Substance abusers come in all shapes and sizes

Norma Clarke, MD
Medical director, Adolescent Treatment Program, The Menninger Clinic; Assistant professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine

The face of substance abuse has no single look; in other words, you can't tell a book by its cover.

Ten years ago on the acute unit of an inpatient hospital, I worked with a
15-year-old-boy named Scott. He was a tall, skinny boy with slightly unkempt blonde curls, green eyes that sparkled with amber and the kind of golden sun-kissed skin typically seen on California surfers. I remember him raging at his misfortune for having the kind of parents who messed up their kid enough to make him need to be in a psychiatric hospital. To make matters even worse, he said, they stuck him in the hospital in the middle of his summer holidays. The girls on the unit were thrilled by his constant anger and rages and his "so cute" good looks. And they agreed with him. How could any parent be so stupid as to admit their child to a hospital for something as silly as smoking marijuana?

Scott saw his parents as outsiders who were interfering in his life. "They're so full of it with all that crap about how I've changed. They just don't want me to grow up. They want me to stay home and do what they tell me for the rest of my life!"

What Scott's parents saw in their son was a boy who, for the past year, rarely went to school and on the days when he did, spent most of his time in the bathroom smoking pot. He had stopped doing homework, had a whole new set of friends whom neither parent knew and he seemed to think he should come and go as he pleased. When confronted by his bewildered parents, he cursed and swore so much that sometimes they were frightened by their own son. He was sullen, moody, isolative and unpredictable. He had never been this way before. The hospitalization followed very soon after an incident in which Scott had come close to physically assaulting his mother, the police had been called and Scott's parents, realizing nothing they had done so far had helped, put him in the hospital. At the time of his admission Scott's father said, "I know he doesn't see it now, but we're the best advocates he has. We can't let him go on using."

A transformation
Scott's treatment, which occurred before the onset of managed care—at a time when you could hospitalize an adolescent in an acute unit for six weeks— consisted of education and group therapy on substance abuse. He had no access to drugs for six weeks, and despite his being diagnosed with a mood disorder prior to his admission, he was not treated with antidepressants or any other psychotropic medications. About five weeks into his stay, I sat in a group with Scott and I can still remember the look of amazement on his face. It was as if he had suddenly stumbled on a profound Truth.

"I didn't realize how smoking pot had changed me. I had no idea. I can't believe I ever threatened to hit my mother. I'm back to myself now, but I still can't figure out how all this happened."

"Myself" meant his moods were stable and he was no longer irritable and raging. "Myself" meant he was interested in the world again. "Myself" meant he wanted to go back to school, was interested in learning, could focus and concentrate again. "Myself" also meant he was back to being shy, socially awkward and tongue-tied around girls. But more on that later.

The 'world' of drugs
I was a brand new child psychiatrist then, fresh out of training, and to tell the truth, I really didn't have that much experience with adolescents (I was still a little scared of them) and had even less experience with treating drug abusers. That's probably why I was as amazed as Scott at the difference in his personality on and off drugs, and that's probably why I still remember Scott. His recovery made as strong an impression on me as it did on him.

Actually, I did know something about drugs, but it was information learned when I worked in the emergency room of a big city hospital.

In that setting drug users were mostly urban dwellers, Black or Hispanic.

If whites came to the hospital, it was because they had come to get drugs in the city and had been caught in the urban violence surrounding urban drug use. I assumed drugs were not available in the suburbs. Drug addicts used marijuana, LSD, cocaine, heroin, PCP. They murdered each other for drug deals gone wrong. They described a world of crack houses and shooting galleries, dirty, rat-infested abandoned buildings where drug dealers and users were the only occupants.

A vivid education
Intravenous cocaine and heroin are damaging to the lining of veins. After periods of use, the veins sclerose-harden-and the user has trouble finding an open vein in which to inject the drug. In my time in the emergency room, I met addicts, teenagers and adults, who literally had sclerosed every vein on the surface of their bodies, necks, hands, scalps, feet, arms, legs. Shooting galleries have people who are experts at finding veins and, for a price, provide a service for desperate addicts. As a second-year surgical resident (I thought I wanted to be a surgeon back then), my fellow residents and I developed our own expertise at finding veins, or intravenous access as we called it. One of our on-call duties was putting intravenous lines into the subclavian veins of the ravaged and ill addicts who came in for medical or surgical treatment. The subclavian is a large vein which runs behind each clavicle (or collar bone).

If the procedure is not done carefully, there is a great risk of puncturing the lung, which is very close to the vein.

It was nothing for us to do five or six of these every night we were on call. Back then I thought I could identify drug users and addicts...the coarse skin, dilated pupils (look for people who wear sunglasses all the time), the track marks on the arms (look for people who wear long sleeves in summer), the fingers, arms and legs swollen from circulatory damage. Urban. Black. Hispanic. Violent. Deadly.

The face of drug abuse
Scott met none of these stereotypes. He was a middle-class white teenager from a semi-suburban, semi-rural part of the state. He'd bought his marijuana from dealers who were students at his high school.

"Everyone knows who they are," he told me. "They can get you anything you want...weed (another name for marijuana), heroin, cocaine, Xanax® (a prescription anti-anxiety medication), Vicodin® (a pain medication). Anything you want."

Scott's friends, all of them from surrounding counties, got their drugs from suppliers at their respective schools. I'd never have identified one of them had I seen them on the street. My experience with Scott went a long way toward teaching me the danger of stereotypes, which serve, I think, as a way to keep most of us thinking the problem is elsewhere.

Read the findings of the National Institute on Drug Abuse (NIDA) 2002 National Results on Adolescent Drug Abuse: Crack and heroin use are not concentrated in urban areas, as is commonly believed, meaning that no parents should assume that their children are immune to these threats simply because they do not live in a city. ...Differences in use by socio-economic class are very small.

Contrary to popular assumptions... African-American youngsters have substantially lower rates of use of most licit and illicit drugs than do whites. These include any illicit drug use, most of the specific illicit drugs, alcohol and cigarettes.... African Americans' use of cigarettes is dramatically lower than for whites.

Publicity helps
According to NIDA, 53percent of all the 8th, 10th and 12th graders surveyed had tried an illicit drug by the time they had completed their grade. Alcohol and marijuana are the two most common drugs of abuse, but there is significant use of heroin, cocaine, amphetamines, the so-called club drugs like Ecstasy and GHB, steroids, inhalants and cigarettes. In 2002 there were moderate declines in the use of marijuana and Ecstasy, amphetamine and methamphetamine and marked decline in the use of volatile inhalants. Heroin, cocaine, Vicodin® and Oxycontin® (a pain reliever related to morphine) held steady, while there were increases in the use of barbiturates (a kind of sedative) and drugs like Valium® and Xanax®.

Teenagers will gradually decrease their use of drugs with a high perceived risk of harm. Michael Rios, the chemical dependency counselor on the Adolescent Treatment Program of The Menninger Clinic, often tells me how little adolescents really know about drugs compared to what they think they know. He tells me that teenagers are often shocked when they learn how much damage drugs really do. That's why Michael is such a big advocate of drug education. NIDA agrees with him.

The decline in Ecstasy and inhalant use is directly related to NIDA's intense publicity campaigns, which have focused on the dangers of Ecstasy and inhalant use and very recent data indicate inhalant use may be on the rise again. Ecstasy use exploded when the drug was first introduced into the market, but now that it has been around long enough for its risks to become apparent, its use is gradually declining from its original peak. Inhalant use has declined because of negative publicity and the perception that inhalants are drugs for kids who are too young to afford "real" drugs.

After the cocaine-induced death of basketball star Len Bias, cocaine use among adolescents underwent a sharp decline because of the sudden increase in perceived risk. Over time, perception of risk with using cocaine has lessened and use has increased to its present level. Marijuana is more damaging to the lungs than cigarette smoke. The marijuana available today is up to 10 times more potent than the marijuana sold during the 1960s, but despite the growing evidence, many people, including parents, continue to think of marijuana as an innocuous drug and perceived risk remains low.

Mythical beliefs
Perceived risk aside, adolescents are notorious for their grandiosity. Imagined invincibility is a large part of normal adolescent development. Bad things will happen to everyone else, but not to them. I once had a 16-year-old drug dealer lecture me, with what I still think of as remarkable adolescent arrogance and condescension, on why he would not become an addict while all those around him were succumbing at an alarming rate. His mind was stronger than drugs, he lectured me. Anyone with a strong mind could be around drugs, even use drugs, and still be unharmed.

He used his product (he was a cocaine dealer) occasionally, but, he said, unlike his parents, cousin and assorted friends, he could stop whenever he wanted to. Despite all he had seen, his mother addicted, his father in jail for drugs, both brothers addicted, a cousin dead of an overdose, he still believed his "strong mind" could keep him safe. I've known many an addict to start at that place of invincibility, but eventually arrive at a time when, according to one addict, "I wasn't using cocaine, the cocaine was using me." The addict was acknowledging that something had happened which had led to his loss of control over his cocaine use. That loss of control defines addiction, and researchers are still trying to understand why it happens to some people and not to others.

The power of addiction
I used to be rather judgmental about drug use, thinking, not unlike the condescending drug-dealing teenager, that addicts were just weak-willed losers. I am embarrassed to say that I thought this even when I finished my adult psychiatry raining. I think I used to feel that if a person made a choice to start then that person could make a choice to stop. It was, to my mind, just that simple.

How could you call addiction a disease when the afflicted had made a clear choice to start using in the first place? But if you look at how people like Scott change with drug use, you have to ask yourself questions. If it was that easy to stop, why would a person lose job, home and family and still keep drinking or using cocaine? Why would an adolescent who has been raped multiple times in a crack house not stop using, but instead keep going back to that same crack house to get drugs? Why would a teenager who had been shot at and mugged by gangs on his trips to find drugs not stop using, but go back again and again to the very place where his life might be on the line? Why didn't Scott stop using when he realized he was failing all his classes, arguing with his parents every day and stealing from them to support his use? Why do people keep using when it is obvious to them and to everyone else that they are playing a losing game?

From almost every addict I have spoken with the answer is clear: they don't stop because they can't. It should be an obvious thing for us to grasp, but most of us do not consciously link our personality, behavior and thoughts to our brain, a powerful but delicate organ. Alterations in the brain can change who we are and how we behave. Drugs and alcohol alter our brains and change who we are. No one is exempt.

Brain damage
It turns out that drugs of abuse act on what scientists call the reward pathway in the brain. The pathway is a normal component of all brains, and usually acts to reinforce certain behaviors. The sensation of pleasure from a good movie, a good meal, a sexual encounter, are possible because of the action of the neurotransmitter dopamine and its actions in the reward pathway. In most life situations, the amount of dopamine in the pathway at any time is carefully controlled by a system of elegant checks and balances. This is important because the amount of dopamine is directly related to the intensity of the sensation of pleasure.

With substance use, the controls over the amount of dopamine are lost. Dopamine pours into the pathway, overwhelming the system and stimulating feelings of intense pleasure. The crash that follows use is related to the sudden depletion of dopamine. People begin to feel better, more normal, as their brains manufacture more dopamine. But the crash may be so severe that some people can't wait for their brains to manufacture more. This is where drugs like cocaine, heroin or amphetamines come in, because they can mimic the actions of dopamine, fooling the brain into thinking it has enough dopamine...and so the cycle begins...use, crash, use more to feel better, crash, use more.. and so on and on it goes.

In addition to the effects on dopamine, drugs like Ecstasy and amphetamines can do permanent damage to the serotonin system. This may result in changes in mood and behaviors. Many adolescent users report problems with memory and concentration after drug use. It is not clear whether these changes are permanent. Recent research is indicating that the adolescent brain may not be as resilient as once thought. There is new evidence that the adolescent brain may be more susceptible to damage from alcohol abuse. The surprise here may be that most of the damage occurs during alcohol withdrawal. There is evidence of shrinkage and cell death in the hippocampus and in the frontal lobes, areas important for memory, and focus and concentration. It is not clear how much function is recovered with cessation of use. Surveys indicate that nearly seven million young people between the ages of 12 and 20 binge-drink at least once a month. Two out of every five college students still binge-drink regularly.

Substance abuse motives vary
There are many reasons why adolescents use. Some are undergoing what I think of as routine adolescent experimentation, but their brains are too susceptible, and once they start, stopping is not easy. Scott, the boy we met earlier, was painfully shy. Smoking weed was his way of easing himself into social contact. He felt using marijuana was safer than using cocaine or heroin. He felt more comfortable, less awkward and seemed able to think of smart and witty things to say. He said he could feel his anxiety leaving him. It was like taking off a too tight jacket. The problem was that in order to manage his shyness he had to keep using. He was learning no new skills to help him manage his shyness. The new behavior was totally dependent on his having marijuana. Once he stopped using, the constricting shyness returned. To make things worse, he began to need more and more marijuana just to feel normal. As he said, drugs don't solve the problem, they just make it worse.

Many adolescents (and adults too) tell a story similar to Scott's. Using drugs to fit in. Using drugs to ease social contact. Using drugs to feel numb. Or to manage intense anxiety, depression or more frightening illnesses, like schizophrenia. The ups and downs in mood and the behavioral changes induced by drugs can be mistaken for a variety of psychiatric illnesses. When Scott's mood and behavior started to change his parents took him to a psychiatrist who diagnosed depression and began treating Scott with anti-depressants. His parents, believing they were protected in their part rural, part suburban world, never thought their son could be abusing drugs.

Times to be wary
Research has shown certain risk periods for drug abuse. One is leaving the family to attend school, and the others are the transitions to middle school, high school and college. The additional social, educational and emotional challenges, when added to the greater availability of drugs, leads to increased risk for some susceptible adolescents. Risk factors for use have been identified: early aggressive behavior, lack of parental supervision, peer substance abuse, availability of drugs and poverty. The more risk factors a child is exposed to, the more likely use becomes. It's the combination of risk factors that matters.

Early use often begins with alcohol, tobacco, marijuana, inhalants and prescription drugs, like sleeping pills and anti-anxiety medications. Adolescents who continue to use will move on to cocaine or other drugs while continuing use of tobacco and alcohol.

There is an anti-drug
It turns out that one of the strongest preventive tools is good parenting. Scott's father was right-he really was his son's best advocate. Parents, it seems, really are an anti- drug. The National Center for Addiction and Substance Abuse (CASA), has identified what it calls "hands-on" and "hands-off" parents.

The children of hands-on parents have a much lower incidence of substance use while the children of hands-off parents have a higher incidence of use. Hands-on parents are parents first and friends last. They keep close tabs on their kids, know where their kids are after school, monitor the CDs their kids buy, let their kids know how very upset they would be if their kids began to use, eat dinner together as a family, are aware of their teen's academic performance and monitor TV and Internet use. It may seem like work, but research indicates that it pays off and that adolescents from hands-on families report closer relationships with parents than adolescents from hands-off households.

Recognition of substance use in adolescence requires an awareness that all adolescents are susceptible. Remember the results of the NIDA survey-parents should not assume their children are protected because they live in suburban or rural areas. Be aware of behavior and mood changes. Look for changes in friends. Maintain a relationship with your adolescent.

There are huge amounts of good information on drugs available from NIDA. Read these things, online or in the print versions, with your adolescents. Such parental interventions pay off and are worth the investment. Adolescents who have been using for some time may need professional treatment. A substance abuse counselor can help with the decision about how best to proceed and whether outpatient or inpatient approaches are needed. But parents are not powerless in the fight against drugs. Well-informed parents are the best anti-drug there is.

Norma Clarke, MD, a child psychiatrist, is medical director of The Menninger Clinic's Adolescent Treatment Program.