Substance abuse and dependence

Definition

Substance abuse is a pattern of behavior that displays many adverse results from continual use of a substance. Substance dependence is a group of behavioral and physiological symptoms that indicate the continual, compulsive use of a substance in self-administered doses despite the problems related to the use of the substance.

Description

The characteristics of abuse are a failure to carry out obligations at home or work, continual use under circumstances that present a hazard (such as driving a car), and legal problems such as arrests. Use of the drug is persistent despite personal problems caused by the effects of the substance on the self or others. In substance dependence, as the patient's tolerance for the drug increases, increased amounts of a substance are needed to achieve the desired effect or level of intoxication. Withdrawal is a physiological and psychological change that occurs when the body's concentration of the substance declines in a person who has been a heavy user.

Substance abuse and dependence cuts across all lines of race, culture, educational, and socioeconomic status, leaving no group untouched by its devastating effects. An estimated 13 million Americans abuse or are dependent on an illegal substance. Substance abuse is an enormous public health problem, with far-ranging effects throughout society. In addition to the toll substance abuse can take on one's physical health, substance abuse is considered to be an important factor in a wide variety of social problems, affecting rates of crime, domestic violence, sexually transmitted diseases (including HIV/AIDS), unemployment, homelessness, teen pregnancy, and failure in school. An estimated 20 percent of the total yearly cost of health care in the United States is spent on the effects of drug and alcohol abuse.

A wide range of substances can be abused. The most common classes include the following:

• opioids, including such prescription pain killers as morphine and demerol, as well as illegal substances such as heroin
• benzodiazapines, including prescription drugs used for treating anxiety , such as valium
• sedatives or "downers," including prescription barbiturate drugs commonly referred to as tranquilizers
• stimulants or "speed," including prescription amphetamine drugs used as weight loss drugs and in the treatment of attention deficit disorder
• cannabinoid drugs obtained from the hemp plant, including marijuana and hashish
• cocaine-based drugs, including cocaine and "crack"
• hallucinogenic or psychedelic drugs, including lysergic acid diethylamide (LSD) or "acid," phencyclidine (PCP) or "angel dust," 3-4 methylenedioxymethamphetamine (MDMA) or "ecstasy," and other PCP-type drugs
• inhalants, including gaseous drugs used in the medical practice of anesthesia, as well as such common substances as paint thinner, gasoline, and glue
• alcoholic drinks
• cigarettes, cigars, and other tobacco products

Those substances of abuse that are actually prescription medications may have been obtained on the street by fraudulent means or may have been a legal, medically indicated prescription that a person begins to use without regard to the directions of his or her physician.

A number of important terms must be defined in order to have a complete discussion of substance abuse. Drug tolerance refers to a person's body being accustomed to the symptoms produced by a specific quantity of a substance. When a person first begins taking a substance, he or she will note various mental or physical reactions brought on by the drug (some of which are the very changes in consciousness that the individual is seeking through substance use). Over time with repeated use, the same dosage of the substance produces fewer of the desired feelings. In order to continue to feel the desired effect of the substance, progressively higher drug doses must be taken.

Demographics

The National Survey on Drug Use and Health (NSDUH) is conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services. In 2003, the study found the rate of substance dependence or abuse was 8.9 percent for youths aged 12 to 17 and 21 percent for persons aged 18 to 25. Among persons with substance dependence or abuse, illicit drugs accounted for 58.1 percent of youths and 37.2 percent of persons aged 18 to 25. In 2003, males were almost twice as likely to be classified with substance dependence or abuse as females (12.2% versus 6.2%). Among youths aged 12 to 17, however, the rate of substance dependence or abuse among females (9.1%) was similar to the rate among males (8.7%). The rate of substance dependence or abuse was highest among Native Americans and Alaska Natives (17.2%). The next highest rates were among Native Hawaiians and other Pacific Islanders (12.9%) and persons reporting mixed ethnicity (11.3%). Asian Americans had the lowest rate (6.3%). The rates among Hispanics (9.8%) and whites (9.2%) were higher than the rate among blacks (8.1%).

Rates of drug use showed substantial variation by age. For example, in 2003, 3.8 percent of youths aged 12 to 13 reported current illicit drug use compared with 10.9 percent of youths aged 14 to 15 and 19.2 percent of youths aged 16 to 17. As in other years, illicit drug use in 2003 tended to increase with age among young persons, peaking among 18 to 20-year-olds (23.3%) and declining steadily after that point with increasing age. The prevalence of current alcohol use among adolescents in 2003 increased with increasing age, from 2.9 percent at age 12 to a peak of about 70 percent for persons 21 to 22 years old. The highest prevalence of both binge and heavy drinking was for young adults aged 18 to 25, with the peak rate of both measures occurring at age 21. The rate of binge drinking was 41.6 percent for young adults aged 18 to 25 and 47.8 percent at age 21. Heavy alcohol use was reported by 15.1 percent of persons aged 18 to 25 and 18.7 percent of persons aged 21. Among youths aged 12 to 17, an estimated 17.7 percent used alcohol in the month prior to the survey interview. Of all youths, 10.6 percent were binge drinkers, and 2.6 percent were heavy drinkers, similar to the 2002 numbers.

In 2003 rates of illicit drug use varied significantly among the major racial-ethnic groups. The rate of illicit drug use was highest among Native Americans and Alaska Natives (12.1%), persons reporting two or more races (12%), and Native Hawaiians and other Pacific Islanders (11.1%). Rates were 8.7 percent for African Americans, 8.3 percent for Caucasians, and 8 percent for Hispanics. Asian Americans had the lowest rate of illicit drug use at 3.8 percent. These rates were unchanged from 2002. Native Americans and Alaska Natives were more likely than any other racial-ethnic group to report the use of tobacco products in 2003. Among persons aged 12 or older, 41.8 percent of Native Americans and Alaska Natives reported using at least one tobacco product in the past month. The lowest current tobacco use rate among racial-ethnic groups in 2003 was observed for Asian Americans (13.8%), a decrease from the 2002 rate (18.6%).

Young adults aged 18 to 25 had the highest rate of current use of cigarettes (40.2%), similar to the rate in 2002. Past month cigarette use rates among youths in 2002 and 2003 were 13 percent and 12.2 percent, respectively, not a statistically significant change. However, there were significant declines in past year (from 20.3% to 19%) and lifetime (from 33.3% to 31%) cigarette use among youths aged 12mto 17 between 2002 and 2003. Among persons aged twelve or older, a higher proportion of males than females smoked cigarettes in the past month in 2003 (28.1% versus 23%). Among youths aged 12 to 17, however, girls (12.5%) were as likely as boys (11.9%) to smoke in the past month. There was no change in cigarette use among boys aged 12 to 17 between 2002 and 2003. However, among girls, cigarette use decreased from 13.6 percent in 2002 to 12.5 percent in 2003.

Causes and symptoms

There is not thought to be a single cause of substance abuse, though scientists are as of 2004 increasingly convinced that certain people possess a genetic predisposition which can affect the development of addictive behaviors. One theory holds that a particular nerve pathway in the brain (dubbed the "mesolimbic reward pathway") holds certain chemical characteristics which can increase the likelihood that substance use will ultimately lead to substance addiction . Certainly, however, other social factors are involved, including family problems and peer pressure . Primary mood disorders (bipolar), personality disorders , and the role of learned behavior can influence the likelihood that a person will become substance dependent.

The symptoms of substance abuse may be related to its social effects as well as its physical effects. The social effects of substance abuse may include dropping out of school or losing a series of jobs, engaging in fighting and violence in relationships, and legal problems (ranging from driving under the influence to the commission of crimes designed to obtain the money needed to support an expensive drug habit).

When to call the doctor

The earlier one seeks help for their child or teen's substance abuse or dependence problems, the better. Regarding the matter of determining if a teen is experimenting or moving more deeply into the drug culture, parents must be careful observers, particularly of the little details that make up a teen's life. Dramatic change in appearance, friends, or physical health may be signs of trouble. If parents believe their child may be drinking or using drugs, they should seek help through a substance abuse recovery program, family physician, or mental health professional.

Diagnosis

The most difficult aspect of diagnosis involves overcoming the patient's denial. Denial is a psychological trait that prevents a person from acknowledging the reality a situation. Denial may cause a person to be completely unaware of the seriousness of the substance use or may cause the person to greatly underestimate the degree of the problem and its effects on his or her life. A physical examination may reveal signs of substance abuse in the form of needle marks, tracks, trauma to the inside of the nostrils from snorting drugs, unusually large or small pupils. With the person's permission, substance use can also be detected by examining in a laboratory an individual's blood, urine, or hair. This drug testing is limited by sensitivity, specificity, and the time elapsed since the person last used the drug.

Treatment

Treatment has several goals, which include helping a person deal with the uncomfortable and possibly life-threatening symptoms associated with withdrawal from an addictive substance (called detoxification), helping a person deal with the social effects which substance abuse has had on his or her life, and efforts to prevent relapse (resumed use of the substance). Individual or group psychotherapy is sometimes helpful.

Detoxification may take from several days to many weeks. Detoxification can be accomplished suddenly, by complete and immediate cessation of all substance use or by slowly decreasing (tapering) the dose that a person is taking, to minimize the side effects of withdrawal. Some substances absolutely must be tapered, because "cold turkey" methods of detoxification are potentially life threatening. Alternatively, a variety of medications may be used to combat the unpleasant and threatening physical symptoms of withdrawal. A substance (such as methadone in the case of heroine addiction) may be substituted for the original substance of abuse, with gradual tapering of this substituted drug. In practice, many patients may be maintained on methadone and lead a reasonably normal life style. Because of the rebound effects of wildly fluctuating blood pressure, body temperature, heart and breathing rates, as well as the potential for bizarre behavior and hallucinations, a person undergoing withdrawal must be carefully monitored.

Alternative treatment

Alternative treatments thought to improve a person's ability to stop substance use include acupuncture and hypnotherapy. Ridding the body of toxins is believed to be aided by hydrotherapy (bathing regularly in water containing baking soda, sea salt or Epsom salts). Hydrotherapy can include a constitutional effect where the body's vital force is stimulated and all organ systems are revitalized. Elimination of toxins is aided as well as by such herbs as milk thistle, burdock, and licorice. Anxiety brought on by substance withdrawal is thought to be lessened by using other herbs, for example valerian, vervain, skullcap, and kava.

Prognosis

After a person has successfully withdrawn from substance use, the even more difficult task of recovery begins. Recovery refers to the life-long efforts of a person to avoid returning to substance use. The craving can be so strong, even years and years after initial withdrawal has been accomplished, that a previously addicted person may be virtually forever in danger of slipping back into substance use. Triggers for such a relapse 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. While some people remain in counseling indefinitely as a way of maintaining contact with a professional who can help monitor behavior, others find that various support groups or twelve-step programs such as Narcotics Anonymous and Alcoholics Anonymous are the most helpful ways of monitoring the recovery process and avoiding relapse.

Prevention

Prevention is best aimed at teenagers, who are at very high risk for substance experimentation. Education regarding the risks and consequences of substance use, as well as teaching methods of resisting peer pressure, are important components of a prevention program. Furthermore, it is important to identify children at higher risk for substance abuse (including victims of physical or sexual abuse, children of parents who have a history of substance abuse, especially alcohol, and children with school failure or attention deficit disorder). These children may require a more intensive prevention program.

Parental concerns

Parents and guardians need to be aware of the power they have to influence the development of their kids throughout the teenage years. Adolescence brings a new and dramatic stage to family life. The changes that are required are not just the teen's to make; parents need to change their relationship with their teenager. It is best if parents are proactive about the challenges of this life cycle stage, particularly those that pertain to the possibility of experimenting with and using alcohol and drugs. Parents should not be afraid to talk directly to their kids about drug use, especially if they have had problems with drugs or alcohol themselves. Parents should give clear, no-use messages about smoking , drugs, and alcohol. It is important for kids and teens to understand that the rules and expectations set by parents are based on parental love and concern for their well-being. Parents should also be actively involved and demonstrate interest in their teen's friends and social activities. Spending quality time with teens and setting good examples are essential. Even if problems such as substance abuse already exist in the teen's life, parents and families can have a positive influence on their teen's behavior.

Resources

BOOKS

Haugen, Hayley Mitchell. Teen Smoking. Minneapolis, MN: Sagebrush Bound, 2004.

Raczek, Linda Theresa. Teen Addiction. San Diego, CA: Lucent Books, 2003.

Stevens, Sally J., and Andrew R. Morral. Adolescent Substance Abuse Treatment in the United States: Exemplary Models from a National Evaluation Study. Binghamton, NY: Haworth Press, 2002.

Townsend, John. Drugs—Teen Issues. Chicago, IL: Raintree, 2004.

PERIODICALS

Johnson, Kate. "Tobacco Dependence: Even Minimal Exposure Can Cause Rapid Onset; Daily Smoking Not Necessary." Family Practice News 34 (June 15, 2004): 66.

Kaminer, Yifah, and Chris Napolitano. "Dial for Therapy: Aftercare for Adolescent Substance Use Disorders." Journal of the American Academy of Child and Adolescent Psychiatry 43 (September 2004): 1171–74.

"SAMHSA Reveals State Estimates of Substance Use for the First Time: Washington, D.C. Ranks Highest in Illegal Drug Use." Alcoholism & Drug Abuse Weekly 16 (August 16, 2004): 1.

"Sexually Active Friends Can Signal Increase in Teen's Substance Abuse Risk." Obesity, Fitness & Wellness Week (September 18, 2004): 410.

Sherman, Carl. "Early Disorders Often Precede Substance Abuse." Clinical Psychiatry News 32 (June 2004): 34.

ORGANIZATIONS

National Council on Alcoholism and Drug Dependence Inc. 20 Exchange Place, Suite 2902, New York, NY 10005. Web site: http://www.ncadd.org.

University of Miami, Center for Treatment Research on Adolescent Drug Abuse. PO Box 019132, Miami, FL 33101. Web site: http://www.miami.edu/ctrada.

WEB SITES

"Fact Sheet: Addiction (Substance Dependence)." New York Presbyterian Hospital. Available online at http://www.noah-health.org/english/illness/mentalhealth/cornell/conditions/substdep.html (accessed November 4, 2004).

"Parents: The Anti-Drug." National Youth Anti-Drug Media Campaign. Available online at http://www.theantidrug.com (accessed November 4, 2004).

Genevieve Pham-Kanter, Ph.D. Ken R. Wells