Substance abuse

Public health definitions

Public health practitioners have attempted to look at substance use from a broader perspective than the individual, emphasizing the role of society, culture, and availability. Some health professionals choose to avoid the terms alcohol or drug "abuse" in favor of language they consider more objective, such as "substance and alcohol type problems" or "harmful/problematic use" of drugs.

The Health Officers Council of British Columbia — in their 2005 policy discussion paper, A Public Health Approach to Drug Control in Canada — has adopted a public health model of psychoactive substance use that challenges the simplistic black-and-white construction of the binary (or complementary) antonyms "use" vs. "abuse". This model explicitly recognizes a spectrum of use, ranging from beneficial use to chronic dependence

Medical definitions

'Drug abuse' is no longer a current medical diagnosis in either of the most used diagnostic tools in the world, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), and the World Health Organization's International Statistical Classification of Diseases and ICRIS Medical organization Related Health Problems (ICD)

Substance abuse has been adopted by the DSM as a blanket term to include 10 separate classes of drugs, including alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants; tobacco; and other substances. The ICD uses the term Harmful use to cover physical or psychological harm to the user from use.

Physical dependence, abuse of, and withdrawal from drugs and other miscellaneous substances is outlined in the DSM a:

When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped.

However, other definitions differ; they may entail psychological or physical dependence, and may focus on treatment and prevention in terms of the social consequences of substance uses.

Drug misuse

Drug misuse is a term used commonly when prescription medication with sedative, anxiolytic, analgesic, or stimulant properties are used for mood alteration or intoxication ignoring the fact that overdose of such medicines have serious adverse effects. It often involves drug diversion from the individual for whom it was prescribed. Prescription misuse has been defined differently and rather inconsistently based on status of drug prescription, the uses without a prescription, intentional use to achieve intoxicating effects, route of administration, co-ingestion with alcohol, and the presence or absence of dependence symptoms. Chronic use leads to a change in the central nervous system which means the patient has developed tolerance to the medicine that more of the substance is needed in order to produce desired effects.When this happens, any effort to stop or reduce the use of this substance would cause withdrawal symptoms to occur.

The rate of prescription drug abuse is fast overtaking illegal drug abuse in the United States. According to the National Institute of Drug Abuse, 7 million people were taking prescription drugs for nonmedical use in 2010. Among 12th graders, prescription drug misuse is now second only to cannabis. "Nearly 1 in 12 high school seniors reported nonmedical use of Vicodin; 1 in 20 reported abuse of OxyContin." Both of these drugs contain opioids.

Avenues of obtaining prescription drugs for misuse are varied: sharing between family and friends, illegally buying medications at school or work, and often "doctor shopping" to find multiple physicians to prescribe the same medication, without knowledge of other prescribers.

Increasingly, law enforcement is holding physicians responsible for prescribing controlled substances without fully establishing patient controls, such as a patient "drug contract." Concerned physicians are educating themselves on how to identify medication-seeking behavior in their patients, and are becoming familiar with "red flags" that would alert them to potential prescription drug abuse.

As a value judgment

Philip Jenkins claims that there are two issues with the term "drug abuse". First, what constitutes a "drug" is debatable. For instance, GHB, a naturally occurring substance in the central nervous system is considered a drug, and is illegal in many countries, while nicotine is not officially considered a drug in most countries. Second, the word "abuse" implies a recognized standard of use for any substance. Drinking an occasional glass of wine is considered acceptable in most Western countries, while drinking several bottles is seen as an abuse. Strict temperance advocates, who may or may not be religiously motivated, would see drinking even one glass as an abuse. Some groups even condemn caffeine use in any quantity. Similarly, adopting the view that any (recreational) use of cannabis or substituted amphetamines constitutes drug abuse implies a decision made that the substance is harmful, even in minute quantities. In the U.S., drugs have been legally classified into five categories, schedule I, II, III, IV, or V in the Controlled Substances Act. The drugs are classified on their deemed potential for abuse. Usage of some drugs is strongly correlated. For example, the consumption of seven illicit drugs (amphetamines, cannabis, cocaine, ecstasy, legal highs, LSD, and magic mushrooms) is correlated and the Pearson correlation coefficient r>0.4 in every pair of them; consumption of cannabis is strongly correlated (r>0.5) with usage of nicotine (tobacco), heroin is correlated with cocaine (r>0.4), methadone (r>0.45), and strongly correlated with crack (r>0.5)

Signs and symptoms

Depending on the actual compound, drug abuse including alcohol may lead to health problems, social problems, morbidity, injuries, unprotected sex, violence, deaths, motor vehicle accidents, homicides, suicides, physical dependence or psychological addiction.

There is a high rate of suicide in alcoholics and other drug abusers. The reasons believed to cause the increased risk of suicide include the long-term abuse of alcohol and other drugs causing physiological distortion of brain chemistry as well as the social isolation. Another factor is the acute intoxicating effects of the drugs may make suicide more likely to occur. Suicide is also very common in adolescent alcohol abusers, with 1 in 4 suicides in adolescents being related to alcohol abuse. In the USA approximately 30% of suicides are related to alcohol abuse. Alcohol abuse is also associated with increased risks of committing criminal offences including child abuse, domestic violence, rapes, burglaries and assaults.

Drug abuse, including alcohol and prescription drugs, can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and also during the withdrawal state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. A protracted withdrawal syndrome can also occur with symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use. Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use.

Cannabis may trigger panic attacks during intoxication and with continued use, it may cause a state similar to dysthymia. Researchers have found that daily cannabis use and the use of high-potency cannabis are independently associated with a higher chance of developing schizophrenia and other psychotic disorders. Severe anxiety and depression are commonly induced by sustained alcohol abuse, which in most cases abates with prolonged abstinence. Even sustained moderate alcohol use may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence.

Drug abuse makes central nervous system (CNS) effects, which produce changes in mood, levels of awareness or perceptions and sensations. Most of these drugs also alter systems other than the CNS. Some of these are often thought of as being abused. Some drugs appear to be more likely to lead to uncontrolled use than others.

Impulsivity

Impulsivity is characterized by actions based on sudden desires, whims, or inclinations rather than careful thought. Individuals with substance abuse have higher levels of impulsivity, and individuals who use multiple drugs tend to be more impulsive. A number of studies using the Iowa gambling task as a measure for impulsive behavior found that drug using populations made more risky choices compared to healthy controls. There is a hypothesis that the loss of impulse control may be due to impaired inhibitory control resulting from drug induced changes that take place in the frontal cortex. The neurodevelopmental and hormonal changes that happen during adolescence may modulate impulse control that could possibly lead to the experimentation with drugs and may lead to the road of addiction. Impulsivity is thought to be a facet trait in the neuroticism personality domain (overindulgence/negative urgency) which is prospectively associated with the development of substance abuse.

Screening and assessment

There are several different screening tools that have been validated for use with adolescents such as the CRAFFT Screening Test and in adults the CAGE questionnaire.

Psychological

From the applied behavior analysis literature, behavioral psychology, and from randomized clinical trials, several evidenced based interventions have emerged: behavioral marital therapy, motivational Interviewing, community reinforcement approach, exposure therapy, contingency management

They help suppress cravings and mental anxiety, improve focus on treatment and new learning behavioral skills, ease withdrawal symptoms and reduce the chances of relapse.

In children and adolescents, cognitive behavioral therapy (CBT) and family therapy currently has the most research evidence for the treatment of substance abuse problems. Well-established studies also include ecological family-based treatment and group CBT. These treatments can be administered in a variety of different formats, each of which has varying levels of research support Research has shown that what makes group CBT most effective is that it promotes the development of social skills, developmentally appropriate emotional regulatory skills and other interpersonal skills. A few integrated treatment models, which combines parts from various types of treatment, have also been seen as both well-established or probably effective. A study on maternal alcohol and drug use has shown that integrated treatment programs have produced significant results, resulting in higher negative results on toxicology screens. Additionally, brief school-based interventions have been found to be effective in reducing adolescent alcohol and cannabis use and abuse. Motivational interviewing can also be effective in treating substance use disorder in adolescents.

Alcoholics Anonymous and Narcotics Anonymous are one of the most widely known self-help organizations in which members support each other not to use alcohol.

Social skills are significantly impaired in people suffering from alcoholism due to the neurotoxic effects of alcohol on the brain, especially the prefrontal cortex area of the brain. It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious, including managing the social environment.

Medication

Pharmacological therapy – A number of medications have been approved for the treatment of substance abuse. These include replacement therapies such as buprenorphine and methadone as well as antagonist medications like disulfiram and naltrexone in either short acting, or the newer long acting form. Several other medications, often ones originally used in other contexts, have also been shown to be effective including bupropion and modafinil.

Methadone and buprenorphine are sometimes used to treat opiate addiction. These drugs are used as substitutes for other opioids and still cause withdrawal symptoms.

Antipsychotic medications have not been found to be useful.

Acamprostate is a glutamatergic NMDA antagonist, which helps with alcohol withdrawal symptoms because alcohol withdrawal is associated with a hyperglutamatergic system.

Dual diagnosis

It is common for individuals with drugs use disorder to have other psychological problems. The terms “dual diagnosis” or “co-occurring disorders,” refer to having a mental health and substance use disorder at the same time. According to the British Association for Psychopharmacology (BAP), “symptoms of psychiatric disorders such as depression, anxiety and psychosis are the rule rather than the exception in patients misusing drugs and/or alcohol.”

Individuals who have a comorbid psychological disorder often have a poor prognosis if either disorder is untreated. Historically most individuals with dual diagnosis either received treatment only for one of their disorders or they didn’t receive any treatment all. However, since the 1980s, there has been a push towards integrating mental health and addiction treatment. In this method, neither condition is considered primary and both are treated simultaneously by the same provider.

Epidemiology

The initiation of drug and alcohol use is most likely to occur during adolescence, and some experimentation with substances by older adolescents is common. For example, results from 2010 Monitoring the Future survey, a nationwide study on rates of substance use in the United States, show that 48.2% of 12th graders report having used an illicit drug at some point in their lives. In the 30 days prior to the survey, 41.2% of 12th graders had consumed alcohol and 19.2% of 12th graders had smoked tobacco cigarettes. In 2009 in the United States about 21% of high school students have taken prescription drugs without a prescription. And earlier in 2002, the World Health Organization estimated that around 140 million people were alcohol dependent and another 400 million with alcohol-related problems.

Studies have shown that the large majority of adolescents will phase out of drug use before it becomes problematic. Thus, although rates of overall use are high, the percentage of adolescents who meet criteria for substance abuse is significantly lower (close to 5%). According to BBC, "Worldwide, the UN estimates there are more than 50 million regular users of morphine diacetate (heroin), cocaine and synthetic drugs."

APA, AMA, and NCDA

In 1932, the American Psychiatric Association created a definition that used legality, social acceptability, and cultural familiarity as qualifying factors:

…as a general rule, we reserve the term drug abuse to apply to the illegal, nonmedical use of a limited number of substances, most of them drugs, which have properties of altering the mental state in ways that are considered by social norms and defined by statute to be inappropriate, undesirable, harmful, threatening, or, at minimum, culture-alien."

In 1966, the American Medical Association's Committee on Alcoholism and Addiction defined abuse of stimulants (amphetamines, primarily) in terms of 'medical supervision':

…'use' refers to the proper place of stimulants in medical practice; 'misuse' applies to the physician's role in initiating a potentially dangerous course of therapy; and 'abuse' refers to self-administration of these drugs without medical supervision and particularly in large doses that may lead to psychological dependency, tolerance and abnormal behavior.

In 1973, the National Commission on Marijuana and Drug Abuse stated:

...drug abuse may refer to any type of drug or chemical without regard to its pharmacologic actions. It is an eclectic concept having only one uniform connotation: societal disapproval. ... The Commission believes that the term drug abuse must be deleted from official pronouncements and public policy dialogue. The term has no functional utility and has become no more than an arbitrary codeword for that drug use which is presently considered wrong.

DSM

The first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (published in 1952) grouped alcohol and drug abuse under Sociopathic Personality Disturbances, which were thought to be symptoms of deeper psychological disorders or moral weakness.

The third edition, published in 1980, was the first to recognize substance abuse (including drug abuse) and substance dependence as conditions separate from substance abuse alone, bringing in social and cultural factors. The definition of dependence emphasised tolerance to drugs, and withdrawal from them as key components to diagnosis, whereas abuse was defined as "problematic use with social or occupational impairment" but without withdrawal or tolerance.

In 1987, the DSM-IIIR category "psychoactive substance abuse," which includes former concepts of drug abuse is defined as "a maladaptive pattern of use indicated by...continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the use (or by) recurrent use in situations in which it is physically hazardous." It is a residual category, with dependence taking precedence when applicable. It was the first definition to give equal weight to behavioural and physiological factors in diagnosis.

By 1988, the DSM-IV defines substance dependence as "a syndrome involving compulsive use, with or without tolerance and withdrawal"; whereas substance abuse is "problematic use without compulsive use, significant tolerance, or withdrawal." Substance abuse can be harmful to your health and may even be deadly in certain scenarios

By 1994, The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association, the DSM-IV-TR, defines substance dependence as "when an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed." followed by criteria for the diagnose

DSM-IV-TR defines substance abuse as:

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household)
2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

The fifth edition of the DSM (DSM-5), planned for release in 2013, is likely to have this terminology revisited yet again. Under consideration is a transition from the abuse/dependence terminology. At the moment, abuse is seen as an early form or less hazardous form of the disease characterized with the dependence criteria. However, the APA's 'dependence' term, as noted above, does not mean that physiologic dependence is present but rather means that a disease state is present, one that most would likely refer to as an addicted state. Many involved recognize that the terminology has often led to confusion, both within the medical community and with the general public. The American Psychiatric Association requests input as to how the terminology of this illness should be altered as it moves forward with DSM-5 discussion.

Legal approaches

Related articles: Drug control law, Prohibition (drugs), Arguments for and against drug prohibition, Harm reduction

Most governments have designed legislation to criminalize certain types of drug use. These drugs are often called "illegal drugs" but generally what is illegal is their unlicensed production, distribution, and possession. These drugs are also called "controlled substances". Even for simple possession, legal punishment can be quite severe (including the death penalty in some countries). Laws vary across countries, and even within them, and have fluctuated widely throughout history.

Attempts by government-sponsored drug control policy to interdict drug supply and eliminate drug abuse have been largely unsuccessful. In spite of the huge efforts by the U.S., drug supply and purity has reached an all-time high, with the vast majority of resources spent on interdiction and law enforcement instead of public health. In the United States, the number of nonviolent drug offenders in prison exceeds by 100,000 the total incarcerated population in the EU, despite the fact that the EU has 100 million more citizens.

Despite drug legislation (or perhaps because of it), large, organized criminal drug cartels operate worldwide. Advocates of decriminalization argue that drug prohibition makes drug dealing a lucrative business, leading to much of the associated criminal activity.

Cost

Policymakers try to understand the relative costs of drug-related interventions. An appropriate drug policy relies on the assessment of drug-related public expenditure based on a classification system where costs are properly identified.

Labelled drug-related expenditures are defined as the direct planned spending that reflects the voluntary engagement of the state in the field of illicit drugs. Direct public expenditures explicitly labeled as drug-related can be easily traced back by exhaustively reviewing official accountancy documents such as national budgets and year-end reports. Unlabelled expenditure refers to unplanned spending and is estimated through modeling techniques, based on a top-down budgetary procedure. Starting from overall aggregated expenditures, this procedure estimates the proportion causally attributable to substance abuse (Unlabelled Drug-related Expenditure = Overall Expenditure × Attributable Proportion). For example, to estimate the prison drug-related expenditures in a given country, two elements would be necessary: the overall prison expenditures in the country for a given period, and the attributable proportion of inmates due to drug-related issues. The product of the two will give a rough estimate that can be compared across different countries.

Europe

As part of the reporting exercise corresponding to 2005, the European Monitoring Centre for Drugs and Drug Addiction's network of national focal points set up in the 27 European Union (EU) Member States, Norway, and the candidates countries to the EU, were requested to identify labeled drug-related public expenditure, at the country level.

This was reported by 10 countries categorized according to the functions of government, amounting to a total of EUR 2.17 billion. Overall, the highest proportion of this total came within the government functions of Health (66%) (e.g. medical services), and Public Order and Safety (POS) (20%) (e.g. police services, law courts, prisons). By country, the average share of GDP was 0.023% for Health, and 0.013% for POS. However, these shares varied considerably across countries, ranging from 0.00033% in Slovakia, up to 0.053% of GDP in Ireland in the case of Health, and from 0.003% in Portugal, to 0.02% in the UK, in the case of POS; almost a 161-fold difference between the highest and the lowest countries for Health, and a 6-fold difference for POS. Why do Ireland and the UK spend so much in Health and POS, or Slovakia and Portugal so little, in GDP terms?

To respond to this question and to make a comprehensive assessment of drug-related public expenditure across countries, this study compared Health and POS spending and GDP in the 10 reporting countries. Results found suggest GDP to be a major determinant of the Health and POS drug-related public expenditures of a country. Labelled drug-related public expenditure showed a positive association with the GDP across the countries considered: r = 0.81 in the case of Health, and r = 0.91 for POS. The percentage change in Health and POS expenditures due to a one percent increase in GDP (the income elasticity of demand) was estimated to be 1.78% and 1.23% respectively.

Being highly income elastic, Health and POS expenditures can be considered luxury goods; as a nation becomes wealthier it openly spends proportionately more on drug-related health and public order and safety interventions.

UK

The UK Home Office estimated that the social and economic cost of drug abuse to the UK economy in terms of crime, absenteeism and sickness is in excess of £20 billion a year. However, the UK Home Office does not estimate what portion of those crimes are unintended consequences of drug prohibition (crimes to sustain expensive drug consumption, risky production and dangerous distribution), nor what is the cost of enforcement. Those aspects are necessary for a full analysis of the economics of prohibition.

United States

These figures represent overall economic costs, which can be divided in three major components: health costs, productivity losses and non-health direct expenditures.

Health-related costs were projected to total $16 billion in 2002.

Productivity losses were estimated at $128.6 billion. In contrast to the other costs of drug abuse (which involve direct expenditures for goods and services), this value reflects a loss of potential resources: work in the labor market and in household production that was never performed, but could reasonably be expected to have been performed absent the impact of drug abuse.

Included are estimated productivity losses due to premature death ($24.6 billion), drug abuse-related illness ($33.4 billion), incarceration ($39.0 billion), crime careers ($27.6 billion) and productivity losses of victims of crime ($1.8 billion).

The non-health direct expenditures primarily concern costs associated with the criminal justice system and crime victim costs, but also include a modest level of expenses for administration of the social welfare system. The total for 2002 was estimated at $36.4 billion. The largest detailed component of these costs is for state and federal corrections at $14.2 billion, which is primarily for the operation of prisons. Another $9.8 billion was spent on state and local police protection, followed by $6.2 billion for federal supply reduction initiatives.

According to a report from the Agency for Healthcare Research and Quality (AHRQ), Medicaid was billed for a significantly higher number of hospitals stays for Opioid drug overuse than Medicare or private insurance in 1993. By 2012, the differences were diminished. Over the same time, Medicare had the most rapid growth in number of hospital stays.

Immigrants and refugees

Immigrant and refugees have often been under great stress, physical trauma and depression and anxiety due to separation from loved ones often characterize the pre-migration and transit phases, followed by "cultural dissonance," language barriers, racism, discrimination, economic adversity, overcrowding, social isolation, and loss of status and difficulty obtaining work and fears of deportation are common. Refugees frequently experience concerns about the health and safety of loved ones left behind and uncertainty regarding the possibility of returning to their country of origin. For some, substance abuse functions as a coping mechanism to attempt to deal with these stressors.

Immigrants and refugees may bring the substance use and abuse patterns and behaviors of their country of origin, or adopt the attitudes, behaviors, and norms regarding substance use and abuse that exist within the dominant culture into which they are entering.

Street children

Street children in many developing countries are a high risk group for substance misuse, in particular solvent abuse. Drawing on research in Kenya, Cottrell-Boyce argues that "drug use amongst street children is primarily functional – dulling the senses against the hardships of life on the street – but can also provide a link to the support structure of the ‘street family’ peer group as a potent symbol of shared experience."

Musicians

In order to maintain high-quality performance, some musicians take chemical substances. As a group they have a higher rate of substance abuse. The most common chemical substance which is abused by pop musicians is cocaine, because of its neurological effects. Stimulants like cocaine increase alertness and cause feelings of euphoria, and can therefore make the performer feel as though they in some ways ‘own the stage’.

Another way in which substance abuse is harmful for a performer (musicians especially) is if the substance being abused is aspirated. The lungs are an important organ used by singers, and addiction to cigarettes may seriously harm the quality of their performance. Smoking causes harm to alveoli, which are responsible for absorbing oxygen.

Veterans

Substance abuse can be another contributing factor that affects physical and mental health of veterans. Substance abuse may also damage personal relationships families and lead to financial difficulty. There is evidence to suggest that substance abuse disproportionately affects the homeless veteran population. A 2015 Florida study compared causes of homelessness between veterans and non veteran populations in a self reporting questionnaire. The results from the study found that 17.8% of the homeless veteran participants attributed their homelessness to alcohol and drug related problems compared to just 3.7% of the non-veteran homeless group.

A 2003 study found that homelessness was associated with access to support from family/friends and services. However, this relationship was not true when comparing homeless participants who had a current substance-use disorders. The U.S. Department of Veterans Affairs provide a summary of treatment options for veterans with substance use disorder. For treatments that do not involve medication, they offer a therapeutic options that focused on finding outside support groups and “looking at how substance use problems may relate to other problems such as PTSD and depression”.