Section XXIV: Performance-Enhancing Supplement Use

Near-Term and Long-Term Effects Of Stimulant Dependence and Withdrawal

Goals of the Exercise

1. Refrain from use of all over-the-counter and illegally obtained performance-enhancing supplements.

2. Verbalize an understanding of the negative health consequences that performance-enhancing supplements can cause.

3. Dispose of all performance-enhancing supplements.

4. Establish and maintain total abstinence while increasing knowledge of the disease and the process of recovery.

5. Learn and use coping strategies to manage urges to relapse into chemical use.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Near-Term and Long-Term Effects of Stimulant Dependence and Withdrawal” activity is for veterans/service members who have become dependent on stimulant drugs and are newly clean and sober or working to achieve that state. This activity is psychoeducational, educating the veteran/service member about effects of this category of drugs and typical things people experience while going through withdrawal. Follow-up can include reading assignments from books listed in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner and/or videotherapy with films suggested for “Substance Abuse” in Rent Two Films and Let's Talk in the Morning, 2nd ed., by John W. Hesley and Jan G. Hesley, published by John Wiley & Sons.

EXERCISE XXIV.A Near-Term and Long-Term Effects of Stimulant Dependence and Withdrawal

Being dependent on any drug, or experiencing withdrawal, is stressful physically, mentally, and emotionally. Each type of drug has its own characteristics and its own dangers—here we are looking at stimulants (i.e., cocaine, amphetamines), and their variants. This will arm you with information to help you have a clear picture of the risks that go with stimulants and lower your levels of stress and anxiety by explaining what are normal and common parts of this experience.

1. We'll start with the effects of the drug, near-term and long-term. With any drug, people use it for its effects. This class of drugs, which includes cocaine, amphet-amines (Adderall, Benzedrine, Dexedrine), methamphetamine, MDMA/Ecstasy, and others, can be swallowed in pill form, smoked, sniffed, or injected. Stimulants cause increased energy, concentration, and motivation; suppressed appetite; and increased confidence. Specifically for these effects, they have been used by military forces in wartime, by athletes, and by people doing tiring and tedious jobs. But there are also dangerous side effects, including higher blood pressure and risk of heart attack or stroke, poorer judgment and impulse control, increased irritability, aggressiveness, paranoia, and hallucinations and delusions due to going too long without sleep. Another side effect is sometimes called “meth mouth.” The drug causes a dry mouth, making teeth vulnerable to decay, since saliva helps protect the teeth from bacteria. Of course, cocaine and its derivatives such as Novocaine, procaine, xylocaine, and so forth, are also used as local short-term anesthetics for dental work and minor surgery.

Also, when a person stops use after any period of use lasting more than a day or so, he or she will usually experience exhaustion and may sleep for much longer than usual. Which of these symptoms have you experienced while using a stimulant, or seen someone else experience?

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2. As with other addictive drugs, there are two other critical long-term effects of stimulants—the development of tolerance and withdrawal. Tolerance means that it takes more of the drug to get the same effect, or that if a person uses the same amount it has less effect with repeated use. This is similar to the experience many people have with other drugs like caffeine (a weaker stimulant in its own right)—the first time they try them the effects are powerful, but over time it may take a pot of coffee to match the effects of the first cup. With stimulants, the effect is mainly due to their triggering release of greater amounts of the brain chemical called dopamine, which leads to the effects described above. The reason tolerance happens is that the body is always trying to keep its chemistry in balance, and this flood of dopamine leads the brain to think it has a surplus and should make less. So over time, the levels of dopamine and/or the number of dopamine receptor cells drop drastically. Have you experienced the development of tolerance? Please describe how the effect has changed over time for you:

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A final note on tolerance: Some of the effect, the partial burnout of the brain's dopamine system, can be permanent with prolonged heavy use. Even after quitting, a user may be less able to feel pleasure and more prone to depression and anxiety for the rest of his or her life.

3. We also said that with repeated use over time, withdrawal develops. When a person whose body has adapted to the presence of the stimulant stops using it, the balance the body has achieved with the stimulant as part of the mix is thrown off again—and since the natural production of dopamine and number of receptor cells has been lowered, it leaves a person worse off than before he or she first used the drug. The withdrawal symptoms for any drug will typically be the opposite of the drug's effects. So for stimulants, what would be the normal short-term withdrawal symptoms? Typical withdrawal effects in stimulant dependence are exhaustion, prolonged sleep, inattention, anxiety, depression that can sometimes include suicidal thoughts, and intense irritability. (Oddly, some effects, such as agitation, increased irritability, paranoia, and temporary psychosis, are common to both extended use and withdrawal.) Please describe any withdrawal symptoms you've experienced:

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A positive note: Even though it's miserable, it's only temporary, and withdrawal from a stimulant is not physically dangerous, unlike some other drugs such as depressants.

4. Many people find another aspect of withdrawal difficult. Long after there is no trace of the drug left in their bodies, they still experience after effects. These can include difficulty concentrating and thinking clearly; problems with memory; anxiety, depression, and irritability; mood swings; emotional numbness or overreaction; trouble with sleep; and trouble with physical coordination. This is called Post-Acute Withdrawal (PAW). It scares people because symptoms may last for weeks or months after the last use of the drug, leading to the fear that the problems will be permanent. If you've been clean long enough that the drugs have left your system, are you experiencing any of these effects? If so, which ones?

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Thankfully, PAW is not permanent. It takes time for the body to restore its chemical balance, but it will keep getting better as time passes. The best way to cope is to watch as the symptoms diminish and recognize your progress.

In this exercise we've gone over the effects of stimulants in use and withdrawal, so you can understand things you've experienced and make informed decisions. You may know someone else who would benefit from this information; if so, please pass it on.

Be sure to bring this handout back to your next therapy session, and be prepared to discuss your thoughts and feelings about the exercise.

Near-Term and Long-Term Effects of Anabolic Steroid Dependence and Withdrawal

Goals of the Exercise

1. Refrain from use of all performance-enhancing supplements.

2. Verbalize an understanding of the negative health consequences that performance-enhancing supplements can cause.

3. Dispose of all performance-enhancing supplements.

4. Establish and maintain total abstinence while increasing knowledge of the disease and the process of recovery.

5. Learn and use coping strategies to manage urges to relapse into chemical use.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The“Near-Term and Long-Term Effects of Anabolic Steroid Dependence and With-drawal” activity is for veterans/service members who have become dependent on anabolic steroids and are newly clean and sober or working to achieve that state. This activity is psychoeducational, educating the veteran/service member about this category of drugs and typical things people experience while going through withdrawal. Follow-up can include reading assignments from books listed in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner, and/or videotherapy using films listed for “Substance Abuse” in Rent Two Films and Let's Talk in the Morning, 2nd ed., by John W. Hesley and Jan G. Hesley, published by John Wiley & Sons.

EXERCISE XXIV.B Near-Term and Long-Term Effects of Anabolic Steroid Dependence and Withdrawal

Being dependent on any drug or experiencing withdrawal, can be very rough physically, mentally, and emotionally. Each type of drug has its own characteristics, including its own dangers—in this exercise we are looking at anabolic steroids. This will arm you for this struggle, with information that can help you have a clear picture of the risks that go with steroid use as well as lowering your levels of stress and anxiety by explaining what are normal and common parts of this experience.

1. We'll start with the effects of anabolic steroids, near-term and long-term. The reason people use any drug is for its effects. This class of drugs, which mimic the action of the male sex hormones testosterone and dihydrotestosterone, can be swallowed in pill form, absorbed via skin patch, or injected. It's important not to confuse anabolic steroids with other steroids sometimes used to treat allergies and autoimmune disorders, like cortisone and prednisone. The effects of anabolic steroids in the body are many and can be dramatic. They increase muscle mass and body and beard hair, make the voice deeper, and increase libido. They are sometimes used medically to treat patients (typically boys) suffering from impaired testosterone production.

Which of these symptoms have you experienced while using an anabolic steroid, if any, or seen someone else experience?

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2. There are also serious negative effects. In women, anabolic steroids also increase body hair, deepen the voice, masculinize the musculoskeletal structure of the body, disrupt the menstrual cycle, and can cause the clitoris to grow. In adult men, they lower sperm production and can cause the testicles to shrink. In both genders, they tend to lower production of natural sex hormones (leading to deficiencies when use is stopped), cause acne, and increase balding on the scalp. In adolescents, they may prematurely stop the growth of the body's long bones, permanently stunting growth. Even more dangerous, anabolic steroids can increase blood pressure and cholesterol levels, raise the risk of stroke; cause heart disease; and raise the risk of several kinds of life-threatening cancers.

In higher doses they can have negative psychological and emotional effects. Anabolic steroids can cause increased aggressiveness and irritability (the pattern informally called “roid rage”), psychosis, and symptoms that can resemble bipolar disorder, both mania and depression, that can become suicidal. Research is ongoing, but it seems that some of these effects can be permanent. Anabolic steroids sometimes seem to be “gateway drugs”—once people start using them, they're more likely to also use other mind-altering substances.

Another common risk factor that is due to the method of use rather than the drug itself, is the danger of transmitting diseases including hepatitis and HIV/AIDS between steroid users who share needles or share multidose vials of the drug.

Scientists are also still researching the risk of physical addiction, with the development of tolerance and withdrawal, but at this point it appears that this risk is minor with these steroids compared to narcotics, stimulants, or depressants. Because of this, withdrawal's effects are also more psychological than strictly physical, most commonly an increase in irritability and depression. Which of these symptoms have you experienced while using an anabolic steroid, if any, or seen someone else experience?

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3. The best estimate of the researchers studying anabolic steroid use is that about 1% of the U.S. population uses them. Users are most likely to be middle-class men in their mid-20s who use the steroids to look better or to improve their performance as amateur athletes; they also estimate that between 2% and 3% of American high school students use anabolic steroids for the same reasons. Steroid users are more likely than average to suffer from a psychological disorder that causes them to see their muscular development as inadequate even when it is average or better, somewhat like the way people with anorexia see themselves as heavier than they are. Steroid users also tend to be in denial about the negative effects and risks and to believe that the researchers reporting the information in this exercise are exaggerating, although the facts here are accurate. Of the effects described in this exercise, which would be the most important to you in the categories of benefits and of dangers or drawbacks?

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Something worth thinking about would be ways you can achieve the benefits you've listed without exposing yourself to the risks. What activities come to mind, if any?

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In this exercise, we've gone over the effects of anabolic steroids, both positive and negative, to help you understand things you may have experienced and make informed decisions. You may know someone else who would benefit from this information; if so, please pass it on.

Be sure to bring this handout back to your next therapy session, and be prepared to discuss your thoughts and feelings about the exercise.