Week 3.

Substance
abuse and harm
A12GIM. Behavioural Sciences Theme
Dr Katy Jones (katy.jones@Nottingham.ac.uk)
Learning outcomes
At the end of this lecture you should be able to:

1.Define terminology related to substance abuse.

2.List substances that people can use and abuse.
3.Describe and apply different theories of addiction to explain the
development of alcohol use disorder.

Warning: We will be discussing the use and abuse of substances

today including alcohol. It is likely some of us will have known
someone who has had or currently has problems with substance
abuse. There are supportive links on the last slide.
Being clear on terminology
Terms you may encounter
• Substance use
• The ingestion of a substance.
• Substance abuse
• “Harmful” or “hazardous” use of substances including
alcohol and illicit drugs.
• Dependence
• A term implying pharmacological effects and
neuroadaptation.
• Addiction
• An understanding of the phenomenon that includes
psychosocial factors.
• Substance use disorder (SUD)
• New category in the DSM-5 to take into account
dependence and hazardous use.
Types of substance

• Legal: Alcohol, tobacco, prescription medication

• Illegal: Heroin, cocaine, methamphetamine,
MDMA, LSD, ketamine, cannabis(?)
• Grey area: Novel substances, synthetic substances

Legal status of some substances changes regularly

depending on reports of harm, media coverage of
an issue, political agenda.
Class Drug Possession Supply and
production
A Crack cocaine, cocaine, Up to 7 years in Up to life in
MDMA, heroin, LSD, magic prison, an prison, an
mushrooms, methadone, unlimited fine unlimited fine
crystal meth or both. or both.
B Amphetamines, Up to 5 years in Up to 14 years
barbiturates, cannabis, prison, an in prison, an
codeine, ketamine, Ritalin, unlimited fine unlimited fine
synthetic cannabinoids, or both. or both.
synthetic cathinones (e.g.,
methadrone)
C Anabolic steroids, Up to 2 years in Up to 14 years
benzodiazepines, GHB, prison, an in prison, an
GBL, BZP, khat unlimited fine unlimited fine
or both (except or both
anabolic
steroids, it’s
not an offence
to possess for
personal use).

https://www.gov.uk/penalties-drug-possession-dealing
Up to date patterns of alcohol and
substance use in UK (2018)
Alcohol use in Great Britain
29.2 million adults drank alcohol in 2017.
People in professional and managerial positions (higher earners) more likely to drink alcohol in the
last week.
Ageis important. Highest consumers were people aged 45-64 years (64.6% said they drank in the past
week).
 16-24 year olds lower in frequency (47.9% drank in past week)
337,000 hospital admissions were attributable to alcohol in 16/17 (39% were aged between 45 and 64,
62% were male).
Drug misuse in England
8.5% 16 to 59 year olds took an illicit drug in the last year
Cannabis was most commonly used drug (6.6% of adults used it in the last year)
7,545 hospital admissions for drug-related mental health/beh disorders.
 33% were aged 25 to 34. 74% of admissions were male patients.
Substance Use Disorder (DSM-5)
The DSM-5 establishes nine types of Substance-Related Disorders:
1.Alcohol

2.Caffeine*

3.Cannabis (e.g., marijuana)

4.Hallucinogens

5.Inhalants

6.Opioid (e.g., heroin)

7.Sedatives, Hypnotics, or Anxiolytics (e.g., valium, "qualudes")
8.Stimulants (cocaine, methamphetamine)
9.Tobacco

*SUD does not apply to caffeine

8
Opioid Use Disorder (OUD) criteria
1.Taking the opioid in larger amounts and for longer than intended
2.Wanting to cut down or quit but not being able to do it
3.Spending a lot of time obtaining the opioid
4.Craving or a strong desire to use opioids
5.Repeatedly unable to carry out major obligations at work, school, or home due to opioid use
6.Continued use despite persistent or recurring social or interpersonal problems caused or made
worse by opioid use
7.Stopping or reducing important social, occupational, or recreational activities due to opioid use
8.Recurrent use of opioids in physically hazardous situations
9.Consistentuse of opioids despite acknowledgment of persistent or recurrent physical or
psychological difficulties from using opioids
10.*Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or
desired effect or markedly diminished effect with continued use of the same amount. (Does not
apply for diminished effect when used appropriately under medical supervision)
11.*Withdrawalmanifesting as either characteristic syndrome or the substance is used to avoid
withdrawal (Does not apply when used appropriately under medical supervision)

Mild: 2-3 symptoms; moderate: 4-5 symptoms; severe: 6-7 symptoms 9

Alcohol Use Disorder (AUD) criteria
In the past year have you:
1.Had times where you ended up drinking more, or longer than you intended?
2.More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
3.Spent a lot of time drinking? Or being sick to get over the after effects?
4.Wanted a drink so badly you couldn’t think of anything else? NEW TO DSM-5
5.Found that drinking- or being sick from drinking- often interfered with taking care of your
home or family? Or caused job or school troubles?
6.Continued to drink even though it was causing trouble with your family and friends?
7.Given up or cut back on activities that were important to you, or gave you pleasure, in order to
drink?
8.More than once gotten into situations while or after drinking that increased your chances of
getting hurt (e.g. driving, swimming, using machinery, walking in an unsafe area, or having
unsafe sex)?
9.Continued to drink even though it was making you feel depressed or anxious or adding to
another health problem? Or after having a memory blackout?
10.Had to drink much more than you once did to get the effect you want? Or found that your
usual number of drinks had much less effect than before?
11.Found that when the effects of alcohol were wearing off, you had withdrawal symptoms such
as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or
sensed things that were not there?

Mild: 2-3 symptoms; Moderate: 4-5 symptoms; Severe: 6 or more symptoms.

Legal substances: How is use
controlled?
QUESTION? What are the recommended alcohol unit guidelines in
the UK at the moment?

History of alcohol units

1984- “Sensible” drinking guidelines first published in 1984. Men
18 per week, women 9.
1990- Men 21 per week, women 14 based on research that
suggested moderate drinking improved your health
2016?

Source: UK Chief Medical Officer Report (2016)

How to calculate alcohol
units
 Alcohol by volume x ml/ 1000= units of alcohol in a drink.
 Your friend has poured you 200ml of 14% Malbec wine.
Calculate the number of alcohol units in your glass here

 Standardised in pubs/bars/restaurants.
 Average home pour will be different- different glass sizes,
likely not measuring, different strength wine or spirits.
Harms of SUDs
 Medical conditions associated
with SUDs
Substance Use Disorder Medical condition
Alcohol Use Disorder Cardiovascular diseases
Cancers
Injuries
Stroke
Cirrhosis
Opioid Use Disorder Arthritis
Chronic pain
Headache
Hepatitis C
Musculoskeletal disorders
Opioid-related disorders
Cannabis Use Disorder Respiratory deficits
Cardiovascular diseases
Lung cancer

Bahorik et al (2017) Journal of Addiction Medicine 11(1):3-9. 

Other types of harm
Direct physical Direct Harm to others Harm to society
harm to person psychological
harm to person
Liver disease Serious mental Harm to Crime
health problems children (pre-
natal or neglect
Brain damage Suicide Relationship
breakdown
Weight loss, Trauma Violence
nutritional
deficits
Stroke, Domestic
cardiovascular violence
disease
Drink or drug
driving
Alcohol and liver
disease
Rehm et al (2010)
We have known about the connection between alcohol use
and liver disease for some time (Rush, 1785).
Low or moderate levels of alcohol consumption are not
associated with marked increases for developing liver cirrhosis.
Risk increases significantly with heavier drinking.
If a person already has liver cirrhosis the risk of mortality
becomes pronounced even at relatively moderate levels of
drinking.
The development of
Alcohol Use Disorders
Factors affecting alcohol
consumption and related harm
• Age
• Gender
• Familial risk factors
• Socioeconomic status
• Economic development
• Culture and context
• Alcohol control and regulation

Source: Global status report on alcohol and health (2014). World

Health Organisation

Also trauma (psychological factor).

18
Age
 Younger people most at risk
 Adolescence?
 Risk taking?
 Early onset (before age 14) relates to greater risk (Grant
and Dawson, 1997).
 Different risk factors for older people (early vs. late
onset), frequent alcohol consumption.
 Changing patterns of consumption in UK and worldwide
concern about older people’s alcohol consumption (WHO,
2012).
 Not enough research about effectiveness of treatment of
AUDs in older people (Rao and Jones, 2018).
Gender
 Male gender associated with heavier alcohol consumption.
 Women now also at risk (gender roles changing, attitudes toward female
drinking changing).
 Physical health outcomes- same level of consumption= poorer outcomes
for women (Rehm et al, 2010a).
 Faster progression of alcohol-related medical conditions such as brain damage
and liver disease (Mann et al, 2005)
 Barriers for women (See: Hecksher & Hesse, 2009)
 Stigma “women don’t get substance use disorders”.
 Professionals reluctant to ask women about their alcohol use- particularly if
doesn’t fit the stereotype of the ‘alcoholic woman’.
 Media can add to bias against women- focus on burdening men, being out of
control, damaging their appearance, moralising (Patterson et al, 2017).
Familial risk factors
Are AUDs inherited?
Heritability relates to genetics and environment
Clark (2006) Multiple genes will influence when alcohol is initiated,
how it is metabolised and how it is reinforced (e.g., more pronounced
psychoactive effects?).
Mistreatment of children due to AUDs (e.g., physical and sexual abuse
or neglect) can lead to problematic drinking in the child later in life.
Verhulst et al (2015) meta-analysis of twin and adoption studies
 Based on 13 twin and 5 adoption studies, AUDs are approximately 50%
heritable.
 Modest shared environment effects (environmental factors of family
environment contribute to the development of AUDs).
Socioeconomic status

Contradictory literature
More abstainers in poorer communities?
Wealthy= higher alcohol consumers (see UK statistics)
BUT manual workers more vulnerable to severe alcohol-
related health outcomes than non-manual workers.
WHY?

 Less able to avoid aversive consequences of behaviour

(fewer resources)
 Higher SES= better healthcare, safer environments to
drink, more support if need to access treatment.
Economic development

 Based on Gross Domestic Product per capita based on

purchasing power parity (GDP-PPP) as a proxy for
economic wealth.
 Greater economic wealth associated with higher levels
of consumption of alcohol.
 Burden of disease and injury will be higher in societies
with lower economic development than more affluent
societies.
 E.g., liver cirrhosis- worse outcome in less affluent
countries due to nutritional deficiencies or viral
hepatitis (Room et al, 2002a).
Culture and alcohol control
and regulation

Effectiveness of alcohol control and policies will influence

level of consumption and development of AUDs (Babor et
al, 2010).
 Labeling
 Guidelines
 Purchasing hours
 Attitude towards alcohol- is it permitted? Is it part of
social/cultural life?
 Advertising.
Trauma and PTSD
Khoury et al, 2010
Background
Trauma and SUD is well established- 70% of adolescents receiving treatment for
substance abuse had a history of trauma exposure
Study
N=587 recruited from primary care settings in USA
Measures of PTSD, substance use, abuse (physical, sexual, and emotional), and
depression.
Physical abuse correlated with all substance abuse (alcohol, cannabis, cocaine,
heroin, tobacco).
Sexual abuse correlated with cannabis and cocaine use (particularly in women).
Emotional abuse correlated with cocaine use.
More childhood trauma and history of cocaine dependence predicted PTSD
symptoms.
Communication
Examine your use of language
 Addiction is usually linked to mental health problems.
We employ the same person-centered approach to
addiction as we do to other conditions.
Terms to avoid
 ”An addict”: stigmatising label for someone. This can
make it difficult for people to see themselves as
separate from their addiction to the substance.
 ”Clean”: This term is sometimes used by people to
describe their own recovery, but some people find it
stigmatising as it implies previously they were “dirty”.
 Drug or substance abuser. Same as above, takes away
the person from their addiction to the substance.
Examine your use of language
 “Doctors, nurses, and other healthcare workers who are in
contact with people who use drugs have a major role to play in
changing the perceptions on drugs. They are often the first point
of contact with people who use drugs, and can be influential in
feeding evidence back to the public”.
 “As they are in a position of trust, they must play an important
advocacy role in improving the provision of services for people
with problematic drug use. In particular, experienced healthcare
professionals must be vocal in defending the usefulness of
treatments that have proven effective—by speaking up in support
of opioid substitution treatment, for example, which is still
stigmatised by large portions of society.”
 O’Dowd (2018). BMJ. For full text see here:
https://www.bmj.com/content/360/bmj.k140
Conclusions
o Be mindful of your definition of substance use/abuse and
substance use disorder.
o Patterns, prevalence and legal status of substances change
frequently so ensure you keep up to date.
o Harms from substance abuse are myriad and differ by
substance. Harms can be psychological and to others (not
just physical).
o AUDs have complex origins (individual, socio/cultural) and
are usually the result of numerous intersecting risk factors.
o Be careful with language you use and assumptions you make.
Selected journal articles cited in this
lecture
Bahorik, A.L., Satre, D.D., Kline-Simon, A.H., et al (2017). Alcohol,
cannabis and opioid use disorders, and disease burden in an integrated
health care system. Journal of Addiction Medicine 11(1):3-9. 
Hecksher, D., & Hesse, M. (2009). Women and substance use disorders.
Mens sana monographs, 7(1), 50.
Khour, L. et al (2010). Substance use, childhood traumatic experience, and
posttraumatic stress disorder in an urban civilian population. Depression
and Anxiety, 27 (12), 1077-1086.
Lund, I. O., Sundin, E., Konijnenberg, C., Rognmo, K., Martinez, P., &
Fielder, A. (2015). Harm to Others from Substance use and Abuse.
O'Dowd, A. (2018). Avoid stigmatising language for people who use drugs,
global commission urges. BMJ: British Medical Journal (Online), 360.
Rehm, J., Taylor, B., Mohapatra, S., Irving, H., Baliunas, D., Patra, J., &
Roerecke, M. (2010). Alcohol as a risk factor for liver cirrhosis: a systematic
review and meta‐analysis. Drug and Alcohol Review, 29(4), 437-445.
Verhulst, B., Neale, M. C., & Kendler, K. S. (2015). The heritability of
alcohol use disorders: a meta-analysis of twin and adoption
studies. Psychological Medicine, 45(5), 1061-1072.
Statistics on alcohol and
drugs for slide 7
 https://digital.nhs.uk/data-and-information/publicatio
ns/statistical/statistics-on-alcohol/2018
 https://files.digital.nhs.uk/publication/c/k/drug-misu-
eng-2018-rep.pdf

 https://www.ons.gov.uk/
peoplepopulationandcommunity/healthandsocialcare/
drugusealcoholandsmoking/bulletins/
opinionsandlifestylesurveyadultdrinkinghabitsingreatbrit
ain/2017#main-points
Other useful resources
CMO current alcohol guidelines
https://assets.publishing.service.gov.uk/government/
uploads/system/uploads/attachment_data/file/545937/
UK_CMOs__report.pdf
Alcohol-related liver disease information
https://www.nhs.uk/conditions/alcohol-related-liver-
disease-arld/
Watch
Louis Theroux: Drinking to Oblivion. A sensitive and powerful
BBC documentary about alcohol abuse (available on Netflix).
Demonstrates the spectrum of alcohol use disorders and
different risk/protective factors.
Drinkers like me. A recent interesting BBC documentary
about heavy drinking in mid-life and the social and individual
factors that can contribute to ongoing use.
Supportive links
 Talk to Frank. https://www.talktofrank.com/
 NHS page about getting help for addictions
https://www.nhs.uk/live-well/healthy-body/addiction-what-is-it/#getting-
help-for-addictions
 Drinkline is the national alcohol helpline. If you're worried about your
own or someone else's drinking, you can call this free helpline in
complete confidence. Call 0300 123 1110 (weekdays 9am to 8pm,
weekends 11am to 4pm).
 Alcoholics Anonymous (AA) is a free self-help group. Its "12-step"
programme involves getting sober with the help of regular support
groups.  
 Al-Anon Family Groups offers support and understanding to the families
and friends of problem drinkers, whether they're still drinking or
not. Alateen is part of Al-Anon and can be attended by 12- to 17-year-
olds who are affected by another person's drinking, usually a parent.