| Substance abuse | |
|---|---|
| Classification and external resources | |
Comparison of the perceived harm for various psychoactive drugs from a poll among medical psychiatrists specialized in addiction treatment[1] |
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| ICD-10 | F10.1-F19.1 |
| ICD-9 | 305 |
| DiseasesDB | 3961 |
| MeSH | D019966 |
Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance (drug) that is not considered dependent. Substance abuse/drug abuse does is not limited to mood-altering or psycho-active drugs. Activity is also considered substance abuse when inappropriately used (as in the case of propofol and Michael Jackson's death, or steroids for performance enhancement in sports). Therefore, mood-altering and psychoactive substances are not the only drugs of abuse. Substance abuse often includes problems with impulse control and impulsivity.
The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts. The terms have a huge range of definitions related to taking a psychoactive drug or performance enhancing drug for a non-therapeutic or non-medical effect. All of these definitions imply a negative judgment of the drug use in question (compare with the term responsible drug use for alternative views). Some of the drugs most often associated with this term include alcohol, amphetamines, barbiturates, benzodiazepines (particularly temazepam, nimetazepam, and flunitrazepam), cocaine, methaqualone, and opioids. Use of these drugs may lead to criminal penalty in addition to possible physical, social, and psychological harm, both strongly depending on local jurisdiction.[2] Other definitions of drug abuse fall into four main categories: public health definitions, mass communication and vernacular usage, medical definitions, and political and criminal justice definitions.
Substance abuse is a form of substance-related disorder.
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Public health practitioners have attempted to look at drug abuse from a broader perspective than the individual, emphasizing the role of society, culture and availability. Rather than accepting the loaded terms alcohol or drug "abuse," many public health professionals have adopted phrases 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 (see diagram to the right).
In the modern medical profession, the three most used diagnostic tools in the world, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM),the World Health Organization's International Statistical Classification of Diseases and ICRIS Medical organization Related Health Problems (ICD), no longer recognize 'drug abuse' as a current medical diagnosis. Instead, DSM has adopted substance abuse[3] as a blanket term to include drug abuse and other things. ICD refrains from using either "substance abuse" or "drug abuse", instead using 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 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) ). Its section Substance dependence begins with:
However, other definitions differ; they may entail psychological or physical dependence,[3] and may focus on treatment and prevention in terms of the social consequences of substance uses.
Drug misuse is a term used commonly for prescription medications with clinical efficacy but abuse potential and known adverse effects linked to improper use, such as psychiatric medications with sedative, anxiolytic, analgesic, or stimulant properties. Prescription misuse has been variably and inconsistently defined based on drug prescription status, the uses that occur without a prescription, intentional use to achieve intoxicating effects, route of administration, co-ingestion with alcohol, and the presence or absence of abuse or dependence symptoms.[4][5] Tolerance relates to the pharmacological property of substances in which chronic use leads to a change in the central nervous system, meaning that more of the substance is needed in order to produce desired effects. Stopping or reducing the use of this substance would cause withdrawal symptoms to occur.[6]
Philip Jenkins points out 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 many Western countries, while drinking several bottles is seen as an abuse. Strict temperance advocates, which may or may not be religiously motivated, would see drinking even one glass as an abuse, and some groups even condemn caffeine use in any quantity. Similarly, adopting the view that any (recreational) use of marijuana or amphetamines constitutes drug abuse implies that we have already decided that substance is harmful even in minute quantities.[7]
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.[8]
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.[9] In the USA approximately 30 percent 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.[10]
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 and cannabis may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate alcohol sustained use may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence.[11]
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.[12]
Traditionally, new pharmacotherapies are quickly adopted in primary care settings, however; drugs for substance abuse treatment have faced many barriers. Naltrexone, a drug originally marketed under the name "ReVia," and now marketed in intramuscular formulation as "Vivitrol" or in oral formulation as a generic, is a medication approved for the treatment of alcohol dependence. This drug has reached very few patients. This may be due to a number of factors, including resistance by Addiction Medicine specialists and lack of resources.[13]
The ability to recognize the signs of drug use or the symptoms of drug use in family members by parents and spouses has been affected significantly by the emergence of home drug test technology which helps identify recent use of common street and prescription drugs with near lab quality accuracy.
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.[14] 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.[14] In 2009 in the United States about 21% of high school students have taken prescription drugs without a prescription.[15] And earlier in 2002, the World Health Organization estimated that around 140 million people were alcohol dependent and another 400 million suffered alcohol-related problems.[16]
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."[17]
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.[20]
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[3]
DSM-IV-TR defines substance abuse as:[21]
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.
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.[22][23] 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.
It is important to obtain estimates of the costs of problems stemming from substance abuse. In order to make informed decisions when allocating scarce resources, policymakers must have a sound understanding of the relative costs of drug-related interventions. Other things being equal, the lower the cost, the more cost-effective a program or intervention will be, or the higher the net economic benefits it will generate. An appropriate drug policy relies on the assessment of drug related public expenditure on efficiency grounds. This is not feasible without giving a preliminary clear and well-defined classification system where costs are properly identified.
Labelled drug-related expenditures are defined as the direct ex-ante 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 fiscal year, 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.[24]
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.[24]
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.[24]
The UK Home Office estimated that the social and economic cost of drug abuse[25] to the UK economy in terms of crime, absenteeism and sickness is in excess of £20 billion a year.[26] However, it 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.[27]
The Home Office has a recent history of taking a hard line on controlled drugs, including those with no known fatalities and even medical benefits,[28] in direct opposition to the scientific community.[29]
In the year 1995, drug abuse cost the American economy $109.8 billion.[13]
Treatment for substance abuse is critical for many around the world. Often a formal intervention is necessary to convince the substance abuser to submit to any form of treatment. Behavioral interventions and medications exist that have helped many people reduce, or discontinue, their substance abuse. From the applied behavior analysis literature, behavioral psychology, and from randomized clinical trials, several evidenced based interventions have emerged:
According to some nurse practitioners, stopping substance abuse can reduce the risk of dying early and also reduce some health risks like heart disease, lung disease, and strokes.[32]
In children and adolescents, cognitive behavioral therapy (CBT) [33] and family therapy [34] currently have the most research evidence for the treatment of substance abuse problems. These treatments can be administered in a variety of different formats, each of which has varying levels of research support [35]
It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious.[36]
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