Substance abuse, also known as drug abuse, is the use of a drug in amounts or by methods that 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 behavior occurs when the person is under the influence of a drug, and long-term personality changes in individuals may also occur.[5] 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.[6]
Lines of cocaine prepared for snorting. Contaminated currency such as banknotes might serve as a fomite of diseases like hepatitis C[7]
Drugs most often associated with this term include alcohol, amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, hallucinogens, methaqualone, and opioids. The exact cause of substance abuse is not clear, but there are two predominant theories: either a genetic predisposition or a habit learned from others, which, if addiction develops, manifests itself as a chronic debilitating disease.[8]
In 2010, about 5% of adults (230 million) used an illicit substance.[2] Of these, 27 million have high-risk drug use—otherwise known as recurrent drug use—causing harm to their health, causing psychological problems, and or causing social problems that put them at risk of those dangers.[2][3] In 2015, substance use disorders resulted in 307,400 deaths, up from 165,000 deaths in 1990.[9][10] 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.[9]
Classification
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Public health definitions
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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".[11] This model explicitly recognizes a spectrum of use, ranging from beneficial use to chronic dependence.
Medical definitions
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Table from the 2010 DrugScience study ranking various drugs (legal and illegal) based on statements by drug-harm experts. This study rated alcohol the most harmful drug overall, and the only drug more harmful to others than to the users themselves.[12]
'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
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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.[13]
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 abuse. Strict temperance advocates, who may or may not be religiously motivated, would see drinking even one glass as 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.[14] 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. The usage of some drugs is strongly correlated.[15] 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 the 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)[15]
Drug misuse
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Drug misuse is a term used commonly when prescription medication with sedative, anxiolytic, analgesic, or stimulant properties is 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 the 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.[16][17] 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,[18] 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.[19] In 2011, "Nearly 1 in 12 high school seniors reported nonmedical use of Vicodin; 1 in 20 reported such use of OxyContin."[20] Both of these drugs contain opioids. Fentanyl is an opioid that is 100 times more potent than morphine, and 50 times more potent than heroin.[21] 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.[22] Misuse of the combination hydrocodone/paracetamol was at its lowest since a peak of 10.5 percent in 2003.[22] This decrease may be related to public health initiatives and decreased availability.[22]
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 the 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.[23]
Signs and symptoms
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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.[24]
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.[25] 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.[26] 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.[27]
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, although extremely unlikely, may in some individuals trigger delusional and other psychotic phenomena long after cessation of use. This is mainly a risk with deliriants, and most unlikely with psychedelics and dissociatives.
Cannabis may trigger panic attacks during intoxication and with continued use, it may cause a state similar to dysthymia.[28] 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.[29][30][31]
Severe anxiety and depression are often 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.[32] 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.[33]
Impulsivity
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Impulsivity is characterized by actions based on sudden desires, whims, or inclinations rather than careful thought.[34] Individuals with substance abuse have higher levels of impulsivity,[35] and individuals who use multiple drugs tend to be more impulsive.[35] 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.[36] 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.[37] 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 addiction.[38] 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.[39]
Screening and assessment
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The screening and assessment process of substance use behavior is important for the diagnosis and treatment of substance use disorders. Screeners is the process of identifying individuals who have or may be at risk for a substance use disorder and are usually brief to administer.[40] Assessments are used to clarify the nature of the substance use behavior to help determine appropriate treatment.[40] Assessments usually require specialized skills, and are longer to administer than screeners.
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.[33]
Targeted assessments
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There are several different screening tools that have been validated for use with adolescents such as the CRAFFT Screening Test[41] and in adults the CAGE questionnaire.[42] 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.[43]
Treatment
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Main article: Drug rehabilitation
Psychological
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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[44][45] 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.[46]
In children and adolescents, cognitive behavioral therapy (CBT)[47] and family therapy[48] 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.[49] These treatments can be administered in a variety of different formats, each of which has varying levels of research support[50] 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.[51] A few integrated[52] treatment models, which combines parts from various types of treatment, have also been seen as both well-established or probably effective.[49] 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.[52] Additionally, brief school-based interventions have been found to be effective in reducing adolescent alcohol and cannabis use and abuse.[53] Motivational interviewing can also be effective in treating substance use disorder in adolescents.[54][55]
Alcoholics Anonymous and Narcotics Anonymous are widely known self-help organizations in which members support each other abstain from substances.[56] Social skills are significantly impaired in people with alcoholism due to the neurotoxic effects of alcohol on the brain, especially the prefrontal cortex area of the brain.[57] It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious,[58] including managing the social environment.
Medication
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See also: Drug rehabilitation § Medications
A number of medications have been approved for the treatment of substance abuse.[59] 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.[60] 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. When a person goes from using fentanyl every day, to not using it at all, they will experience a point where they need to get used to not using the substance. This is called withdrawal.[citation needed]
Antipsychotic medications have not been found to be useful.[61] Acamprostate[62] is a glutamatergic NMDA antagonist, which helps with alcohol withdrawal symptoms because alcohol withdrawal is associated with a hyperglutamatergic system.
Heroin-assisted treatment
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Opiates v opioids illustrated with diagrams and sub-classifications
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 harm-reduction strategies, significant progress in the reduction of drug-related deaths has been achieved in those countries. For example, the US, devoid of such measures, has 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.[63][64]
Dual diagnosis
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Main article: Dual diagnosis
It is common for individuals with drugs use disorder to have other psychological problems.[65] 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."[66]
Individuals who have a comorbid psychological disorder often have a poor prognosis if either disorder is untreated.[65] Historically most individuals with dual diagnosis either received treatment only for one of their disorders or they did not 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.[66]
Epidemiology
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.[67] 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.[67] In 2009 in the United States about 21% of high school students have taken prescription drugs without a prescription.[68] 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.[69]
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%).[70] According UN estimates, there are "more than 50 million regular users of morphine diacetate (heroin), cocaine and synthetic drugs."[71]
More than 70,200 Americans died from drug overdoses in 2017.[64] Among these, the sharpest increase occurred among deaths related to fentanyl and synthetic opioids (28,466 deaths).[64] See charts below.