Office of Justice Programs Drug Court Clearinghouse and Technical Assistance Project
                      American University
                                
                                
                                
                      Issues Paper Series
                                
                                
                                
                                
                                
                                
                                
                 The Interrelationship Between 
              the Use of Alcohol and Other Drugs:
                                
             Overview for Drug Court Practitioners
                                
                                
                       John N. Marr, M.S.
                                
                                
                                
                                
                                
                          August 1999
                                
                                
                                
                                
                                
                                
                                
                                
                                
                                
                                
                                
                       
This report was prepared by the Office of Justice Programs (OJP) Drug Court Clearinghouse and Technical
Assistance Project at American University, Washington, D.C. This project is supported by Grant Nos. 95-
DC-MX-KOO2 and 98-NU-VX-K018, awarded by the Drug Courts Program Office, OJP, U.S. Department
of Justice. Opinions in this document are those of the authors and do not necessarily represent the official
position or policies of the U.S. Department of Justice.
                                                            Foreword

     Almost all drug court programs prohibit or strongly discourage the use of alcohol by drug
court participants. The justification, however, for imposing such restrictions has been
questioned particularly since, unlike controlled substances, the use and possession of alcohol are
legal except under certain specified conditions (e.g., while driving, by minors).

     The purpose of this issues paper is to address the underlying physiological, sociological and
psychological foundation for prohibiting persons addicted to controlled substances from using
alcohol. This paper addresses the interaction of alcohol with other drugs as well as the effect of
alcohol on the system of individuals who have been using controlled substances, even if they are
currently abstinent. The paper is designed to alert the lay reader to the most critical issues relevant
to addressing this topic and is intended to provide an overview for drug court officials primarily lay
persons for working with treatment experts in addressing this complex process. The paper,
however, is by no means a definitive treatment of the issues and should be used only as a guide for
working with experts in the field.

     The author, John N. Marr, received an M.S. in counseling psychology from the University of
Nevada. He heads Choices Unlimited of Las Vegas, Nevada, a private organization that provides the
treatment services for most of Nevada's adult, juvenile and family drug courts. Mr. Marr lectures
frequently on pharmacological issues relevant to drug treatment programs.

     The pharmacological effect and interaction of various stimulants, depressants, hallucinogens
and other substances on the human system is a complex science requiring years of specialized study
and training. We hope this paper will be useful to drug court officials in providing an introductory
overview to issues relevant to the topic and, in particular, to the effect of alcohol on persons who
have been addicted to other substances, to assist them in working with experts to further address
these issues in the design and operations of local drug court programs.

                                   Caroline S. Cooper, Director
                                   OJP Drug Court Clearinghouse and 
                                        Technical Assistance Project
                                   American University
                                                                
                                
                                
                                
                                
                            Contents
                                
                                
     I.    Introduction

     II.  The Physiological Effects of Alcohol and Other Drugs

     III. The Interaction of Alcohol with Other Drugs
                                
                              Chart: Physiological Attributes of Major Categories of 
                    Drugs and Their Interaction with Alcohol 
                                
     IV.  Frequently Asked Questions

     
     I.    Introduction

     It is common for substance abuse treatment programs, probation departments and courts to
place restrictions on alcohol consumption by persons under their care or jurisdiction for drug- or
alcohol-related offenses. These restrictions are imposed because of the following presumptions:

                The further use of alcohol by defendants already involved with alcohol or
          other drugs can lead to other addictions.
                The use of alcohol by such defendants can trigger cross-addictions, with the
          result that the "drinker" will revert to his/her old drug-using activities because of the
          physiological, psychological or sociological effects of the alcohol used either by
          itself or in conjunction with other drugs. 

     Despite the nearly universal acceptance of total sobriety policies for alcoholics and other
addicts by treatment providers and, in particular, by drug courts, very little has been written in
support of such policies for the layperson not specially trained in addiction medicine.
 
     The purpose of this issues paper is to provide, in a simple and unscientific format, the rationale
for such policies and to address frequently asked questions regarding these policies that have emerged
from the drug court experience.

     II.    The Physiological Effects of Alcohol and Other Drugs

     All human beings instinctively seek to satisfy such basic needs as obtaining food, water,
shelter, sexual gratification and other forms of pleasure. Each of these drives results in one of two
mental/emotional states:

          1.   If the drive is not fulfilled, the person experiences frustration, anxiety, irritability
          and/or anger. 

          2.   If the drive is fulfilled, the person experiences a reward manifested in feelings of
          pleasure, satisfaction and well-being.

     Each "drive state" is located in a specific part of the brain and is connected to the brain's
pleasure centers. When a drive is satisfied, brain chemicals, or neurotransmitters, such as dopamine,
endorphin, norepenephrine and serotonin, are released in the message centers of the brain, causing
the person to experience pleasure.

     Repeated introduction of alcohol and other drugs into the human neurological system triggers
a release of dopamine, serotonin or endorphin in the pleasure centers of the brain. This release upsets
the brain's ability to naturally release and replenish its chemical reservoirs. Thus, the person becomes
unable to attain feelings of pleasure and well-being without using alcohol or other drugs.

Stimulants (e.g., amphetamines, cocaine) release dopamine, which results in the individual
experiencing a sense of excited euphoria. Depressants (e.g., barbiturates, benzodiazepines,
methaqualione) release endorphin, which causes the individual to experience a sense of calm euphoria.
Alcohol increases the release of serotonin, which is responsible for controlling such feelings as the
desire for food and water, sexual responses and aggression. The brain's response to the artificially
stimulated release of neurotransmitters is more intense than when instinctive drives are allowed to
emerge naturally. Moreover, as the message centers are bombarded by an overflow of
neurotransmitters, additional receptors are created to process the excess stimuli.

     When the stimulation is exhausted, reduced or withheld, "frustrated" receptors are left
with nothing to process. With natural neurotransmitter levels then below normal, the brain will strive
to replenish them and will, for a time, be insensitive to the natural chemicals that exist in the body that
might otherwise have responded for this purpose. The mental/emotional state thereby created is
referred to as "craving."

     When an individual who has been using alcohol or other drugs tries to abstain from them, the
neurological damage caused by this receptor insensitivity leads the user to experience the state of
sobriety as a feeling opposite to the state of euphoria. Without the artificial pleasure and stimulation
induced by alcohol or other drugs, the individual experiences a profound, and often prolonged,
inability to experience pleasure through normal means. Instead, the individual experiences unfulfilled
instinctive drives, resulting in increased dysphoria, anxiety, anger, frustration and craving.

     III.  The Interaction of Alcohol with Other Drugs

     Alcohol, taken by itself, has the effect of a central nervous system (CNS) depressant.
However, when mixed with other drugs, alcohol can produce additional reactions, such as the
following:

                          Increase the sedative effect of CNS depressant drugs.
                          Inhibit a drug's metabolism by competing with the drug for
               the same enzymes. This prolongs the drug's availability in the system, thereby
               increasing the risk of harmful side effects.
                          Transform some drugs into toxic chemicals, damaging the
               liver or other organs.

The chart below summarizes the physiological and clinical attributes of major categories of drugs and
their interaction with alcohol.

Physiological Attributes of Major Categories of Drugs and Their Interaction with Alcohol 

Drug

Physical Indications of
Abuse
Clinical Symptoms of
Withdrawal and Treatment
Issues
Effect of Interaction with
Alcohol

Alcohol (booze, liquor)
Other forms: ethanol, ethyl
alcohol
Drowsiness, state of
sedation, excitement,
exhilaration, stumbling,
staggering, irrationality,
irritability, loss of control,
violent behavior, slurred
speech, blackouts, aroma
Hypertension, sweating, anxiety,
panic, insomnia, tremors, seizures,
hallucinations, weakness, lack of
energy, cravings, disorientation,
nausea, vomiting
NA

Marijuana (grass, pot, weed,
bud, joint, reefer, cubie, dope)
Dry mouth and throat,
bloodshot eyes, "high" (2-4
hrs) indicated by
giggling/laughing, altered
sense of time, impaired
immediate recall, slowed
motor skills and reaction
time, distorted perceptions.
Use can lead to arrested
mental/emotional
development and memory
loss.
No specific withdrawal syndrome
has been identified, but the
following are common to THC
users: insomnia, hyperactivity,
decreased appetite. Users can test
positive for several weeks
following use.
Exacerbates sedative affect
and increases level of
intoxication from both drugs

Cocaine (coke, snow, nose
candy, toot)
Forms: powdered (snorted),
cocaine hydrochloride (injected),
rock or crack
Mood elevation/euphoria,
increased energy/alertness,
decreased appetite,
insomnia, anxiety,
irritability, sense of
increased strength,
increased sex drive
"Crash" up to 4 days after use,
consisting of three phases:
Phase I: 8 hrs-4 days
Phase II: 1-15 weeks
Phase III: indefinite
Symptoms: depression 1-2 years,
agitation, paranoia, high craving,
weakness, fatigue, strong desire to
sleep, eating binges
Length of withdrawal and relapse
potential are high. Treatment must
address depression and paranoia
that can develop. Individual must
find alternatives to simulate brain
rebalancing, must force activity
and meaning into life.
Potentially very dangerous
because alcohol increases
blood pressure and weakens
portions of the heart wall,
making client more
susceptible to overdose

During the early stages of
drug use, alcohol may
exaggerate the effect of other
drugs, while during the later
stages it may mitigate slightly
the stimulant effects; however,
this is not an exact science,
and regardless of the stage of
drug use, alcohol will have a
negative effect

Sedatives-Hypnotics (sedatives,
barbs, downers, goofballs, reds,
ludes)
Forms: tablets, pills, capsules
(can be injected)
Similar to alcohol but
aggression less likely:
disinhibition, euphoria,
massive mood swings,
drowsiness, slurred speech,
confusion and
disorientation, impaired
judgment
Anxiety, irritability, restlessness
and agitation, tremors of hands
and eyelids ("blinking spasm"),
weakness, insomnia, seizures 1-7
days after last use, fever,
psychosis, suicidal thoughts
Depresses cardiac and
pulmonary functions, severe
drowsiness, possible coma or
fatal respiratory depression

Opiates 
Related drugs: opium,
morphine, codeine, heroin (junk,
snuff, horse, scag, smack),
dilaudid, percodan, methadone,
Demerol, Darvon, lortab
Severe pupil constriction,
euphoria, slowed speech,
respiratory failure, itching,
constipation, sedation/
drowsiness, nausea and
vomiting (occurs early and
goes away), lowered bodily
functions (pulse,
temperature, blood
pressure, reflexes)
Anxiety, panic insomnia, yawning,
tearing eyes, runny nose, sweats,
goosebumps, muscular twitches,
muscle aches and cramps (severe),
"bones ache", diarrhea, nausea and
vomiting, increased bodily
functions, physical withdrawal
often accompanied by fear ("I'm
dying"), panic, anxiety. Use of a
nonnarcotic, such as acupuncture,
clomidine or narcan, can assist
withdrawal.
Enhances the sedative effect
of both alcohol and opiates,
increasing the risk of overdose

Hallucinogens
LSD: acid, psilocybin,
mushrooms, silly putty,
mescaline, peyote buttons,
morning glory seeds, heavenly
blue, seeds, nutmeg,
"penitentiary acid"
STP (serenity, tranquility, peace,
designer drugs)
Altered perception (all
senses affected), impaired
cognitive functions,
euphoria, anxiety,
depression, "religious" or
mystical experiences,
psychosis, delusional
thinking, depersonalization
and disassociation
No withdrawal syndrome, but
flashbacks possible for weeks or
months, with delusional, episodic
psychosis, fear of flashbacks, fear
of losing one's mind
Specific results of interaction
unknown 

              IV. Frequently Asked Questions
                                
               Question:      What physiological effect does alcohol have on the brain?

     Response: Alcohol is a CNS depressant. It is carried through the body to the brain and
continues to depress brain responses until the liver has had the chance to oxidize the alcohol from
acetaldehyde into water, carbon dioxide and energy. The average liver is capable of oxidizing about
one-half ounce of alcohol per hour, which is the amount of alcohol in the standard drink. As alcohol
enters the system, it passes through the three main areas of the brain by way of the bloodstream:

                            the frontal lobe (cortex), which controls judgment and
                          reason (caution, reasoning, common sense and inhibition are
                          diminished when this portion of the brain is exposed to
                          alcohol);
          
                           the midbrain (limbic), which regulates muscle control as
                          well as governs emotions and reward sites (gait, movement
                          and emotions, ranging from depression to euphoria, are
                          affected by alcohol in this part of the brain); and
          
                           the hind brain (brain stem), which controls bodily
                          functions, such as heart rate, respiration and body
                          temperature (excess depression in this area of the brain can
                          result in a variety of physical consequences, including
                          death).
          
          
                   Question:      Does consumption of alcohol lead to the use of other drugs?

     Response:     The introduction of alcohol into the frontal lobe of the brain affects
reasoning, judgment and self-control. When under the influence of alcohol, persons who would
normally have enough invested in their recovery not to partake of controlled substances experience
mild euphoria and loss of inhibition, which often results in behaviors that would not occur if the
individual were sober. Clients regularly indicate that drug use episodes after a period of sobriety
occur after alcohol consumption.

                   Question:      Is alcohol a "gateway" drug leading to increased drug abuse?
     
     Response:     A great deal of research has been conducted on this topic that supports
the finding that alcohol is a gateway drug and, in many cases, leads to more serious drug addictions.
In a 1996 study, the National Center on Addiction and Substance Abuse at Columbia University
reported the following: 

     More than 67% of individuals who started drinking before age 15 went on to use other illicit
     drugs, compared with less than 4% of those who never drank....An individual who starts
     drinking before the age of 15 is 101 times more likely to use cocaine than someone who never
     drank.
     
The study further concluded that children who drink are 50 times more likely to abuse cocaine than
those who don't drink.

     A review of 5% of the active cases in the Las Vegas, Nevada, adult drug court program
concluded that 27% of the program participants whose drug of choice was either cocaine,
methamphetamine and/or heroin began their drug use with alcohol. Another 29% began by using
alcohol and marijuana together and then progressed to "harder" drugs. By combining these two
groups with the 30% whose initial drug of abuse was marijuana, the conclusion is obvious. Eighty-six
percent (86%) of all program participants whose current drug of choice is not alcohol or marijuana
began their drug-using behavior with one or both of these drugs.

                   Question:      What is the effect of combining alcohol and other drugs of abuse? Does the
                   alcohol enhance the effect of other drugs? Does it balance out the
                   effect of stimulants or otherwise counteract their negative side effects?

     Response:     The synergistic effect of poly drug use, when alcohol is one of the drugs, is
complex. Many variables must be considered in responding to this question. What are the drugs? Are
they stimulants or depressants? How much was taken and over what period of time?

        Alcohol Combined with Depressants

          The combination of alcohol, which is a depressant, with other CNS depressants, such
        as barbiturates, can create a dangerous physical situation for the individual involved.
        Both the alcohol and the barbiturate, as depressants, slow down almost all bodily
        functions. What would not be a dangerous amount of either drug by itself can, when
        they are taken together, create an interaction in the body leading to overdose. If not
        caught in time, this overdose of alcohol with another CNS depressant will undoubtedly
        result in major physical consequences for the individual, possibly death. 

        Alcohol Combined with Stimulants

          Some addicts use alcohol to help counteract the effect of CNS stimulants, such as
        cocaine or amphetamines. Marijuana is also used for this purpose, but since alcohol is
        a legal drug, it is easier to come by. Both alcohol and marijuana are used by addicts to
        self-medicate (e.g., relax, "mellow out") and to counteract the "tweaking" effect of
        stimulants.

          The most common stimulant effects that alcohol or marijuana can counteract are
        anxiety, shakes and tweaking.
        
        
                        Question: Why do most treatment programs require that drug users not use alcohol?

     Response:   Physiologically, alcohol may affect the brain by altering the levels of
certain neurotransmitters. Some neurotransmitters are diminished, while others (dopamine and
serotonin, for example) are stimulated. In either case, the brain is forced to compensate for either the
decrease or increase of these neurotransmitters within the brain chemistry. In the case of an increase
in stimulated neurotransmitters, the brain produces more receptors to interact with the increase in
stimulated neurotransmitters and inhibits receptor sites for those neurotransmitters that have been
diminished. When the alcohol is removed, the brain chemistry becomes greatly unbalanced, resulting
in cravings and other withdrawal symptoms, such as anxiety and disorientation.
 
    Heavy use of alcohol over a prolonged period can result in additional physical problems,
including brain lesions, Wernicke-Korsakoff syndrome (short-term memory loss), stomach ulcers and
cirrhosis of the liver. The dangers of developing one or more of these conditions is particularly high
among drug court populations, where most of the individuals suffer from compulsive, addictive
personalities manifested in a wide range of compulsive behaviors. A compulsive cocaine user, for
example, exhibits a high likelihood of becoming a compulsive eater, gambler or alcoholic. Great care
must therefore be taken to guard against drug addicts becoming addicted to other substances. 

    Psychologically, addicts do not drink simply because they like the taste of alcohol any more
than they use cocaine because it is refreshing. Despite any arguments to the contrary, drinking by an
addict is simply a form of drug-seeking behavior, with the depressant effect of the alcohol being far
more significant than the taste. If this were not true, addicts would choose to drink nonalcoholic beer
or wine. The psychological urge of an addict to take something to help relax or to feel different is a
red flag that relapse is under way and, without intervention, further drug use will occur.

    Sociologically, most drug addicts and alcoholics associate certain people, places and things
with drinking and using drugs. Even moderate drinking can lead an addict to revert to a lifestyle and
frequent an environment associated with prior drug-using behavior. Such an environment can trigger
future abuse. One of the true clichs of recovery is that one must change playgrounds and playmates.
Drinking can open the gate to the old playground.

                 Question:   Upon what basis do drug courts require that drug court participants or
                 persons court-ordered into treatment also abstain from a legal substance,
                 such as alcohol?

    Response:    Legal precedent has been established supporting the required abstinence
from alcohol by persons who have a documented history of substance abuse when it is clear that
future use of alcohol may lead to future criminality. In People v. Smith (1983) 145 Cal. App. 3d 1032,
1034, the California Court of Appeals, Fourth Appellate District, issued a leading decision in this
regard, maintaining that alcohol consumption lessens self-control and thus may facilitate a reduction
in the drug user's ability to abstain from further drug use. In issuing the opinion, the court cited
Pollack, Drug Use and Narcotic Addiction (1967), University of Southern California Institute of
Psychiatry and Law for the Judiciary, pp. 1-2, 4-5.

    More recently, the California Court of Appeals upheld the prohibition regarding alcohol use
for a probationer convicted of cocaine possession in The People v. Gloria Elizabeth Beal, Ct. of
Appeal, Fourth Appellate District, Division One, State of California, D027755, Super. Ct. No. SCD
1 2429.

    Persons entering treatment courts, or drug courts, are required to sign petitions to participate
and voluntarily place themselves into treatment programs that operate under the jurisdiction of the
court. These petitions generally contain a statement acknowledging the required restriction on alcohol
use, for the reasons stated in the response to the previous question, and a statement acknowledging
that a violation of this rule could result in the application of criminal sanctions under the court's
contempt powers. Persons sentenced to probation generally sign similar acknowledgments regarding
the prohibition of alcohol use as a condition of probation. The prohibition against alcohol use is
further spelled out in most probation or parole agreements, with an acknowledgment signed by the
defendant that a violation of the no drugs or alcohol rule could result in the filing of revocation
procedures. People v. Bravo (1987) 43 Cal. 3d 600, upheld the court's requirement of a defendant's
waiver, as a condition of probation, of his or her Fourth Amendment right regarding searches that
might turn up evidence of alcohol use.