Decoding the Thin Line Between Use and Abuse.
Have you ever stopped to think about how often you say "cheers" before a sip
of wine, or the caffeine jolt that fuels your morning? That, my friends, falls
under the umbrella of substance use. But hold on, there s another term lurking
in the shadows: substance abuse. What separates these two concepts? Buckle up,
folks, because it s time to navigate the often-blurry spectrum of substance
consumption.
Substance use is simply the act of consuming a substance that alters
your body or mind. It s as broad as having a glass of wine with dinner, taking
a prescribed medication, or even the occasional energy drink pick-me-up. This
doesn t inherently mean harm, and for many, it s a perfectly normalized part
of life.
Substance abuse, however, steps into trickier territory. It s
characterized by a compulsive use of a substance, despite negative
consequences. Think: missing work due to hangovers, neglecting relationships
for the next fix, or engaging in risky behavior under the influence. This
pattern disrupts daily life, leading to social, emotional, and physical harm.
Remember, the line between "use" and "abuse" can be thin and
fuzzy. It s about recognizing the negative impact a substance has on your life
and well-being. If you or someone you know is struggling with substance abuse,
reach out for help. There are countless resources available, and seeking
support is the first step on the road to recovery.
This blog is just a starting point. It s crucial to remember that individual
experiences with substance use are complex and varied. If you have concerns,
always reach out to a healthcare professional or a trusted mental health
resource for tailored advice and support.
Let s break down the stigma, encourage open conversations, and navigate the
spectrum of substance consumption with understanding and empathy. Together, we
can create a healthier and more supportive environment for everyone.
Substance abuse and addictions results from the misuse of harmful or addictive
substances which include, alcohol, illegal or street drugs, prescription and
over-the-counter medicines, and volatile chemicals.
The resultant problems include both mental and physical illnesses, and family,
housing, employment, and legal difficulties. Treatment of substance abuse
disorder is complex and challenging as the reason for substance abuse and
addiction is unique for each abuser. Further, the family environment and
situation of each abuser is unique. Treatment and management of substance
abuse need to take into account all these. Both psychological and
pharmacological interventions are used that may include detoxification and
substitute prescribing.
The use and misuse of drugs is increasing and affecting our children, youth,
men and women, and the elderly also. In this Unit, you will learn about the
substance abuse disorder, various drugs used, and the assessment and treatment
of substance abuse.
Drug abuse is a maladaptive pattern of drug use leading to clinically
significant impairment or distress, as manifested by one or more of four
symptoms or criteria in a 12-month period.
-
Recurrent drug use may result in a failure to fulfill major role
obligations at work, school, or home. Repeated absences, tardiness, poor
performance, suspensions, or neglect of duties in major life domains
suggests that use has crossed over into abuse.
-
Recurrent drug use in situations in which it is physically hazardous is a
sign of abuse. Operating machinery, driving a car, swimming, or walking in
a dangerous area while under the influence indicates drug abuse.
-
Recurrent drug-related legal problems, such as arrests for disorderly
conduct or DUI [driving under the influence] arrests, are indicative of
abuse.
-
Recurrent use, despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the drug,
is indicative of abuse. For example, getting into arguments or fights with
others, passing out at others’ houses, or acting inappropriately in front
of others (which is disapproved of) is indicative of abuse.
Alternatively, a diagnosis of substance dependence, a more severe disorder,
subsumes a diagnosis of substance abuse. There are seven other criteria that,
if met, constitute substance dependence.
Criteria for Substance Dependence
The criteria for substance dependence, provided by the DSM-IV-TR, include a
maladaptive pattern of drug use leading to clinically significant impairment
or distress, as manifested by three or more of the following seven symptoms
occurring in the same 12-month period.
-
Tolerance is experienced. Tolerance entails a
need for markedly increased amounts of a drug to achieve the desired drug
effect or a markedly diminished effect with continued use of the same
amount of the drug.
-
Withdrawal is experienced. Either a
characteristic withdrawal syndrome occurs when one terminates using the
drug, or the same or a similar drug is taken to relieve or avoid the
syndrome.
-
Larger amounts of the drug are taken over a longer period than was
intended.
For example, an alcohol-dependent individual may intend to drink only two
drinks on a given evening but ends up having 15 drinks, or to “party” over
the weekend but the party lasts for 2 weeks until there is no more money
for alcohol.
-
There exists a persistent desire or unsuccessful effort to cut down
or control drug use.
For example, a drug-dependent individual may decide to control his or her
use but ends up abstaining on some evenings and using in excess on other
evenings.
-
A great deal of time is spent on activities needed to obtain the drug,
use the drug, or recover from its effects.
For example, a person may travel long distances or search all day to
obtain cocaine, use the drug that night, and miss work the next day to
recover and catch some rest. In this scenario, 2 days were spent for 1
night of “getting high.”
-
Important social, occupational, or recreational activities are given up
or reduced because of drug use.
For example, the drug abuser may be very high, passed out, or hung over
much of the time and thus may not spend time with family and friends like
he or she did before becoming dependent.
-
Drug use continues despite knowledge of having a persistent or
recurrent physical or
psychological problem that is
likely to have been caused or worsened by the drug.
For example, someone who becomes paranoid after continued methamphetamine
use and is hospitalized but continues to use it after release from the
hospital exhibits this symptom.
Alternatively, the 10th revision of the International Statistical
Classification of Diseases and Related Health Problems (ICD-IO) provides eight
classifications of consequences from the use of a substance in its section on
mental and
behavioural disorders
due to psychoactive substance use (Chapter 5; F10-F19). The ICD-IO definition
focuses more on the mental or physical health complications and not social,
legal, or environmentally hazardous consequences of abuse, as does the
DSM-IV-TR.
Let us know a few terms that we come across while discussing about substance
abuse and addiction.
a) Acute intoxication
The pattern of reversible physical and mental abnormalities caused by the
direct effects of the substance. These are specific and characteristic for
each substance. Most substances have both pleasurable and unpleasant acute
effects; for some, the balance of positive and negative effects is situation-,
dose- and route-dependent.
b) At-risk use
A pattern of substance use where the person is at increased risk of harming
their physical or mental health. This is not a discrete point but shades into
both normal consumption and harmful use. At-risk use depends not only on
absolute amounts taken but the situations and associated behaviours.
c) Harmful use
The continuation of substance use despite evidence of damage to the user’s
physical or mental health or to their social, occupational, and familial
well-being. This damage may be denied or minimised by the individual
concerned.
d) Withdrawal
Where there is physical dependence on a drug, abstinence will generally lead
to features of withdrawal. These are characteristic for each drug. Some drugs
are not associated with any withdrawals; some with mild symptoms only; and
some with significant withdrawal syndromes. Clinically significant withdrawals
are recognised in dependence on alcohol, opiates, nicotine, benzodiazepines,
amphetamines, and cocaine. Symptoms of withdrawal are often the opposite of
the acute effects of the drug.
e) Complicated withdrawal
Withdrawals can be simple, as above or complicated by the development of
seizures, delirium, or psychotic features.
f) Substance-induced psychotic disorder
Illness characterised by hallucinations and/or delusions occurring as a direct
result of substance-induced neurotoxicity. Psychotic features may occur during
intoxication and withdrawal states, or develop on a background of harmful or
dependent use. There may be diagnostic confusion between these patients and
those with primary psychotic illness and comorbid substance misuse.
Substance-induced illnesses will be associated in time with episodes of
substance misuse and may have atypical clinical features, (e.g. late first
presentation with psychosis, prominence of non-auditory hallucinations).
g) Cognitive impairment syndromes
Reversible cognitive deficits occur during intoxication. Persisting impairment
(in some cases amounting to dementia) caused by chronic substance use is
recognised for alcohol,volatile chemicals, benzodiazepines, and, debatably,
cannabis. Cognitive impairment is associated with heavy chronic harmful
use/dependence and shows gradual deterioration with continued use and either a
halt in the rate of decline or gradual improvement on abstinence.
h) Residual disorders
Several conditions exist (e.g. alcoholic hallucinosis,; persisting
drug-induced psychosis; LSD flashbacks, where there are continuing symptoms
despite continuing abstinence from the drug.
i) Exacerbation of pre-existing disorder
All other
psychiatric
illnesses, especially
anxiety
and
panic disorders
, mood disorders, and psychotic illnesses may be associated with comorbid
substance use. Although this may result in exacerbation of the patient’s
symptoms and a decline in treatment effectiveness, it can be understood as a
desire to self-medicate (e.g. alcohol taken as a hypnotic in depressive
illness) or escape unpleasant symptoms. Sometimes there is debate about
whether there is, for example, a primary mood disorder with secondary alcohol
use or vice versa. Careful examination of the time course of the illness may
reveal the answer. In any case, it is advisable to address substance misuse
problems first as this may produce secondary mood improvements and continuing
substance misuse will limit antidepressant treatment effectiveness.
j) The Dependence syndrome
Dependence includes both physical dependence (the physical adaptations to
chronic, regular use) and psychological dependence (the behavioural
adaptations). In some drugs (e.g. hallucinogens), no physical dependence
features are seen. This is a clinical syndrome describing the features of
substance dependence. These features form the core of both ICD-10 and DSM-IV
descriptions of substance dependence.
Primacy of drug-seeking behaviour: The drug and the
need to obtain it become the most important things in the person’s life,
taking priority over all other activities and interests. Thus drug use becomes
more important than retaining a job or relationships, remaining financially
solvent, and in good physical health and may diminish moral sense leading to
criminal activity and fraud. If the person rates drug use above health, then
stern warnings about impending illness are likely to mean little.
Narrowing of the drug-taking repertoire: The user
moves from a range of drugs to a single drug taken in preference to all
others. The setting of drug use, the route of use, and the individuals with
whom the drug is taken may also become stereotyped.
Increased tolerance to the effects of the drug: The
user finds that more of the drug must be taken to achieve the same effects.
They may also attempt to combat increasing tolerance by choosing a more
rapidly acting route of administration, (e.g. IV rather than smoked), or by
choosing a more rapidly acting form, (e.g. freebase cocaine rather than
cocaine hydrochloride). In advanced dependence there may be a sudden loss of
previous tolerance; the mechanism for this is unknown. Clinically, tolerance
is exhibited by individuals who are able to display no or few signs of
intoxication while at a blood level in which intoxication would be evident in
a non-dependent individual.
Loss of control of consumption: A subjective sense
of inability to restrict further consumption once the drug is taken.
Signs of withdrawal on attempted abstinence: A
withdrawal syndrome, characteristic for each drug, may develop. This may be
only regularly experienced in the mornings because at all other times the
blood level is kept above the required level.
Drug taking to avoid development of withdrawal symptoms:
The user learns to anticipate and avoid withdrawals, (e.g. having the drug
available on waking).
Continued drug use despite negative consequences:
The user persists in drug use even when threatened with significant losses as
a direct consequence of continued use, (e.g. marital break-up, prison term,
loss of job).
Rapid reinstatement of previous pattern of drug use after abstinence:
Characteristically, when the user relapses to drug use after a period of
abstinence, they are at risk of a return to the dependent pattern in a much
shorter period than the time initially taken to reach dependent use.
The Concept of Addiction
‘Addiction’ is a disease characterised by compulsion, loss of
control, and continued use in spite of adverse consequences (Coombs, 1997;
Smith & Seymour, 2001). The primary elements of addictive disease are three
Cs:
Compulsive use: an irresistible impulse; repetitive
ritualized acts and intrusive, ego-dystonic (i.e., ego alien) thoughts e.g.
the person cannot start the day without a cigarette and/or a cup of coffee.
Evening means a ritual martini, or two, or three. In and of itself, however,
compulsive use doesn’t automatically mean addiction.
Loss of control: the inability to limit or resist
inner urges; once begun it is very difficult to quit, if not impossible,
without outside help. This is the pivotal point in addiction. The individual
swears that there will be no more episodes, that he or she will go to the
party and have two beers. Instead, the person drinks until he or she
experiences a blackout and swears the next morning to never do it again; only
to repeat the behaviour the following night. The individual may be able to
stop for a period of time, or control use for a period of time, but will
always return to compulsive, out-of-control use.
Continued use despite adverse consequences: use of
the substance continues inspite of increasing problems that may include
declining health, such as liver impairment in the alcohol addict;
embarrassment, humiliation, shame; or increasing family, financial, and legal
problems.
Drug addiction refers to a situation where drug procurement and
administration appear to govern the individual’s behaviour, and where the drug
seems to dominate the individual’s motivational hierarchy. Jaffe (1975) has
described addiction as
“a behavioural pattern of compulsive drug use, characterized by
overwhelming involvement with the use of a drug, the securing of its supply,
and a high tendency to relapse after withdrawal (abstinence).”
This definition follows the general lexical usage of the term and is
consistent with the word’s etymology (Bozarth 1987).
Drug addiction is defined behaviourally. It carries no connotations regarding
the drug’s potential adverse effects, the social acceptability of drug usage,
or the physiological consequences of chronic drug administration (Jaffe 1975).
This latter point is especially important because some investigators have
mistakenly used the term addiction to describe the development of physical
dependence (see Bozarth 1987a, 1989; Jaffe 1975). Although drug addiction
frequently has adverse medical consequences, it is usually associated with
strong social disapproval, and it is sometimes accompanied by the development
of physical dependence, these factors do not define addiction nor are they
invariably associated with it. Drug addiction is an extreme case of compulsive
drug use associated with strong motivational effects of the drug.
Substance dependence is the term which formally replaced
‘addiction’ in medical terminology in 1964 when the World Health
Organizations Expert Committee on Drug Abuse proposed that the terms addiction
and habituation be replaced with the term dependence and distinguished between
two types- psychological dependence and physical dependence. Psychological
dependence refers to “the experience of impaired control over drug use” while
physical dependence involves “the development of tolerance and withdrawal
symptoms upon cessation of use of the drug, as a consequence of the body’s
adaptation to the continued presence of a drug event” (UNIDCP, 1998).
Researchers and clinicians traditionally limit ‘addiction’ to alcohol and
other drugs. Yet, neuroadaptation, the technical term for the biological
processes of tolerance and withdrawal, also occurs when substance-free
individuals become addicted to pathological gambling, pornography, eating,
overwork, shopping, and other compulsive excesses.
Acquisition and Maintenance Phases of Addiction
Drug addiction is frequently divided into two phases—acquisition and maintenance. This conceptual partition acknowledges that different factors may be
involved in these two phases and that different degrees of drug-taking
behaviour are associated with these phases. The progression from the
acquisition phase to the maintenance phase of addiction is not a quantal
change, but rather it represents a shift in the importance of various factors
that control the individual’s behaviour along with an increase in the
motivational strength of the drug-taking behaviour.
Prior to the first experience with a drug, the direct rewarding effects of
drug administration are largely irrelevant in governing the individual’s
behaviour except of course in that expectancies are developed from social
interactions (e.g., media exposure, conversations with experienced users).
Initiation of drug-taking behaviour is governed by intrapersonal and
sociological variables such as curiosity about the drug’s effects or peer
pressure to try the drug.
After initial exposure to the drug, pharmacological variables are relevant and
will influence subsequent drug-taking behaviour.
Intrapersonal and sociological factors are probably still important in
determining continued drug use, but they are less significant as the potent
rewarding effects are repeatedly experienced.
At some point there is a shift in control from intrapersonal/sociological to
pharmacological factors in governing drug-taking behaviour. This is
concomitant with a marked increase in the motivational strength of the drug
and with a progression from casual to compulsive drug use and ultimately to
drug addiction. This may occur very rapidly for some drugs such as heroin or
free-base cocaine and much more slowly for other drugs such as alcohol.
The division of addiction into two separate phases does not presume that
different mechanisms are involved in each phase. Rather, the demarcation
acknowledges the possibility of different mechanisms but more importantly
emphasizes differences in the motivational strength between the acquisition
and maintenance of addictive behaviour. The same psychobiological process
underlies both phases but additional variables are important in the
acquisition of addiction. These other variables lose much of their influence
as the addiction fully develops and as it becomes increasingly under control
of basic pharmacological mechanisms.
In summary, drug use that leads to decrement in performance of major life
roles, dangerous action, legal problems, or social problems indicates a
substance abuse disorder.