The links between licit and illcit drugs

Legal and political separation has meant that at national levels, there has been little consideration of the role of these types of drugs in illicit drug using behaviours. Similarly there is little of relevance to describe in the prevention literature that does not already cover classic drug interventions.
It has been argued that because of their rapid action on the brain, all classes of psychoactive drugs attract those who seek or need instant reward and gratification; a ‘short circuiting of the pleasure/pain principle’.
A report by the United Nations International Drug Control Programme (World Drug Report 1997) states that, “prevailing family attitudes in matters of health care and health consciousness may influence both licit and illicit drug use”. For example it has been suggested that the practice of family members commonly giving each other injections may have contributed to the high incidence of injecting drug use in Italy, because syringes are perceived as a “normal component of domestic medical equipment”.
The ‘pro-drug socialization model’ proposes that a person may be socialized into a prodrug lifestyle (NIDA 1980). For example, families where the parent (or parents) use licit drugs (over the counter and prescribed) might in effect teach their children that drugs “are good and provide a solution to one’s problems”.
Like illicit drugs, prevalence of consumption of these types of drug differs between populations, for example, individuals with stressful jobs differ very much from a socially comparable segment of the local population, which may lead to discrete occupational risks (e.g. Barbeau et al., 2004; Bang and Kim, 2001; Omar et al., 2005).
In a large self report study of US college students (n = 10904), the life time prevalence of non-medical use of prescription stimulants was 6.9% (McCabe et al., 2005). Multivariate regression analyses indicated non-medical use was higher among college students who were male, white, members of fraternities and sororities and earned lower grade point averages. Rates were higher at colleges located in the north-eastern region of the US and colleges with more competitive admission standards. Non-medical prescription stimulant users were also more likely to report use of alcohol, cigarettes, marijuana, ecstasy, cocaine and other risky behaviors.
Applying a logistic regression analysis to data from the National Household Survey on Drug Abuse it was found that nearly 1.3 million Americans aged 12 years and older experience problem use of prescription drugs signifying physiological dependence or heavy daily use (Simoni-Wastila and Strickler, 2004). Those at greatest risk include older adults, females, those in poor/fair health, and daily alcohol drinkers. There was no link reported between prescription drug use and illicit drugs

· Drug use in the work place is often used to face up to challenges, or to support activities. In one French sample, workers were asked to complete an anonymous self-questionnaire during their annual compulsory examination to assess their aptitude for work (Lapeyre-Mestre et al., 2004). Data collected concerned socioprofessional characteristics, perceived stress, job satisfaction and satisfaction outside of the workplace, and the use of licit psychoactive substances (alcohol, coffee, drugs) to face up to job strain. One-third of workers used drugs in the context of work: 20% used drugs to be in good form at work, 12% used drugs in the workplace to alleviate an awkward symptom (e.g. socialisation), and 18% used drugs to relax after a difficult day's work. Apart from alcohol use, psychological distress and female gender were associated with such behaviour.

· It has been demonstrated that an excessive use of alcohol, caffeine, and nicotine provokes a variety of sleep disturbances: an increase in sleep latency, nocturnal awakenings, a reduction in slow sleep waves, a reduction in the total sleep time, and a poor self-report (Sierra et al., 2002). However, the effect of these substances on sleep in a social consumption context (non-excessive) is not understood yet. Non-excessive daily consumption of alcohol, caffeine, and tobacco provokes a poor sleep quality, a greater sleep latency, a greater number of sleep disturbances, and a greater daytime dysfunction. These characteristics and quality of are similar to the characteristics and sleep quality of substance dependent subjects. Poor sleep quality should also be added to the diverse negative effects of an excessive psychoactive substance consumption

· Comparison of populations who consume caffeinated beverages with those who drink decaffeinated beverages allow investigation of differences and drivers of use. In a large US study of 12,467 persons; 36% drank caffeinated coffee only, 13% drank decaffeinated coffee only, 27% drank both types and 24% drank no coffee (Shlonsky et al., 2004). Odds ratios estimated from logistic regression analyses revealed that compared with regular (caffeinated) coffee drinkers or abstainers, decaffeinated coffee drinkers were less likely to be heavy coffee drinkers, smokers, alcohol drinkers, users of caffeinated soft drinks and medication and to be free of illness. Increased decaffeinated coffee drinking was associated with older age, female sex, African American ethnicity, use of special diets, and vascular, gastrointestinal, or neuropsychiatric symptoms.

There are many putative interactions between these types of drugs. Of interest are those between caffeine drinks and alcohol beverages, which are often sold in nightclubs and bars. There are popular reports that this combination of alcohol and energy drinks (such as Red Bull and similar beverages, which contain caffeine, taurine, carbohydrates, etc.) are used to reduce the depressant effects of alcohol on central nervous system. In one investigation designed to verify the effects of alcohol, and alcohol combined with energy drink, on the performance of volunteers in a maximal effort test fourteen healthy subjects completed a double-blind protocol made up of four sessions: control (water), alcohol (1.0 g/kg), energy drink (3.57 ml/kg Red Bull(R)), and alcohol + energy drink, each 1 week apart (Ferreira et al., 2004). The performance in the maximal effort test observed after alcohol + energy drink ingestion was similar to that observed after alcohol only. No significant differences between alcohol and alcohol + energy drink were detected in the physiological and biochemical parameters analyzed. These findings suggest that energy drinks, at least in the tested doses, did not improve performance or reduce alterations induced by acute alcohol ingestion.
Caffeine beverages have been shown to potentiate the reinforcing and stimulant subjective effects of nicotine in cigarette smokers (Jones and Griffiths, 2003), which has implications for smoking cessation strategies.
The caffeine-withdrawal syndrome has been well characterized and there is sufficient empirical evidence to warrant inclusion of caffeine withdrawal as a disorder in the DSM and revision of diagnostic criteria in the ICD (Juliano and Griffiths, 2004). Of 49 symptom categories identified, the following 10 fulfilled validity criteria: headache, fatigue, decreased energy/activeness, decreased alertness, drowsiness, decreased contentedness, depressed mood, difficulty concentrating, irritability, and foggy/not clearheaded. In addition, flu-like symptoms, nausea/vomiting, and muscle pain/stiffness are judged likely to represent valid symptom categories. In experimental studies, the incidence of headache was 50% and the incidence of clinically significant distress or functional impairment was 13%. Typically, onset of symptoms occurred 12-24 h after abstinence, with peak intensity at 20-51 h, and for a duration of 2-9 days. In general, the incidence or severity of symptoms increased with increases in daily dose; abstinence from doses as low as 100 mg/day produced symptoms. Expectancies are not a prime determinant of caffeine withdrawal and that avoidance of withdrawal symptoms plays a central role in habitual caffeine consumption.
In a US study characterizing the symptoms of caffeine dependence in adolescents, thirty-six adolescents who consumed caffeine daily and had some features of caffeine dependence underwent outpatient evaluation (Bernstein et al., 2002). Evaluation included the Diagnostic Interview Schedule for Children-IV-Youth Version (DISC-IV) and modified DISC-IV questions that assessed caffeine dependence based oil DSM-IV substance dependence criteria. Of 36 subjects, 41.7%, (n = 15) reported tolerance to caffeine. 77.8%, (it = 28) described withdrawal symptoms after cessation or reduction of caffeine intake, 38.9% (n = 14) reported desire or unsuccessful attempts to control use, and 16.7%, (it = 6) endorsed use despite knowledge of physical or psychological problems associated with caffeine. There was no significant difference in the amount of caffeine consumed daily by caffeine dependent versus non-dependent teenagers.
In a 1-year follow-up of daily caffeine-using adolescents 23.8% (n=5) still met criteria for caffeine dependence (Oberstar et al., 2002). Four of these participants developed caffeine dependence during the follow-up period. Other substance dependence disorders were not overrepresented in the caffeine dependent group compared to the caffeine nondependent group. The most commonly reported withdrawal symptoms in dependent teenagers (at baseline and follow-up combined) were feeling drowsy/tired, fatigued, or sluggish/slowed down (83.3% each) and headache (75.0%). Caffeine dependence occurs in some adolescents who drink caffeine daily and is marked by symptoms similar to those found in adults.
The relations between the intake of alcohol and that of caffeinated beverages, as well as cigarette smoking, was examined in a group of chronic alcoholics in an Israeli treatment center (Amit et al., 2004). When data from the total sample was analyzed, relationships between alcohol and caffeinated beverages intake and between alcohol intake and smoking were observed. Caffeine use and smoking were also related. In addition, a subgroup of subjects with a family history of alcoholism revealed correlations between alcohol and caffeine consumption, between alcohol intake and smoking, as well as caffeine use and smoking. Subjects without a family history of alcoholism also showed relationships between alcohol and caffeine use and smoking. However, coffee intake and tobacco use was not related in this subgroup. The relevance of the findings to previous reports concerning alcohol drinking and smoking as well as the intake of coffee appear to be consistent with a notion of interaction between these respective behaviors occurring at a behavioral level rather than a genetic one. The link between caffeine and alcohol consumption has received some support in pre-clinical studies where pre-administration of caffeine promoted alcohol drinking in rats (Kunin et al., 2000).

Amit Z, Weiss S, Smith BR, Markevitch S (2004) Use of caffeine-based products and tobacco in relation to the consumption of alcohol - An examination of putative relationships in a group of alcoholics in Israel. EUROPEAN ADDICTION RESEARCH 10 (1): 22-28

Bang KM, Kim JH (2001) Prevalence of cigarette smoking by occupation and industry in the United States. AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 40 (3): 233-239

Barbeau EM, Leavy-Sperounis A, Balbach ED (2004) Smoking, social class, and gender: what can public health learn from the tobacco industry about disparities in smoking?
TOBACCO CONTROL 13 (2): 115-120

Bernstein GA, Carroll ME, Thuras PD, Cosgrove KP, Roth ME (2002) Caffeine dependence in teenagers DRUG AND ALCOHOL DEPENDENCE 66 (1): 1-6

Ferreira SE, de Mello MT, Rossi MV, Souza-Formigoni MLO (2004) Does an energy drink modify the effects of alcohol in a maximal effort test?
ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH 28 (9): 1408-1412

Jones HE, Griffiths RR (2003) Oral caffeine maintenance potentiates the reinforcing and stimulant subjective effects of intravenous nicotine in cigarette smokers. PSYCHOPHARMACOLOGY 165 (3): 280-290

Juliano LM, Griffiths RR (2004) A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features PSYCHOPHARMACOLOGY 176 (1): 1-29

Kubo Shlonsky A, Klatsky AL, Armstrong MA (2003) Traits of persons who drink decaffeinated coffee. Anals of Epidemiology 13(4): 273-279

Kunin D, Gaskin S, Rogan F, Smith BR, Amit Z (2000) Caffeine promotes ethanol drinking in rats - Examination using a limited-access free choice paradigm ALCOHOL 21 (3): 271-277

Lapeyre-Mestre M, Sulem P, Niezborala M, Ngoundo-Mbongue TB, Briand-Vincens D, Jansou P, Bancarel Y, Chastan E, Montastruc JL (2004) Taking drugs in the working environment: A study in a sample of 2106 workers in the Toulouse metropolitan area THERAPIE 59 (6): 615-623

McCabe SE, Knight JR, Teter CJ, Wecshler C (2005). Non medical use of prescription stimulants among US college students: prevalence and correlates from a national survey. Addiction 99: 96 - 106

National Institute on Drug Abuse. (1980) Research 30: Theories on Drug Abuse. Maryland: Department of Health and Human Services.

(www.nida.nih.gov/pdf/monographs/download30.html)

Oberstar JV, Bernstein GA, Thuras PD (2002) Caffeine use and dependence in adolescents: One-year follow-up JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY 12 (2): 127-135

Omar MM, Al-Mulla KF, Al-Seleem TA, Murad B, Radovanovic Z (2005) Middle East aircrew use of alcohol, tobacco, coffee, and medicaments. AVIATION SPACE AND ENVIRONMENTAL MEDICINE 76 (4): 395-398

Sierra JC, Jimenez-Navarro C, Martin-Ortiz JD (2002) Quality of sleep in university students: the importance of sleep hygiene SALUD MENTAL 25 (6): 35-43

Simoni-Wastila L, Strickler G (2004) Risk factors associated with problem use of prescription drugs. American journal of Public Health 94:266 - 268

United Nations International Drug Control Programme (1997). World Drug Report. United Nations Office on Drugs and Crime

(http://www.unodc.org/adhoc/world_drug_report_1997/Contents/CONT.pdf)

Legal and political separation has meant that at national levels, there has been little consideration of the role of these types of drugs in illicit drug using behaviours. Similarly there is little of relevance to describe in the prevention literature that does not already cover classic drug interventions.
It has been argued that because of their rapid action on the brain, all classes of psychoactive drugs attract those who seek or need instant reward and gratification; a ‘short circuiting of the pleasure/pain principle’.
A report by the United Nations International Drug Control Programme (World Drug Report 1997) states that, “prevailing family attitudes in matters of health care and health consciousness may influence both licit and illicit drug use”. For example it has been suggested that the practice of family members commonly giving each other injections may have contributed to the high incidence of injecting drug use in Italy, because syringes are perceived as a “normal component of domestic medical equipment”.
The ‘pro-drug socialization model’ proposes that a person may be socialized into a prodrug lifestyle (NIDA 1980). For example, families where the parent (or parents) use licit drugs (over the counter and prescribed) might in effect teach their children that drugs “are good and provide a solution to one’s problems”.
Like illicit drugs, prevalence of consumption of these types of drug differs between populations, for example, individuals with stressful jobs differ very much from a socially comparable segment of the local population, which may lead to discrete occupational risks (e.g. Barbeau et al., 2004; Bang and Kim, 2001; Omar et al., 2005).
In a large self report study of US college students (n = 10904), the life time prevalence of non-medical use of prescription stimulants was 6.9% (McCabe et al., 2005). Multivariate regression analyses indicated non-medical use was higher among college students who were male, white, members of fraternities and sororities and earned lower grade point averages. Rates were higher at colleges located in the north-eastern region of the US and colleges with more competitive admission standards. Non-medical prescription stimulant users were also more likely to report use of alcohol, cigarettes, marijuana, ecstasy, cocaine and other risky behaviors.
Applying a logistic regression analysis to data from the National Household Survey on Drug Abuse it was found that nearly 1.3 million Americans aged 12 years and older experience problem use of prescription drugs signifying physiological dependence or heavy daily use (Simoni-Wastila and Strickler, 2004). Those at greatest risk include older adults, females, those in poor/fair health, and daily alcohol drinkers. There was no link reported between prescription drug use and illicit drugs

There are many putative interactions between these types of drugs. Of interest are those between caffeine drinks and alcohol beverages, which are often sold in nightclubs and bars. There are popular reports that this combination of alcohol and energy drinks (such as Red Bull and similar beverages, which contain caffeine, taurine, carbohydrates, etc.) are used to reduce the depressant effects of alcohol on central nervous system. In one investigation designed to verify the effects of alcohol, and alcohol combined with energy drink, on the performance of volunteers in a maximal effort test fourteen healthy subjects completed a double-blind protocol made up of four sessions: control (water), alcohol (1.0 g/kg), energy drink (3.57 ml/kg Red Bull(R)), and alcohol + energy drink, each 1 week apart (Ferreira et al., 2004). The performance in the maximal effort test observed after alcohol + energy drink ingestion was similar to that observed after alcohol only. No significant differences between alcohol and alcohol + energy drink were detected in the physiological and biochemical parameters analyzed. These findings suggest that energy drinks, at least in the tested doses, did not improve performance or reduce alterations induced by acute alcohol ingestion.
Caffeine beverages have been shown to potentiate the reinforcing and stimulant subjective effects of nicotine in cigarette smokers (Jones and Griffiths, 2003), which has implications for smoking cessation strategies.
The caffeine-withdrawal syndrome has been well characterized and there is sufficient empirical evidence to warrant inclusion of caffeine withdrawal as a disorder in the DSM and revision of diagnostic criteria in the ICD (Juliano and Griffiths, 2004). Of 49 symptom categories identified, the following 10 fulfilled validity criteria: headache, fatigue, decreased energy/activeness, decreased alertness, drowsiness, decreased contentedness, depressed mood, difficulty concentrating, irritability, and foggy/not clearheaded. In addition, flu-like symptoms, nausea/vomiting, and muscle pain/stiffness are judged likely to represent valid symptom categories. In experimental studies, the incidence of headache was 50% and the incidence of clinically significant distress or functional impairment was 13%. Typically, onset of symptoms occurred 12-24 h after abstinence, with peak intensity at 20-51 h, and for a duration of 2-9 days. In general, the incidence or severity of symptoms increased with increases in daily dose; abstinence from doses as low as 100 mg/day produced symptoms. Expectancies are not a prime determinant of caffeine withdrawal and that avoidance of withdrawal symptoms plays a central role in habitual caffeine consumption.
In a US study characterizing the symptoms of caffeine dependence in adolescents, thirty-six adolescents who consumed caffeine daily and had some features of caffeine dependence underwent outpatient evaluation (Bernstein et al., 2002). Evaluation included the Diagnostic Interview Schedule for Children-IV-Youth Version (DISC-IV) and modified DISC-IV questions that assessed caffeine dependence based oil DSM-IV substance dependence criteria. Of 36 subjects, 41.7%, (n = 15) reported tolerance to caffeine. 77.8%, (it = 28) described withdrawal symptoms after cessation or reduction of caffeine intake, 38.9% (n = 14) reported desire or unsuccessful attempts to control use, and 16.7%, (it = 6) endorsed use despite knowledge of physical or psychological problems associated with caffeine. There was no significant difference in the amount of caffeine consumed daily by caffeine dependent versus non-dependent teenagers.
In a 1-year follow-up of daily caffeine-using adolescents 23.8% (n=5) still met criteria for caffeine dependence (Oberstar et al., 2002). Four of these participants developed caffeine dependence during the follow-up period. Other substance dependence disorders were not overrepresented in the caffeine dependent group compared to the caffeine nondependent group. The most commonly reported withdrawal symptoms in dependent teenagers (at baseline and follow-up combined) were feeling drowsy/tired, fatigued, or sluggish/slowed down (83.3% each) and headache (75.0%). Caffeine dependence occurs in some adolescents who drink caffeine daily and is marked by symptoms similar to those found in adults.
The relations between the intake of alcohol and that of caffeinated beverages, as well as cigarette smoking, was examined in a group of chronic alcoholics in an Israeli treatment center (Amit et al., 2004). When data from the total sample was analyzed, relationships between alcohol and caffeinated beverages intake and between alcohol intake and smoking were observed. Caffeine use and smoking were also related. In addition, a subgroup of subjects with a family history of alcoholism revealed correlations between alcohol and caffeine consumption, between alcohol intake and smoking, as well as caffeine use and smoking. Subjects without a family history of alcoholism also showed relationships between alcohol and caffeine use and smoking. However, coffee intake and tobacco use was not related in this subgroup. The relevance of the findings to previous reports concerning alcohol drinking and smoking as well as the intake of coffee appear to be consistent with a notion of interaction between these respective behaviors occurring at a behavioral level rather than a genetic one. The link between caffeine and alcohol consumption has received some support in pre-clinical studies where pre-administration of caffeine promoted alcohol drinking in rats (Kunin et al., 2000).