Substance Abuse and Dependence

Definition

Substance abuse and dependence refer to any continued pathological use of a medication, non-medically indicated drug (called drugs of abuse), or toxin. They normally are distinguished as follows.Substance abuse is any pattern of substance use that results in repeated adverse social consequences related to drug-taking—for example, interpersonal conflicts, failure to meet work, family, or school obligations, or legal problems. Substance dependence, commonly known as addiction, is characterized by physiological and behavioral symptoms related to substance use. These symptoms include the need for increasing amounts of the substance to maintain desired effects, withdrawal if drug-taking ceases, and a great deal of time spent in activities related to substance use.Substance abuse is more likely to be diagnosed among those who have just begun taking drugs and is often an early symptom of substance dependence. However, substance dependence can appear without substance abuse, and substance abuse can persist for extended periods of time without a transition to substance dependence.

Description

Substance abuse and dependence are disorders that affect all population groups although specific patterns of abuse and dependence vary with age, gender, culture, and socioeconomic status. According to data from the National Longitudinal Alcohol Epidemiologic Survey, 13.3% of a survey group of Americans exhibited symptoms of alcohol dependence during their lifetime, and 4.4% exhibited symptoms of alcohol dependence during the past 12 months. According to the 1997 National Household Survey on Drug Abuse, 6.4% of those surveyed had used an illicit drug in the past month.Although substance dependence can begin at any age, to people aged 18 to 24 have relatively high substance use rates, and dependence often arises sometime during the ages of 20 to 49. Gender proportions vary according to the class of drugs, but substance use disorders are in general more frequently seen in men. A 2004 report revealed that in a 2002 national survey, more than 2.6 million youths age 12 to 17 had used inhalants more than once.In addition to being an individual health disorder, substance abuse and dependence may be viewed as a public health problem with far-ranging health, economic, and adverse social implications. Substance-related disorders are associated with teen pregnancy and the transmission of sexually transmitted diseases (STDs), as well as failure in school, unemployment, domestic violence, homelessness, and crimes such as rape and sexual assault, aggravated assault, robbery, burglary, and larceny. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the estimated cost of alcohol-related disorders alone (including health care expenditures, lost productivity, and premature death) was $166.5 billion in 1995.The term substance, when discussed in the context of substance abuse and dependence, refers to medications, drugs of abuse, and toxins. These substances have an intoxicating effect, desired by the user, which can have either stimulating (speeding up) or depressive/sedating (slowing down) effects on the body. Substance dependence and/or abuse can involve any of the following 10 classes of substances:

alcohol
amphetamines (including "crystal meth," some medications used in the treatment of attention deficit disorder [ADD], and amphetamine-like substances found in appetite suppressants)
cannibis (including marijuana and hashish)
cocaine (including "crack")
hallucinogens (including LSD, mescaline, and MDMA ["ecstasy"])
inhalants (including compounds found in gasoline, glue, and paint thinners)
nicotine (substance dependence only)
opioids (including morphine, heroin, codeine, methadone, oxycodone [Oxycontin (TM)])
phencyclidine (including PCP, angel dust, ketamine)
sedative, hypnotic, and anxiolytic (anti-anxiety) substances (including benzodiazepines such as valium, barbiturates, prescription sleeping medications, and most prescription anti-anxiety medications)

Caffeine has been identified as a substance in this context, but as yet there is insufficient evidence to establish whether caffeine-related symptoms fall under substance abuse and dependence.Substances of abuse may thus be illicit drugs, readily available substances such as alcohol or glue, over-the-counter drugs, or prescription medications. In many cases, a prescription medication that becomes a substance of abuse may have been a legal, medically indicated prescription for the user, but the pattern of use diverges from the use prescribed by the physician.

Frequency Of Substance Abuse By Gender And Age
Men
Ages 18 to 29	17 to 24 percent
Ages 30 to 44	11 to 14 percent
Ages 45 to 64	6 to 8 percent
Over age 65	1 to 3 percent
Women
Ages 18 to 29	4 to 10 percent
Ages 30 to 44	2 to 4 percent
Ages 45 to 64	1 to 2 percent
Over age 65	less than 1 percent

Causes and symptoms

Causes

The causes of substance dependence are not well established, but three factors are believed to contribute to substance-related disorders: genetic factors, psychopathology, and social learning. In genetic epidemiological studies of alcoholism, the probability of identical twins both exhibiting alcohol dependence was significantly greater than with fraternal twins, thus suggesting a genetic component in alcoholism. It is unclear, however, whether the genetic factor is related to alcoholism directly, or whether it is linked to other psychiatric disorders that are known to be associated with substance abuse. For example, there is evidence that alcoholic males from families with depressive disorders tend to have more severe courses of substance dependence than alcoholic men from families without such family histories.These and other findings suggest substance use may be way to relieve the symptoms of a psychological disorder. In this model, unless the underlying pathology is treated, attempts to permanently stop substance dependence are ineffective. Psychopathologies that are associated with substance dependence include antisocial personality disorder, bipolar disorder, depression, anxiety disorder, and schizophrenia.A third factor related to substance dependence is social environment. In this model, drug-taking is essentially a socially learned behavior. Local social norms determine the likelihood that a person is exposed to the substance and whether continued use is reinforced. For example, individuals may, by observing family or peer role models, learn that substance use is a normal way to relieve daily stresses. External penalties, such as legal or social sanctions, may reduce the likelihood of substance use.At the level of neurobiology, it is believed that substances of abuse operate through similar pathways in the brain. The chemical changes induced by the stimulation of these pathways by initial use of the substance lead to the desire to continue substance use, and eventual substance dependence.

Symptoms

The DSM-IV-TR identifies seven criteria (symptoms), at least three of which must be met during a given 12-month period, for the diagnosis of substance dependence:

Tolerance, as defined either by the need for increasing amounts of the substance to obtain the desired effect or by experiencing less effect with extended use of the same amount of the substance.
Withdrawal, as exhibited either by experiencing unpleasant mental, physiological, and emotional changes when drug-taking ceases or by using the substance as a way to relieve or prevent withdrawal symptoms.
Longer duration of taking substance or use in greater quantities than was originally intended.
Persistent desire or repeated unsuccessful efforts to stop or lessen substance use.
A relatively large amount of time spent in securing and using the substance, or in recovering from the effects of the substance.
Important work and social activities reduced because of substance use.
Continued substance use despite negative physical and psychological effects of use.

Although not explicitly listed in the DSM-IV-TR criteria, "craving," or the overwhelming desire to use the substance regardless of countervailing forces, is a universally-reported symptom of substance dependence.Symptoms of substance abuse, as specified by DSM-IV-TR, include one or more of the following occurring during a given 12-month period:

Substance use resulting in a recurrent failure to fulfill work, school, or home obligations (work absences, substance-related school suspensions, neglect of children).
Substance use in physically hazardous situations such as driving or operating machinery.

Substance use resulting in legal problems such as drug-related arrests.
Continued substance use despite negative social and relationship consequences of use.

In addition to the general symptoms, there are other physical signs and symptoms of substance abuse that are related to specific drug classes:

Signs and symptoms of alcohol intoxication include such physical signs as slurred speech, lack of coordination, unsteady gait, memory impairment, and stupor, as well as behavior changes shortly after alcohol ingestion, including inappropriate aggressive behavior, mood volatility, and impaired functioning.
Amphetamine users may exhibit rapid heartbeat, elevated or depressed blood pressure, dilated (enlarged) pupils, weight loss, as well as excessively high energy, inability to sleep, confusion, and occasional paranoid psychotic behavior.
Cannibis users may exhibit red eyes with dilated pupils, increased appetite, dry mouth, and rapid pulse; they may also be sluggish and slow to react.
Cocaine users may exhibit rapid heart rate, elevated or depressed blood pressure, dilated pupils, weight loss, in addition to wide variations in their energy level, severe mood disturbances, psychosis, and paranoia.
Users of hallucinogens may exhibit anxiety or depression, paranoia, and unusual behavior in response to hallucinations (imagined sights, voices, sounds, or smells that appear real). Signs include dilated pupils, rapid heart rate, tremors, lack of coordination, and sweating. Flashbacks, or the re-experiencing of a hallucination long after stopping substance use, are also a symptom of hallucinogen use.
Users of inhalants experience dizziness, spastic eye movements, lack of coordination, slurred speech, and slowed reflexes. Associated behaviors may include belligerence, tendency toward violence, apathy, and impaired judgment.
Opioid drug users exhibit slurred speech, drowsiness, impaired memory, and constricted (small) pupils. They may appear slowed in their physical movements.
Phencyclidine users exhibit spastic eye movements, rapid heartbeat, decreased sensitivity to pain, and lack of muscular coordination. They may show belligerence, predisposition to violence, impulsiveness, and agitation.
Users of sedative, hypnotic, or anxiolytic drugs show slurred speech, unsteady gait, inattentiveness, and impaired memory. They may display inappropriate behavior, mood volatility, and impaired functioning.

Other signs are related to the form in which the substance is used. For example, heroin, certain other opioid drugs, and certain forms of cocaine may be injected. A person using an injectable substance may have "track marks" (outwardly visible signs of the site of an injection, with possible redness and swelling of the vein in which the substance was injected). Furthermore, poor judgment brought on by substance use can result in the injections being made under dangerously unhygienic conditions. These unsanitary conditions and the use of shared needles are risk factors for major infections of the heart, as well as infection with HIV (the virus that causes AIDS), certain forms of hepatitis (a liver infection), and tuberculosis.Cocaine is often taken as a powdery substance which is "snorted" through the nose. This can result in frequent nosebleeds, sores in the nose, and even erosion (an eating away) of the nasal septum (the structure that separates the two nostrils).Overdosing on a substance is a frequent complication of substance abuse. Drug overdose can be purposeful (with suicide as a goal), or due to carelessness, the unpredictable strength of substances purchased from street dealers, mixing of more than one type of substance, or as a result of the increasing doses that a person must take to experience intoxicating effects. Substance overdose can be a life-threatening emergency, with the specific symptoms depending on the type of substance used. Substances with depressive effects may dangerously slow the breathing and heart rate, drop the body temperature, and result in a general unresponsiveness. Substances with stimulatory effects may dangerously increase the heart rate and blood pressure, produce abnormal heart rhythms, increase body temperature, induce seizures, and cause erratic behavior.

Diagnosis

Tools used in the diagnosis of substance dependence include screening questionnaires and patient histories, physical examination, and laboratory tests. A simple and popular screening tool is the CAGE questionnaire. CAGE refers to the first letters of each word that forms the basis of each of the four questions of the screening exam:

Substance abuse often causes a variety of medical abnormalities and conditions throughout the body, as shown in the illustration above. (Illustration by Electronic Illustrators Group.)

Have you ever tried to Cut down on your substance use?
Have you ever been Annoyed by people trying to talk to you about your substance use?
Do you ever feel Guilty about your substance use?
Do you ever need an Eye opener (use of the substance first thing in the morning) in order to start your day?

A "yes" answer to two or more of these questions is an indication that the individual should be referred for more thorough work-up for substance dependency or abuse.In addition to CAGE, other screening questionnaires are available. Some are designed for particular population groups such as pregnant women, and others are designed to more thoroughly assess the severity of substance dependence. These questionnaires, known by their acronyms, include AUDIT, HSS, HSQ, PRIME-MD, ACE, TWEAK, s-MAST, and SADD. There is some variability among questionnaires in terms of how accurately and comprehensively they can identify individuals as substance dependent.Patient history, as taken through the direct interview, is important for identifying physical symptoms and psychiatric factors related to substance use. Family history of alcohol or other substance dependency is also useful for diagnosis.A physical examination may reveal signs of substance abuse. These signs are specific to the substances used, as well as needle marks, tracks, or nasal erosion.With the individual's permission, substance use can be detected through laboratory testing of his or her blood, urine, or hair. Laboratory testing, however, may be limited by the sensitivity and specificity of the testing method, and by the time elapsed since the person last used the drug.One of the most difficult aspects of diagnosis involves overcoming the patient's denial. Denial is a psychological state during which a person is unable to acknowledge the (usually negative) circumstances of a situation. In this case, denial leads a person to underestimate the degree of substance use and of the problems associated with substance use.

Treatment

According to the American Psychiatric Association, there are three goals for the treatment of people with substance use disorders: (1) the patient abstains from or reduces the use and effects of the substance; (2) the patient reduces the frequency and severity of relapses; and (3) the patient develops the psychological and emotional skills necessary to restore and maintain personal, occupational, and social functioning.In general, before treatment can begin, many treatment centers require that the patient undergo detoxification. Detoxification is the process of weaning the patient from his or her regular substance use. Detoxification can be accomplished "cold turkey," by complete and immediate cessation of all substance use, or by slowly decreasing (tapering) the dose which a person is taking, to minimize the side effects of withdrawal. Some substances must be tapered because "cold turkey" methods of detoxification are potentially life threatening. In some cases, medications may be used to combat the unpleasant and threatening physical and psychological symptoms of withdrawal. For example, methadone is used to help patients adjust to the tapering of heroin use.Treatment itself consists of three parts: (1) assessment; (2) formulation of a treatment plan; (3) psychiatric management. The first step in treatment is a comprehensive medical and psychiatric evaluation of the patient. This evaluation includes:

a history of the patient's past and current substance use, and its cognitive, psychological, physiological, and behavioral effects
a medical and psychiatric history and examination
a history of psychiatric treatments and outcomes
a family and social history
screening of blood, breath, or urine for substances
other laboratory tests to determine the presence of other conditions commonly found with substance use disorders

After the assessment is made, a treatment plan is formulated. Treatment plans vary according to the needs of the specific patient and can change for the same patient as he or she undergoes different phases of the disorder. Plans typically involve the following elements: (1) a strategy for the psychiatric management of the patient; (2) a strategy for reducing effects or use of substances, or for abstinence; (3) efforts to ensure compliance with the treatment program and to prevent relapse; (4) treatments for other conditions associated with substance use. Initial therapy and treatment setting (hospital, residential treatment, partial hospitalization, outpatient) decisions are made as part of the treatment plan, but because substance use disorders are considered a chronic condition requiring long-term care, these plans can and do change through the course of treatment.The third step, psychiatric management of the patient, is the implementation of the treatment plan. Psychiatric management of the patient includes establishing a trusting relationship between clinician and patient; monitoring the patient's progress; managing the patient's relapses and withdrawal; diagnosing and treating associated psychiatric disorders; and helping the patient adhere to the treatment plan through therapy and the development of skills and social interactions that reinforce a drug-free lifestyle.As part of the treatment process, patients typically undergo psychosocial therapy and, in some cases, pharmacologic treatment. Psychosocial therapeutic modalities include cognitive-behavioral therapy, behavioral therapy, individual psychodynamic or interpersonal therapy, group therapy, family therapy, and self-help groups. Pharmacologic treatment may include medications that ease withdrawal symptoms, reduce craving, interact negatively with substances of abuse to discourage drug-taking, or treat associated psychiatric disorders.

Alternative treatment

The efficacy of alternative treatments for substance use disorders remains for the most part ambiguous. One treatment that has been recently shown to have variable success is the use of acupuncture in treating substance dependence. In 2000, a randomized controlled trial of the effect of acupuncture on cocaine addiction reported that acupuncture significantly reduced the cocaine use of study participants. A 1999 meta-analysis (summary analysis of studies), however, reported that acupuncture had no statistically significant effect on smoking cessation.There has been movement toward examining some touted treatments in more rigorous clinical trials. In particular, there has been some interest in Pueraria lobata, or kudzu, an herb that has reputedly been used in Chinese medicine to treat alcoholism. Preclinical trials of an herbal formula with kudzu have shown that increased consumption of the herbal formula is associated with decreased consumption of alcohol. Toxicity studies show few ill effects of the formula, and human trials are currently being undertaken to more fully evaluate the efficacy of this treatment.The effectiveness of electroacupuncture (the practice of acupuncture accompanied by the application of low levels of electrical current at acupuncture points) in alleviating opiate withdrawal symptoms is also being examined. Preclinical trials suggest that electroacupuncture treatment given prior to the administration of naxolone seems to alleviate the withdrawal effects of naxolone.

Prognosis

Recovery from substance use is notoriously difficult, even with exceptional treatment resources. Although relapse rates are difficult to accurately obtain, the NIAAA cites evidence that 90% of alcohol dependent users experience at least one relapse within the 4 years after treatment. Relapse rates for heroin and nicotine users are believed to be similar. Certain pharmacological treatments, however, have been shown to reduce relapse rates.Relapses are most likely to occur within the first 12 months of having discontinued substance use. Triggers for relapses can include any number of life stresses (problems on the job or in the marriage, loss of a relationship, death of a loved one, financial stresses), in addition to seemingly mundane exposure to a place or an acquaintance associated with previous substance use.The development of adaptive life skills and ongoing drug-free social support are believed to be two important factors in avoiding relapse. The effect of the support group Alcoholics Anonymous has been intensively studied, and a 1996 meta-analysis noted that long-term sobriety appears to be positively related to Alcoholics Anonymous attendance and involvement. Support for family members in addition to support for the individual in recovery is also important. Because substance dependence has a serious impact on family functioning, and because family members may inadvertently maintain behaviors that initially led to the substance dependence, ongoing therapy and support for family members should not be neglected.

Prevention

Prevention is best aimed at teenagers and young adults aged 18-24 who are at very high risk for substance experimentation. Prevention programs should include an education component that outlines the risks and consequences of substance use and a training component that gives advice on how to resist peer pressure to use drugs.Furthermore, prevention programs should work to identify and target children who are at relatively higher risk for substance abuse. This group includes victims of physical or sexual abuse, children of parents who have a history of substance abuse, and children with poor school performance and/or attention deficit disorder. These children may require more intensive intervention.

Key terms

Addiction — The state of being both physically and psychologically dependent on a substance.Dependence — A state in which a person requires a steady concentration of a particular substance to avoid experiencing withdrawal symptoms.Detoxification — A process whereby an addict is withdrawn from a substance.Intoxication — The desired mental, physical, or emotional state produced by a substance.Street drug — A substance purchased from a drug dealer; may be a legal substance, sold illicitly (without a prescription, and not for medical use), or it may be a substance that is illegal to possess.Tolerance — A phenomenon whereby a drug user becomes physically accustomed to a particular dose of a substance, and requires increasing dosages in order to obtain the same effects.Withdrawal — Those side effects experienced by a person who has become physically dependent on a substance, upon decreasing the substance's dosage or discontinuing its use.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, DC: American Psychiatric Association, 2000.

Periodicals

"Inhalant Abuse Becomes Focus of SAMHSA Guidelines, Prevention Effors." Alcoholism & Drug Abuse Weekly March 22, 2004: 1-4.Schneider, Robert K., James L. Levenson, and Sidney H. Schnoll. "Update in Addiction Medicine." Annals of Internal Medicine 134 (March 6, 2001): 387-395.