Chapter 14: Social Drugs

"The great majority of people who use drugs never come to the attention of doctors, lawyers, and policemen."²¹ The use of social drugs by many in our society is almost a given fact in this new century. People find drug use as a method of gaining social acceptance, an escape from their perceived difficulties, or a habit they obtained inadvertently. In the context of this chapter the term "social drug" is limited to alcohol, tobacco (including smokeless tobacco), marijuana, cocaine, and some examples of the newer club drugs, for example, ecstasy. It would be impossible to discuss all of the social drugs in one chapter. There are entire books written specifically on each of the types of drugs discussed in this chapter. For more details about any of the specific social drugs the reader is encouraged to read one of the available books, articles or other print media available from numerous sources. The United States government has numerous web pages dedicated to curbing drug abuse and have a great deal of up-to-date information that may be found at the following web address: www.cdc.gov. A text by Miller et al (2000) is an excellent source of information to gain a better understanding of the many factors relating to why adolescents begin a drug abuse way of life.

It is argued that most of the socially abused drugs do not have automatic, universal effects on everyone that uses them.¹⁰ That is to say, a person starting to abuse a drug for social reasons may not experience any type of the "claimed" effects until they actually learn and experience the effects that specific drug can have on their individual system. The athlete may have to use the drug on a number of occasions to experience the greatest effects from that drug. Many people who abuse a drug such as alcohol, tobacco, marijuana or similar drugs indicate the first time or first few times they use these drugs they do not experience any euphoric effect. Many relate they have a negative experience when using these drugs initially. It may take a number of drug use experiences for the athlete to begin experiencing any joyful effect, which is an indicator regarding the amount of drug use before he or she admits a problem exists. (Table 14–1)

Many times, the long-term effects of drug abuse are emphasized. However, it is important to remember that there are acute effects of drug use that affect each of us everyday. Examples of acute effects of social drug abuse include the problems associated with alcohol and street drugs. Alcohol is a factor in up to 50 percent of all head injuries.²² Many times the conflict and disarray in the stands or streets after a game is related to alcohol use by the fans.

The quality control of illegal drugs is nonexistent, thus resulting in overdoses and immediate death to many users. Street drugs may also contain many different substances used as "fillers" or can be adulterated by toxins, pesticides, fungi, bacteria or any one of a number of unknown contaminants as a result of manufacturer, such as in a kitchen, garage, or even the back of a van. These contaminants can cause acute reactions not always related to the drug's intended effect.

There are so many different types of social drugs and many more "street names" for each of these drugs. It is virtually impossible to keep track of all the names of these drugs; therefore, the athletic trainer is encouraged to talk with their athletes regularly to determine the most recent vernacular for street drugs. (Table 14–2)

Additionally, the abuse of drugs is a problem that can start at a young age. Some surveys and published research indicate that drug abuse can begin in the early teen years.¹³ Use of alcohol and tobacco can begin in late childhood or adolescents for some children.¹³ Increasing emphasis is being put on early education programs in the schools and various youth programs to assist the adolescent and teenager in avoiding drugs all together.

High school is a difficult time for teenagers; these young people can be easily influenced in both negative and positive ways. This is a time in their lives when social acceptance is of paramount importance. If a teenager cannot find social acceptance through his or her own experiences he or she may begin to choose other methods of becoming "part of the crowd." Unfortunately, drug use is one way these teenagers may find acceptance and friendship.²³ Out of peer pressure, or the need to "be cool" or for the feel of sophistication, a person may start to use drugs. Other indicators of reasons why adolescents might start drug use are for fun or out of simple curiosity.²³

The athletic trainer should be aware of the characteristics of a teenager who might become a drug abuser. There appears to be an increase in drug abuse in non-intact families (one parent missing) and homes that have no religious affiliation or activity.^14,24 Interestingly, there does not appear to be large differences in alcohol and drug abuse among ethnic groups in high school seniors.¹⁴ Additionally, there are personality characteristics the athletic trainer can look for in athletes that may be "indicators of a drug user to be." Some of these characteristics are outlined here:

• Alien

• Rebelliousness

• Non-conformity

• Accepts deviant behavior in others

• Lack of ambition

• Lack of commitment to school

• Impulsive

• Preoccupied by pleasure seeking

• Minimal concern for risk

• Poor problem-solving and coping skills

• Low self-esteem

• History of physical and psychological illness²⁵

High school student athletes are not of legal age to use alcohol or tobacco and should be discouraged from using these substances if for no other reason than the age requirements. Some local schools, districts, and even states have mandatory penalties for underage use of social drugs.

As an example, the state of Massachusetts Interscholastic Athletic Association (MIAA) has developed and published a "Chemical Health Eligibility Rule" for the high school athletes, coaches and administrators to follow in determining eligibility for an athlete.

The MIAA then goes on to explain what the penalties are for violating this rule for a first and second time offender. Hopefully, this will provide an impetus for the athlete to start thinking about the harmful effects of social drugs and plan for a healthy lifestyle when he or she is out of high school. Other states and school districts may have similar rules and regulations.

The college years are critical years for young adults because this may be the first time the student is out of the parents' home living on their own, making own decisions, and not having to report daily activities to the parents. This is a time when student-athletes are willing to try new activities they were not able do when living at home. Many college students have squandered their first year of higher education by spending far too much time enjoying their newfound freedom. Interestingly, it is noteworthy to remember that after the age of 21, rarely do people try new drugs in an experimental fashion.¹³

To ensure that the college experience is beneficial for the student-athlete, the National Collegiate Athletic Association (NCAA) has been tracking and surveying collegiate athletes for many years in almost every area of their collegiate lives. Other researchers are also interested in determining the substance abuse profiles in collegiate athletes, but as has been pointed out, these studies are reflective of only a small time period.⁶ Continued monitoring of national, regional, state and local drug abuse patterns are imperative to taking control of this ever-increasing problem.

The NCAA has been interested since the mid 1980s in the student-athlete's use of social drugs. Documented now are the types of social drugs athletes might be using and the approximate percentage of athletes participating in social drug use. Even though alcohol use is declining, there still remains a significant percentage of athletes using alcohol on a regular basis. Marijuana use has remained at the same levels since 1989, and smokeless tobacco has seen a minor decline in use. It is also interesting to note that there continues to be a small population of student-athletes using cocaine and psychedelic drugs. (Figure 14–1)

There are records of alcohol availability and use in most every society over the history of the earth. Alcohol use by professional and recreational athletes has been accepted for years. The idea that an athlete goes out to have a beer or two after the game is a common occurrence by athletes in professional sports. By doing this, many fans and other people also drink alcohol after a game or match and this has become a source of concern regarding drunk driving. In vehicle-related deaths, alcohol is the number one killer of teenagers and young adults in North America.¹⁹ The reasons why athletes consume alcohol are as varied as the sports in which they participate. Some athletes actually think the use of alcohol provides them with enhanced ability in their sport. Others consume alcohol for the stress-relieving properties it provides by desensitizing the central nervous system. The American College of Sports Medicine (ACSM) published a "Current Comment" in 2000 to help educate the public about the mixture of alcohol and athletic performance.

In the statement by the ACSM, they point out that a small amount of alcohol in the athlete's system (0.02–0.05 g/dL) can decrease hand tremors, improve balance and throwing accuracy, which might be helpful for an archer or other athletes of that type.¹ However, even this small amount of alcohol can retard reaction time and eye-hand coordination, making it much more difficult to perform at high levels in most other sports. More alcohol in the athlete's system has a negative effect on motor skills. Alcohol will also increase an athlete's speed times in short- and long-distance activity. Chronic alcohol use results in various detrimental effects to the organs of the body, such as liver cirrhosis, heart disease, diabetes, and mental disorders. Alcohol can also create an imbalance in the hormonal status of the body, thus creating a more arduous task for the body in building and rebuilding muscle tissues.

Adverse Effects

The detrimental acute effects of alcohol are many times overlooked, as the consumption of alcohol has become a method of reducing stress and increasing joyfulness in many people. Acutely, alcohol is responsible for mental and physical impairment, such as slurred speech, deficits in coordination and reaction time, decreased visual acuity, dehydration and an increase in acidic metabolites. Additionally, it should be stressed to pregnant or possibly pregnant women that alcohol crosses the placenta very easily and can harm the developing fetus.²⁶ For these reasons, and many others, the athletic trainer should be vigilant in denouncing the use of alcohol by athletes.

Tobacco was originally promoted for use by people with pain, headaches, labor pains, and a variety of other problems as a medicinal drug to limit the effects of pain. In 1604, King James I tried to limit the use of tobacco as he stated "it hurt the brain & lungs, was not pretty to look at and smelled bad."²⁷ As you can see by looking at the percentages of teenagers using tobacco in Table 14–3, there still exists a real problem with young people smoking cigarettes. Tobacco can be a very complex drug that includes many more chemicals than just tobacco but is initially used by many people for social reasons. Some people argue that smoking calms them down in stressful situations and others claim that smoking helps them to reduce their weight. The initiation of cigarette smoking can lead to a physical addiction to the chemicals contained in tobacco.

There are many different chemicals (over 4000) inhaled when a cigarette is smoked, but the most critical is nicotine.¹⁷ When a person smokes a cigarette, nicotine reaches the brain within just a few seconds of being inhaled. Nicotine produces a similar reaction in the brain as the neurotransmitter acetylcholine but also produces other effects. The other effects can include a chemical reaction in the brain producing the enjoyment of smoking, which leads to continued cigarette smoking. Depending on the mental state and mood of the individual at the time of cigarette smoking, nicotine can produce a stimulatory or depressive effect. It has been reported that nicotine will reduce monoamine oxidase B activity, which is involved in dopamine breakdown, thus reducing some motivating behavior.⁵

Adverse Effects

In a report by The Centers for Disease Control and Prevention (CDC), more than 430,000 people die annually as a result of cigarette smoking.² Outside the central nervous system, the chemicals in cigarette smoke can lead to a great deal of damage to a variety of tissues. Obviously, damage to the lungs is the most commonly reported problem with cigarette smoking. In the lungs the cilia are overworked and damaged, the airway passages are scarred and the tendency for lung cancer is greatly increased. Additionally, cigarette smoke can produce stimulatory effects on the user such as trembling, shaking, agitation, and nausea or vomiting depending on the type of tobacco and the smoking experience of the person. Nicotine can also produce an irregular heart rate, blood flow irregularities, an increased blood clotting mechanism, and increases in the circulating triglycerides leading to myocardial infarction. The possibility of coronary heart disease is much greater in smokers because of the narrowing of the coronary arteries by the excessive fats from the circulating triglycerides. The excess fats also produce an increase in blood pressure and ultimately strokes in these individuals.

Still, there are many adverse effects of cigarette smoking that are less commonly popularized. Problems such as ulcers, tooth and gum diseases, breathing disorders such as asthma or emphysema, skin disorders, complications in pregnancy and the increased possibility of stillbirth, as well as many others are rarely discussed because they are minor in comparison to the more obvious and costly problems (lung cancer) produced by cigarette smoking. Additionally, there is evidence that second-hand smoke is damaging to those who do not smoke. Many of these same problems are associated with people interacting or having regular contact with smokers even though they do not smoke themselves. Children can be greatly affected by passive smoke and can experience many health-related disorders including breathing difficulties and other general health problems.

The good news about smoking is that quitting will be beneficial to everyone. The smoker will enjoy better health and the people around them will also be less prone to breathing and other health problems related to second-hand smoke. Encourage athletes to quit smoking and work with them to find a way to overcome the dependence on tobacco they have acquired. For those who want to stop smoking, there are numerous behavioral programs, chemical products from chewing gums to lozenges to patches and other techniques. A person may find it necessary to use a combination of pharmacological and behavioral interventions to ultimately stop smoking. Physician assistance may be necessary in getting the proper program of smoking cessation prescribed.

The biggest hurdle to smoking cessation is the recidivism of smokers. More than 90% of the people who quit smoking will experience a relapse within 1 year of stopping.¹⁷ Quitting smoking is difficult, and any person in the process of quitting will need a great deal of support to maintain abstinence from this habit.

The hemp plant commonly used for making rope is the source for marijuana leaves, which are dried and smoked to produce a minor psychedelic reaction for the user. Marijuana is considered a minor psychedelic drug because the user does not have a total and complete break with reality as is the case with major psychedelics like LSD. Marijuana has been written about in many other countries for more than 4,000 years where it has been used as a sedative, to treat constipation, obesity, loss of appetite, and other problems. In the 1960s and 1970s marijuana became a very popular drug among young people who could not legally buy alcohol but wanted a "high" of some type.

The active ingredient in marijuana is tetrahydrocannabinol, but it also contains over 400 other chemicals. It is one of the most debated and talked about illegal substances in the medical and recreational drug user communities. There are numerous groups trying to get marijuana legalized for medicinal purposes in a variety of states. To date, the federal government has not accepted the legalization arguments put forth by any of the medical or other groups attempting to decriminalize or legalize marijuana.

Athletes have been known to smoke marijuana before contests to reduce their stress levels or to relax allowing them, as some argue, to perform better in competition. This relaxation technique however, does not make sense to most athletes. If smoking marijuana produces a lethargic effect why would an athlete want to have less energy and a decreased ability to learn and concentrate during a competitive match? Each individual athlete should find legal and safe methods to reduce pregame stress that allow them to both maintain their ability to concentrate and keep their energy at the greatest levels.

Adverse Effects

The use of marijuana has some predictable adverse effects for the user. Some of the acute effects that may accompany the use of marijuana are: anxiety and panic attacks, paranoia, increased mood alterations, increased heart rate, breaks with reality, memory, concentration and learning impairment, decreased ambition and motivation, and other similar side effects. The chronic effects of marijuana smoking also include those problems associated with tobacco smoking, with the inhalation of chemicals leading to lung diseases. Marijuana cigarettes may have more damaging chemicals than regular tobacco cigarettes because of how the drug is processed before being sold to the user. Long-term users can expect many of the same physiological changes as cigarette smokers having sinusitis, chronic cough (smokers hack), shortness of breath and other lung disorders resulting from smoke inhalation. There have been reports of other respiratory diseases, precancerous changes, memory and concentration problems.^4,31

To the surprise of many, there is a medicinal use for cocaine. It can be used as a local anesthetic but is not a common drug selected by most physicians for this purpose. As discussed in Chapter 10 there are many other local anesthetics considered much safer and more effective in their anesthetic properties.

The history of cocaine use goes back thousands of years in South America. Cocoa leaves have been and are still currently used by the natives in South American to provide them with much the same purpose many other people drink coffee; to get a stimulatory effect. Cocoa leaves are the raw materials needed to produce cocaine. Cocoa leaves are processed and made into a paste. The paste is further refined into a powder. Sometimes the paste does not go through further processing and refinement and is utilized by the drug abuser in the paste form. The processing of the cocoa leaves typically takes place in the country of origin. Most of the cocaine produced in the world comes from Bolivia, Columbia, and Peru. The cocaine powder or paste is then shipped out of the country to illegal distributors throughout the world.

Cocaine powder can be "snorted" through the nostrils, which is then taken up into the blood vessels and passed on to the central nervous system, where it stimulates the noradrenaline, serotonin, and dopamine neurotransmitters. The stimulation of these neurotransmitters produces a "high" and is associated with increased pleasure, activity level, and a general feeling of "well being".

For the effects of cocaine to be experienced quicker, the user may elect to use another method of getting it to their central nervous system. The drug user may use the "freebase" method. This method requires the cocaine powder be alkalinized to remove the hydrochloride salt, thus providing a substance that can be heated and smoked. Using the freebase method produces a delivery of the active ingredient to the brain at approximately the same speed as an intravenous injection. If a drug user tries to smoke cocaine powder, the heat required to vaporize cocaine powder destroys the active ingredient. Further processing of the cocaine powder to remove the salt allows the active ingredient to be vaporized at a much lower temperature. Thus, the cocaine can then be smoked. The other form of cocaine that is referred to is "crack," which is a homemade or imitation form of freebase. Crack is usually smoked in a special pipe, piece of aluminum foil or some other crude method by the user to get the rapid desired effect.

The use of intravenous injection is possible after the powder is dissolved in water although this is not a common usage technique. Additionally, the user may try to swallow the cocaine to get it into their system. Oral intake of cocaine requires the drug to be absorbed from the intestinal tract, routed via the blood stream to the liver, where it is metabolized. This method results in a much slower and less effective delivery to the brain. Injection is the quickest and most effective way of getting the drug to the brain, and oral intake is the slowest and least effective method of taking cocaine.

Adverse Effects

Many cocaine users snort the cocaine through their nostrils which results in a constriction of the blood vessels in the immediate area. With increased use this can lead to necrosis of the tissues in the local area and chronic runny nose and/or collapse of the nasal cartilage, among other related problems. Smoking the drug is very hard on the structures of the lungs and can lead to chest pains and lung disorders such as bronchitis. Possibly the most significant problem is the stimulatory effect it produces on the central nervous system. This stimulation of the nervous system can result in an increase in blood pressure, heart rate, sweating, anxiety, and other central nervous system controlled activities which can sometimes result in death. A single use of cocaine has been reported to cause death. Again, the impurity and contamination of street drugs must be a factor the potential user should be aware of when electing to try this drug. Therefore, the athlete must understand that every person's body will react differently to the use of this and other drugs.

Ecstasy

Methylenedioxymethamphetamine (MDMA), also better known as ECSTASY, is one of the most popular "club drugs" available today. These drugs are sometimes referred to as entactogens. "Entactogens" is a term that has been coined to describe the class of drugs that increases a person's "warm and friendly feelings" for others. Ecstasy or MDMA is an amphetamine derivative, as can be seen by the amphetamine group at the end of the chemical name. Its chemical structure is related to both amphetamine and mescaline. Over the years, more than 1000 chemical variations of ecstasy have been produced.²⁸

According to Robson, the Merck pharmaceutical company takes credit for first synthesizing this drug in about 1912 and obtained the patent rights for it in 1914. At that time it was suggested that it could be used as a weight control drug. However, it was not commercially marketed but did get a restart in the 1950s when the United States Army was testing it for use in psychological warfare. Recreational use started in the late 1960s, and in the 1970s it was used by some psychologists to aid in different types of therapy. In psychotherapy, it was suggested that it allowed people to communicate more effectively.²⁸

Ecstasy utilizes the serotonin and dopamine neurotransmitters to create a stimulatory effect in the central nervous system. By stimulating a "flood of serotonin" within the brain, a person feels friendly to everyone he or she comes in contact with during the time period the drug is in effect. When researchers gave ecstasy to animals, it resulted in an increased temperature, heart rate, salivation and actually caused convulsions in high doses. Because it is an illegal drug and cannot be prescribed, it is not used in human research any longer. The use of ecstasy and resulting emergency room visits isncreased dramatically over the period from 1994 to 1999. In 1994 there were about 250 reported emergency room visits compared with an estimated 2850 cases of ecstasy overdose in 1999.³ In reviewing the most recent United State government drug abuse report,³² it appears that ecstasy use declined among high school students over the years 2000–2002. High school seniors who reported using ecstasy at some time in their life dropped from 11% in 2000 to 10.5% in 2002. This is not a significant reduction in the number of high school seniors taking ecstasy but a decline in the total number of students trying this drug.

Adverse Effects

This drug is an illegal substance with many adverse effects. The main effect that people who take this drug are trying to achieve is the sudden exhilaration that comes anywhere from 20 to 90 minutes after oral consumption of the tablet. The feeling of exhilaration that the person experiences can last from 3 to 5 hours depending on the metabolism rate of the individual. It is also reported that the first experience using ecstasy is the most rewarding for the person, with subsequent experiences being less positive.²⁹ It should also be remembered that this drug is typically taken in combination with one or multiple other party drugs such as alcohol, tobacco, marijuana, amphetamines, cocaine, etc. Some of the reported effects of ecstasy include being more friendly with others, and less aggressive and less defensive in interpersonal interactions. People report that they can overcome many of the stresses that are involved in everyday life including obsessive behavior and impulsiveness. It is claimed by many users that speech is enhanced and the perception of time is diminished when using Ecstasy. Adverse effects occurring during the original 3 to 5 hours include nausea and vomiting.

Interestingly, the reported effects of ecstasy use can last up to a week in some individuals. Some report that for 1 week, they have an increased ability to interact with others and experience a decrease in fear, aggression, obsessive behavior, and anxiety. The adverse effects some experience for the week are a decrease in sleep and/or appetite, fatigue, depression, libido, restlessness, and a decreased ability to perform mental and physical tasks.¹²

This drug can have both acute and chronic toxic effects in the athlete.¹¹ Memory loss and decreased mental functioning is a neurotoxic effect that results from use of even a single dose of ecstasy. Memory loss can include recognition and long-term memory.^15,20 Mental functioning that has been documented to be impaired by Ecstasy use includes both immediate and delayed word recall. Other more obvious acute signs and symptoms include nausea, vomiting, dehydration, fainting, clumsiness, uncoordinated movements, increased body temperature, generalized "hangover" liver damage, and kidney failure,

Athletes could be willing to try ecstasy with their friends on a weekend, during a vacation period, or at some other time for any one of a number of reasons. As the athletic trainer, you should be able to explain the adverse effects the athlete may encounter days or even weeks after taking this drug. Encourage athletes to avoid the use of this drug because it could result in long-term disability or even death.

Gammahydroxybutyrate

Gammahydroxybutyrate (GHB) is growing in popularity as a drug that creates a sense of euphoria or a feeling similar to alcohol intoxication in people. Some bodybuilders also use GHB to help them get into the deepest phase of the sleep cycle and remain in that stage for a longer time period.³⁰ It is suggested that the deepest sleep cycles are associated with increased natural release of human growth hormone which will provide a greater muscle growth potential.³³

GHB was originally developed as an anesthetic, but the effectiveness to limit or stop pain was never fully developed in this drug. It was determined that it could be of assistance in helping one to sleep. Later it was discovered that it had euphoric properties possibly emanating from its effect on the neurotransmitters in the central nervous system. GHB is rapidly absorbed in the mouth and begins to produce its effects within an hour after ingestion. It can be purchased in tablet or powder form at natural food stores in some states within the United States or on the internet at multiple sites in tablet, powder and solution forms. States such as California, Hawaii, Nevada, Texas, Georgia, Florida, Rhode Island and others have banned the sale of this drug completely. The probability of other states, if not all states, outlawing this drug in the future is great.

Adverse Effects

As with any of the social drugs, GHB is usually taken in combination with alcohol or other drugs because occurrence of use is frequently found in nightclubs, bars, and parties. The combined effects of GHB with other drugs can cause nausea, vomiting, muscle weakness, extreme fatigue, respiratory depression, and sometimes coma. The window between a nontoxic and toxic dose is small, and even a little too much GHB can cause an adverse reaction. Athletes should be cautioned from using GHB even to assist them with getting to sleep or other nonthreatening uses. The total effects produced by this drug have not been documented, and there are too many questions still not answered regarding this drug.

1. The initial use of social drugs by many athletes result in effects that are?

   1. immediate

   2. learned over time

   3. delayed

   4. greater than chronic users

2. Acute reactions to drug abuse can be caused by all of the following EXCEPT:

   1. additives to the drug

   2. combining multiple drugs

   3. mood of the drug abuser

   4. environmental temperature

3. According to government and research studies, why do high school students start to use alcohol and tobacco?

   1. legal age in some states

   2. acceptance by peers

   3. parental acceptance

   4. hormonal changes

4. What are the signs or personality characteristics that indicate an athlete could become a drug abuser?

   1. ambitious

   2. committed

   3. deliberate

   4. nonconformist

5. After what age has research shown that experimental drug abuse is reduced?

   1. 18

   2. 21

   3. 25

   4. 30

6. What effect does alcohol have on the gross motor skills of an athlete's performance in basketball?

   1. decreased reaction time

   2. increased reaction time

   3. reduces dehydration

   4. increases hormonal balance

7. Approximately how many chemicals are present in cigarette smoke?

   1. 25

   2. 100

   3. 2000

   4. 4000

8. Which of the following drugs currently has medicinal use accepted by mainstream physicians?

   1. alcohol

   2. tobacco

   3. marijuana

   4. cocaine

9. Most cocaine abusers prefer which method of use to get the most rapid effect from the drug?

   1. snorting

   2. smoking

   3. injecting

   4. oral

10. Ecstasy creates which chemical response in the body resulting in the desired effect to the drug abuser?

    1. increase in serotonin release

    2. decrease in dopamine release

    3. increase in insulin release

    4. increase in beta-endorphine release

11. GHB is used by body-builders to:

    1. increase growth hormone release during sleep

    2. decrease serotonin release during exercise

    3. increase dopamine release during exercise

    4. decrease beta-endorphine release during sleep