Substance abuse

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"Drug abuse" redirects here. For the album, see Drug Abuse (album).

Substance abuse

Other names Drug abuse, substance use disorder, substance misuse

disorder

A tin containing drugs and drug paraphernalia

Specialty Psychiatry

Complications Drug overdose

Frequency 27 million[1][2]

Deaths 307,400 (2015)[3]

A person sniffing an inhalant

Substance abuse, also known as drug abuse, is the use of a drug in

amounts or by methods which are harmful to the individual or others. It is a
 form of substance-related disorder. Differing definitions of drug abuse are
used in public health, medical and criminal justice contexts. In some cases,
criminal or anti-social behaviour occurs when the person is under the
influence of a drug, and long-term personality changes in individuals may also
occur.[4] In addition to possible physical, social, and psychological harm, the
use of some drugs may also lead to criminal penalties, although these vary
widely depending on the local jurisdiction. [5]
Drugs most often associated with this term
include: alcohol, amphetamines, barbiturates, benzodiazepines, cannabis, coc
aine, hallucinogens, methaqualone, and opioids. The exact cause of
substance abuse is not clear, but there are two predominant theories: either a
genetic disposition which is learned from others, or a habit which,
if addiction develops, manifests itself as a chronic debilitating disease. [6]
In 2010 about 5% of people (230 million) used an illicit substance. [1] Of these
27 million have high-risk drug use otherwise known as recurrent drug use
causing harm to their health, psychological problems, or social problems that
put them at risk of those dangers.[1][2] In 2015 substance use disorders resulted
in 307,400 deaths, up from 165,000 deaths in 1990. [3][7] Of these, the highest
numbers are from alcohol use disorders at 137,500, opioid use disorders at
122,100 deaths, amphetamine use disorders at 12,200 deaths, and cocaine
use disorders at 11,100.[3]

Contents

 1Classification
o 1.1Public health definitions
o 1.2Medical definitions
o 1.3Value judgment
o 1.4Drug misuse
 2Signs and symptoms
o 2.1Impulsivity
o 2.2Screening and assessment
 3Treatment
o 3.1Psychological
o 3.2Medication
o 3.3Heroin-assisted treatment
o 3.4Dual diagnosis
 4Epidemiology
 5History
o 5.1APA, AMA, and NCDA
o 5.2DSM
 6Society and culture
o 6.1Legal approaches
o 6.2Cost
 7Special populations
o 7.1Immigrants and refugees
o 7.2Street children
o 7.3Musicians
o 7.4Veterans
o 7.5Sex and gender
 8See also
 9References
 10External links

Classification[edit]
Public health definitions[edit]

A drug user receiving an injection of the opiate heroin

Public health practitioners have attempted to look at substance use from a

broader perspective than the individual, emphasizing the role of society,
culture, and availability. Some health professionals choose to avoid the terms
alcohol or drug "abuse" in favor of language considered more objective, 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".[8] This model explicitly
recognizes a spectrum of use, ranging from beneficial use to chronic
dependence.
Medical definitions[edit]

A 2010 study ranking various illegal and legal drugs based on statements by drug-harm experts.
Alcohol was found to be the overall most dangerous drug. [9]

'Drug abuse' is no longer a current medical diagnosis in either of the most

used diagnostic tools in the world, the American Psychiatric
Association's Diagnostic and Statistical Manual of Mental Disorders (DSM),
and the World Health Organization's International Classification of
Diseases (ICD).
Value judgment[edit]

This diagram depicts the correlations among the usage of 18 legal and illegal drugs: alcohol,
amphetamines, amyl nitrite, benzodiazepines, cannabis, chocolate, cocaine, caffeine, crack,
ecstasy, heroin, ketamine, legal highs, LSD, methadone, magic mushrooms (MMushrooms),
nicotine and volatile substance abuse (VSA). Usage is defined as having used the drug at least
once during years 2005–2015. The colored links between drugs indicate the correlations with |r|
>0.4, where |r| is the absolute value of the Pearson correlation coefficient. [10]

Philip Jenkins suggests 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
most Western countries, while drinking several bottles is seen as an abuse.
Strict temperance advocates, who may or may not be religiously motivated,
would see drinking even one glass as an abuse. Some groups (Mormons, as
prescribed in “the Word of Wisdom”) even condemn caffeine use in any
quantity. Similarly, adopting the view that any (recreational) use
of cannabis or substituted amphetamines constitutes drug abuse implies a
decision made that the substance is harmful, even in minute quantities. [11] In
the U.S., drugs have been legally classified into five categories, schedule I, II,
III, IV, or V in the Controlled Substances Act. The drugs are classified on their
deemed potential for abuse. Usage of some drugs is strongly correlated. [12] For
example, the consumption of seven illicit drugs (amphetamines, cannabis,
cocaine, ecstasy, legal highs, LSD, and magic mushrooms) is correlated and
the Pearson correlation coefficient r>0.4 in every pair of them; consumption of
cannabis is strongly correlated (r>0.5) with usage of nicotine (tobacco), heroin
is correlated with cocaine (r>0.4) and methadone (r>0.45), and is strongly
correlated with crack (r>0.5)[12]
Drug misuse[edit]
Drug misuse is a term used commonly when prescription
medication with sedative, anxiolytic, analgesic, or stimulant properties are
used for mood alteration or intoxication ignoring the fact that overdose of such
medicines can sometimes have serious adverse effects. It sometimes
involves drug diversion from the individual for whom it was prescribed.
Prescription misuse has been defined differently and rather inconsistently
based on status of drug prescription, the uses without a prescription,
intentional use to achieve intoxicating effects, route of administration, co-
ingestion with alcohol, and the presence or absence of dependence
symptoms.[13][14] Chronic use of certain substances leads to a change in the
central nervous system known as a 'tolerance' to the medicine such that more
of the substance is needed in order to produce desired effects. With some
substances, stopping or reducing use can cause withdrawal symptoms to
occur,[15] but this is highly dependent on the specific substance in question.
The rate of prescription drug use is fast overtaking illegal drug use in the
United States. According to the National Institute of Drug Abuse, 7 million
people were taking prescription drugs for nonmedical use in 2010. Among
12th graders, nonmedical prescription drug use is now second only
to cannabis.[16] In 2011, "Nearly 1 in 12 high school seniors reported
nonmedical use of Vicodin; 1 in 20 reported such use of OxyContin." [17] Both of
these drugs contain opioids. A 2017 survey of 12th graders in the United
States, found misuse of OxyContin of 2.7 percent, compared to 5.5 percent at
its peak in 2005.[18] Misuse of the combination hydrocodone/paracetamol was
at its lowest since a peak of 10.5 percent in 2003. [18] This decrease may be
related to public health initiatives and decreased availability. [18]
Avenues of obtaining prescription drugs for misuse are varied: sharing
between family and friends, illegally buying medications at school or work,
and often "doctor shopping" to find multiple physicians to prescribe the same
medication, without knowledge of other prescribers.
Increasingly, law enforcement is holding physicians responsible for
prescribing controlled substances without fully establishing patient controls,
such as a patient "drug contract". Concerned physicians are educating
themselves on how to identify medication-seeking behavior in their patients,
and are becoming familiar with "red flags" that would alert them to potential
prescription drug abuse.[19]

Signs and symptoms[edit]

Rational scale to assess the harm of recreational drug use [20]

Physical Dependence Social Avg.

Drug Drug class
harm liability harm harm

Methamphetamine CNS stimulant 3.00 2.80 2.72 2.92

 Rational scale to assess the harm of recreational drug use [20]

Physical Dependence Social Avg.

Drug Drug class
harm liability harm harm

Heroin Opioid 2.78 3.00 2.54 2.77

Cocaine CNS stimulant 2.33 2.39 2.17 2.30

Barbiturates CNS depressant 2.23 2.01 2.00 2.08

Methadone Opioid 1.86 2.08 1.87 1.94

Alcohol CNS depressant 1.40 1.93 2.21 1.85

Ketamine Dissociative anesthetic 2.00 1.54 1.69 1.74

Benzodiazepines Benzodiazepine 1.63 1.83 1.65 1.70

Amphetamine CNS stimulant 1.81 1.67 1.50 1.66

Tobacco Tobacco 1.24 2.21 1.42 1.62

Buprenorphine Opioid 1.60 1.64 1.49 1.58

Cannabis Cannabinoid 0.99 1.51 1.50 1.33

Solvent drugs Inhalant 1.28 1.01 1.52 1.27

4-MTA Designer SSRA 1.44 1.30 1.06 1.27

 Rational scale to assess the harm of recreational drug use [20]

Physical Dependence Social Avg.

Drug Drug class
harm liability harm harm

LSD Psychedelic 1.13 1.23 1.32 1.23

Methylphenidate CNS stimulant 1.32 1.25 0.97 1.18

Anabolic steroids Anabolic steroid 1.45 0.88 1.13 1.15

GHB Neurotransmitter 0.86 1.19 1.30 1.12

Ecstasy Empathogenic stimulant 1.05 1.13 1.09 1.09

Alkyl nitrites Inhalant 0.93 0.87 0.97 0.92

Khat CNS stimulant 0.50 1.04 0.85 0.80

show

Notes about the harm ratings

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.[21]
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.[22] 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. [23] In the US,
approximately 30% 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.[24]
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 withdrawal. In some cases, 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. Both alcohol, barbiturate as well as
benzodiazepine withdrawal can potentially be fatal. Abuse
of hallucinogens can trigger delusional and other psychotic phenomena long
after cessation of use.
Cannabis may trigger panic attacks during intoxication and with continued
use, it may cause a state similar to dysthymia.[25] Researchers have found that
daily cannabis use and the use of high-potency cannabis are independently
associated with a higher chance of developing schizophrenia and
other psychotic disorders.[26][27][28]
Severe anxiety and depression are commonly induced by sustained alcohol
abuse. Even sustained moderate alcohol use may increase anxiety and
depression levels in some individuals. In most cases, these drug-induced
psychiatric disorders fade away with prolonged abstinence. [29] Similarly,
although substance abuse induces many changes to the brain, there is
evidence that many of these alterations are reversed following periods of
prolonged abstinence.[30]
Impulsivity[edit]
Impulsivity is characterized by actions based on sudden desires, whims, or
inclinations rather than careful thought. [31] Individuals with substance abuse
have higher levels of impulsivity,[32] and individuals who use multiple drugs
tend to be more impulsive.[32] A number of studies using the Iowa gambling
task as a measure for impulsive behavior found that drug using populations
made more risky choices compared to healthy controls. [33] There is a
hypothesis that the loss of impulse control may be due to impaired inhibitory
control resulting from drug induced changes that take place in the frontal
cortex.[34] The neurodevelopmental and hormonal changes that happen
during adolescence may modulate impulse control that could possibly lead to
the experimentation with drugs and may lead to the road of addiction.
[35]
 Impulsivity is thought to be a facet trait in the neuroticism personality
domain (overindulgence/negative urgency) which is prospectively associated
with the development of substance abuse.[36]
Screening and assessment[edit]
There are several different screening tools that have been validated for use
with adolescents such as the CRAFFT Screening Test[37] and in adults
the CAGE questionnaire.[38]
Some recommendations for screening tools for substance misuse in
pregnancy include that they take less than 10 minutes, should be used
routinely, include an educational component. Tools suitable for pregnant
women include i.a. 4Ps, T-ACE, TWEAK, TQDH (Ten-Question Drinking
History), and AUDIT.[39]
Given that addiction manifests in structural changes to the brain, it is possible
that non-invasive magnetic resonance imaging could help diagnose addiction
in the future.[30]

Treatment[edit]
Psychological[edit]
From the applied behavior analysis literature, behavioral psychology, and
from randomized clinical trials, several evidenced based interventions have
emerged: behavioral marital therapy, motivational Interviewing, community
reinforcement approach, exposure therapy, contingency management[40]
[41]
 They help suppress cravings and mental anxiety, improve focus on
treatment and new learning behavioral skills, ease withdrawal symptoms and
reduce the chances of relapse.[42]
In children and adolescents, cognitive behavioral therapy (CBT)[43] and family
therapy[44] currently has the most research evidence for the treatment of
substance abuse problems. Well-established studies also include ecological
family-based treatment and group CBT. [45] These treatments can be
administered in a variety of different formats, each of which has varying levels
of research support[46] Research has shown that what makes group CBT most
effective is that it promotes the development of social skills, developmentally
appropriate emotional regulatory skills and other interpersonal skills. [47] A few
integrated[48] treatment models, which combines parts from various types of
treatment, have also been seen as both well-established or probably effective.
[45]
 A study on maternal alcohol and other drug use has shown that integrated
treatment programs have produced significant results, resulting in higher
negative results on toxicology screens.[48] Additionally, brief school-based
interventions have been found to be effective in reducing adolescent alcohol
and cannabis use and abuse.[49] Motivational interviewing can also be effective
in treating substance use disorder in adolescents. [50][51]
Alcoholics Anonymous and Narcotics Anonymous are widely known self-help
organizations in which members support each other abstain from substances.
[52]
 Social skills are significantly impaired in people suffering
from alcoholism due to the neurotoxic effects of alcohol on the brain,
especially the prefrontal cortex area of the brain.[53] It has been suggested
that social skills training adjunctive to inpatient treatment of alcohol
dependence is probably efficacious,[54] including managing the social
environment.
Medication[edit]
A number of medications have been approved for the treatment of substance
abuse.[55] These include replacement therapies such
as buprenorphine and methadone as well as antagonist medications
like disulfiram and naltrexone in either short acting, or the newer long acting
form. Several other medications, often ones originally used in other contexts,
have also been shown to be effective including bupropion and modafinil.
Methadone and buprenorphine are sometimes used to treat opiate addiction.
[56]
 These drugs are used as substitutes for other opioids and still cause
withdrawal symptoms but they facilitate the tapering off process in a controlled
fashion.
Antipsychotic medications have not been found to be useful.
[57]
 Acamprostate[58] is a glutamatergic NMDA antagonist, which helps with
alcohol withdrawal symptoms because alcohol withdrawal is associated with a
hyperglutamatergic system.
Heroin-assisted treatment[edit]
Three countries in Europe have active HAT programs, namely England,
the Netherlands and Switzerland. Despite critical voices by conservative think-
tanks with regard to these liberal approaches, significant progress in the
reduction of drug-related deaths has been achieved in those countries. For
example the US, devoid of such measures, have seen large increases in
drug-related deaths since 2000 (mostly related to heroin use), while
Switzerland has seen large decreases. In 2018, approximately 60,000 people
have died of drug overdoses in America, while in the same time period,
Switzerland's drug deaths were at 260. Relative to the population of these
countries, the US has 10-times more drug-related deaths compared to the
Swiss Confederation, which in effect illustrates the efficacy of HAT to reduce
fatal outcomes in opiate/opioid addiction. [59][60]
Dual diagnosis[edit]
Main article: Dual diagnosis
It is common for individuals with drugs use disorder to have other
psychological problems.[61] The terms “dual diagnosis” or “co-occurring
disorders,” refer to having a mental health and substance use disorder at the
same time. According to the British Association for Psychopharmacology
(BAP), “symptoms of psychiatric disorders such as depression, anxiety and
psychosis are the rule rather than the exception in patients misusing drugs
and/or alcohol.”[62]
Individuals who have a comorbid psychological disorder often have a poor
prognosis if either disorder is untreated.[61] Historically most individuals with
dual diagnosis either received treatment only for one of their disorders or they
didn't receive any treatment all. However, since the 1980s, there has been a
push towards integrating mental health and addiction treatment. In this
method, neither condition is considered primary and both are treated
simultaneously by the same provider.[62]

Epidemiology[edit]

Disability-adjusted life year for drug use disorders per 100,000 inhabitants in 2004.

  no data
  <40
  40–80
  80–120
  120–160
  160–200
  200–240
  240–280
  280–320
  320–360
  360–400
  400–440
  >440

The initiation of drug use including alcohol 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.[63] 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.[63] In 2009 in the United States about 21% of high
school students have taken prescription drugs without a prescription. [64] And
earlier in 2002, the World Health Organization estimated that around 140
million people were alcohol dependent and another 400 million with alcohol-
related problems.[65]
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%).[66] According to BBC, "Worldwide,
the UN estimates there are more than 50 million regular users of morphine
diacetate (heroin), cocaine and synthetic drugs." [67]
More than 70,200 Americans died from drug overdoses in 2017.[68] Among
these, the sharpest increase occurred among deaths related
to fentanyl and synthetic opioids (28,466 deaths).[68] See charts below.


Drug use is higher in countries with high economic inequality
 

Total recorded alcohol per capita consumption (15+), in litres of pure alcohol [69]
 

Total yearly U.S. drug deaths.[68]

 

US yearly overdose deaths, and the drugs involved.[68]