Substance Abuse

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Substance abuse, also known as drug abuse, is a patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others, and is a form of substance-related disorder. Widely differing definitions of drug abuse are used in public health, medical and criminal justice contexts. In some cases criminal or anti-social behavior occurs when the person is under the influence of a drug, and long term personality changes in individuals may occur as well.[2] In addition to possible physical, social, and psychological harm, use of some drugs may also lead to criminal penalties, although these vary widely depending on the local jurisdiction.[3]

Drugs most often associated with this term include: alcohol, barbiturates, benzodiazepines, cannabis, cocaine, methaqualone, opioids and substituted amphetamines. The exact cause of substance abuse is not clear, with theories including one of two: either a genetic disposition which is learned from others, or a habit which if addiction develops, it manifests itself as a chronic debilitating disease.[4]

Substance abuse is widespread globally with an estimated 120 million users of hard drugs such as cocaine, heroin, and other synthetic drugs.[citation needed] In 2013 drug use disorders resulted in 127,000 deaths up from 53,000 in 1990.[5] The highest number of deaths are from opioid use disorders at 51,000.[5] Cocaine use disorder resulted in 4,300 deaths and amphetamine use disorder resulted in 3,800 deaths.[5] Alcohol use disorders resulted in an additional 139,000 deaths.[5]

Classification[edit]

Public health definitions[edit]

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[edit]

'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[6] 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.[7] 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.[6]

However, other definitions differ; they may entail psychological or physical dependence,[6] and may focus on treatment and prevention in terms of the social consequences of substance uses.

Drug misuse[edit]

Legal drugs are not necessarily safer. A 2010 study asked drug-harm experts to rank various illegal and legal drugs. Alcohol was found to be the overall most dangerous drug.

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.[8][9] 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.[10]

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.[11] "Nearly 1 in 12 high school seniors reported nonmedical use of Vicodin; 1 in 20 reported abuse of OxyContin."[12] 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.[13]

As a value judgment[edit]

Correlations between drugs usage. Correlations between usage of 18 legal and illegal drugs: alcohol, amphetamines, amyl nitrite, benzodiazepine, cannabis, chocolate, cocaine, caffeine, crack, ecstasy, heroin, ketamine, legal highs, LSD, methadone, magic mushrooms (MMushrooms), nicotine and volatile substance abuse (VSA). Links indicate correlations with absolute values of Pearson correlation coefficient r above 0.4. Medium, strong, and very strong correlations are indicated by the colour of link.[14]

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.[15] 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.[14] 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)[16]

Signs and symptoms[edit]

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.[17]

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.[18] 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.[19]

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.[20] 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.[21][22] 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.[23]

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.[24]

Impulsivity[edit]

Impulsivity is characterized by actions based on sudden desires, whims, or inclinations rather than careful thought.[25] Individuals with substance abuse have higher levels of impulsivity,[26] and individuals who use multiple drugs tend to be more impulsive.[26] 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.[27] 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.[28] 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.[29]

Screening and assessment[edit]

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.

Treatment[edit]

Psychological[edit]

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[30][31]

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.[32]

In children and adolescents, cognitive behavioral therapy (CBT)[33] and family therapy[34] 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.[35] These treatments can be administered in a variety of different formats, each of which has varying levels of research support[36] A few integrated[37] treatment models, which combines parts from various types of treatment, have also been seen as both well-established or probably effective.[35] 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.[37] Additionally, brief school-based interventions have been found to be effective in reducing adolescent alcohol and cannabis use and abuse.[38] Motivational interviewing can also be effective in treating substance use disorder in adolescents.[39][40]

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.[41]

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.[42] It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious,[43] including managing the social environment.

Medication[edit]

Pharmacological therapy - A number of medications have been approved for the treatment of substance abuse.[44] 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.[45] These drugs are used as substitutes for other opioids and still cause withdrawal symptoms.

Antipsychotic medications have not been found to be useful.[46]

Acamprostate[47] is a glutamatergic NMDA antagonist, which helps with alcohol withdrawal symptoms because alcohol withdrawal is associated with a hyperglutamatergic system.

Dual diagnosis[edit]

Main article: Dual diagnosis

It is common for individuals with drugs use disorder to have other psychological problems.[48] 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.”[49]

Individuals who have a comorbid psychological disorder often have a poor prognosis if either disorder is untreated.[48] 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.[49]