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.
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.
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.