs and those that respond to stress.

Piazza PV, Le Moal M: Pathophysiological basis of vulnerability to drug abuse: role of an interaction between stress, glucocorticoids, and dopaminergic neurons. Annu Rev Pharmacol Toxicol 1996; 36:359-378.
Kreek MJ, Koob G: Drug dependence: Stress and dysregulation of brain reward pathways. Drug Alcohol Depend 1998; 51:23-47.
Piazza PV, Le Moal M: The role of stress in drug self-administration. Trends Pharmacol Sci 1998; 19(2):67-74.

Researchers have shown that, among drug-free cocaine abusers in treatment, exposure to personal stress situations led to consistent and significant increases in cocaine craving, along with activation of emotional stress and a physiological stress response. In another study of cocaine abusers in treatment, significant increases in cocaine and alcohol craving were observed with stress and drug cues imagery but not with neutral-relaxing imagery.

Sinha R, Catapano D, O'Malley S: Stress-induced craving and stress response in cocaine dependent individuals. Psychopharmacology 1999; 142:343-351.
Sinha R, Fuse T, Aubin LR, O'Malley SS: Psychological stress, drug-related cues, and cocaine craving. Psychopharmacology 2000; 152:140-148.

A follow-up study of smokers who had completed a national smoking cessation program showed that there is a strong relationship between stress coping resources and the ability to sustain abstinence.

Matheny KB, Weatherman KE: Predictors of Smoking Cessation and Maintenance. Journal of Clinical Psychology 1998; 54(2):223-235.

Animal studies have shown that stress induces relapse to heroin, cocaine, alcohol, and nicotine self-administration.

Shaham Y, Stewart J: Stress reinstates heroin-seeking in drug-free animals: an effect mimicking heroin, not withdrawal. Psychopharmacology 1995; 119:334-341.
Erb S, Shaham Y, Stewart J: Stress reinstates cocaine-seeking behavior after prolonged extinction and a drug-free period. Psychopharmacology 1996; 128:408-412.
Stewart J: Pathways to relapse: the neurobiology of drug- and stress-induced relapse to drug-taking. Journal of Psychiatry & Neuroscience 2000; 25:125-136
Ahmed SH, Koob GF: Cocaine- but not food-seeking behavior is reinstated by stress after extinction. Psychopharmacology 1997; 132:289-295.
Lê AD, Quan B, Juzytch W, Fletcher PJ, Joharchi N, Shaham Y: Reinstatement of alcohol-seeking by priming injections of alcohol and exposure to stress in rats. Psychopharmacology 1998; 135:169-174.
Y. Buczek, Lê AD, Wang A, Stewart J, Shaham Y: Stress reinstates nicotine seeking but not sucrose solution seeking in rats. Psychopharmacology 1999; 144:183-188.
Posttraumatic Stress Disorder (PTSD) and Substance Abuse
Research shows that Posttraumatic Stress Disorder (PTSD), a psychiatric disorder, may develop in people after they experience or witness life-threatening events such as terrorist incidents, military combat, natural disasters, serious accidents, or violent personal assaults like rape. Research also shows that PTSD is a risk factor for substance abuse and addiction. Because the events that occurred on September 11, 2001, were experienced by thousands of people, as well as rescue workers in and around the vicinity of the attacks, and were televised to millions across the world, it is likely that some individuals may develop behavioral and emotional re-adjustment problems. Symptoms of PTSD can include reexperiencing the trauma; avoidance of people, places, and thoughts connected to the event; and arousal, which may include trouble sleeping, exaggerated startle response, and hypervigilance. People who develop such symptoms may be more prone to escape from the realities of the day by self-medicating with drugs (Khantzian. Am J Psychiatry 1985). In fact, clinical observations suggest that PTSD patients may use psychoactive substances without a physician?s directions to relieve traumatic memories and other symptoms associated with PTSD (Brown. Drug Alcohol Dependence 1994).

Selected Research Findings on PTSD and Substance Use Disorders
High rates of comorbidity of PTSD and substance use disorders were first reported in war-related studies, in which as many as 75% of combat veterans with lifetime PTSD also met criteria for alcohol abuse or dependence.

Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss DS: Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. New York, Brunner/Mazel, 1990.

In a general population study, the overall lifetime rate of PTSD was 7.8%. Among men with a lifetime history of PTSD, 34.5% reported drug abuse or dependence at some point in their lives versus 15.1% of men without PTSD. For women, 26.9% with a lifetime history of PTSD reported drug abuse or dependence during their lives versus 7.6% of women without PTSD.

Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB: Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52:1048-1060.

Among adolescents lifetime rates of PTSD have been found ranging from 6.3%, in a community sample of older adolescents, to 29.6%, in substance-dependent adolescents aged 15 to 19 receiving treatment. And, among the substance-dependent adolescents, 19.2% currently had PTSD.

Giaconia RM, Reinherz HZ, Silverman AB, Pakiz B, Frost AK, Cohen E: Traumas and posttraumatic stress disorder in a community population of older adolescents. J Am Acad Child Adolesc Psychiatry 1995; 34:1369-1379.
Deykin EY, Buka SL: Prevalence and risk factors for posttraumatic stress disorder among chemically dependent adolescents. Am J Psychiatry 1997; 154:752-757

Persons with a lifetime history of PTSD have elevated rates of co-occurring disorders. Among men with PTSD during their lives, rates of co-occuring alcohol abuse or dependence are the highest, followed by depression, conduct disorder, and drug abuse or dependence. Among women with PTSD during their lives, rates of comorbid depression are highest, followed by some anxiety disorders, alcohol abuse or dependence, and drug abuse or dependence.

Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB: Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52:1048-1060.

Patients with PTSD commonly have substance use disorders, particularly abuse of and dependence on central nervous system depressants. This frequent co-occurrence of PTSD and substance use, suggests that the two are related.

Jacobsen LK, Southwick SM, Kosten TR: Substance Use Disorders in Patients with Posttraumatic Stress Disorder: A Review of the Literature. Am J Psychiatry 2001; 158(8):1184-1190.

The most recent thinking about the association between PTSD and substance use disorders suggests that for combat veterans (Bremner. Am J Psychiatry 1996) and civilians (Chilcoat. Arch Gen Psych 1998), the onset of PTSD typically precedes the onset of substance use disorders.

Saxon AJ, Davis TM, Sloan KL, McKnight KM, McFall ME, Kivlahan DR: Trauma, Symptoms of Posttraumatic Stress Disorder, and Associated Problems Among Incarcerated Veterans. Psychiatric Services 2001; 52(7):959-964.

In a study of 1007 young adults designed to look for a causal relationship between PTSD and substance use disorders, researchers found that when they reevaluated the participants at 3 and 5 years after an initial assessment, PTSD was associated with a more than 4-fold increased risk of drug abuse and dependence. The risk for abuse or dependence was highest for prescribed psychoactive drugs. The results suggest that drug abuse or dependence in persons with PTSD might be caused by efforts to self-medicate.

Chilcoat HD, Breslau N: Postraumatic Stress Disorder and Drug Disorders. Archives of General Psychiatry, 1998; 55:913-917.

Heroin-addicted patients who undergo so-called ultrarapid, anesthesia-assisted detoxification suffer withdrawal symptoms as severe as those endured by patients in detoxification by traditional methods, according to a NIDA-funded clinical trial. Researchers Dr. Eric Collins and colleagues at the College of Physicians and Surgeons of Columbia University concluded that there is no compelling reason to use general anesthesia in the treatment of opiate dependence, especially as it presents particular safety concerns. The new findings corroborate those of three international studies.

The ultrarapid detox technique, developed about 15 years ago by clinicians who hoped to mitigate the discomfort of withdrawal and speed the initiation of relapse prevention therapy, relies on a general anesthetic to sedate the patient for several hours while an opiate blocker precipitates withdrawal.The method is not covered by insurance, which makes it difficult to determine how many patients have received anesthesia-assisted detox.

To compare anesthesia-assisted detox with other approaches, Dr. Collins and colleagues enrolled 106 people seeking heroin detox at Columbia University Medical Center's Clinical Research Center. The patients, aged 21 through 50, had abused heroin every day during the past month. All spent 3 days as Center inpatients during detox, then were scheduled for twice-weekly outpatient relapse prevention psychotherapy and naltrexone maintenance (50 mg/day) for 12 weeks.

The investigators randomly assigned the participants to one of three detox methods (see chart). The goal of each method was to minimize patients' discomfort during withdrawal. In the ultrarapid approach, physicians put patients under anesthesia for 4 to 6 hours while administering naltrexone, a medication that precipitates withdrawal by blocking opioid molecules from their receptors in the brain. In the second method, patients remained awake and took a single dose of buprenorphine, a medication that eases withdrawal symptoms by moderating and smoothing the rate of opioid clearance from the brain. In the third approach, patients also remained awake and received clonidine and other nonopioid medications as needed to counter symptoms for all 3 inpatient days. These medications were available to all groups as needed for the duration of the inpatient phase. Throughout detox, the researchers closely monitored patients for complications, assessed physical indications of withdrawal, and asked the participants to rate their subjective experiences.