Substance abuse and dependence

Substance abuse and dependence

Substance abuse is the continued compulsive use of mind-altering substances despite personal, social, and/or physical problems caused by the substance use.

Abuse may lead to dependence, in which increased amounts are needed to achieve the desired effect or level of intoxication and the patient’s tolerance for the drug increases.

Substance abuse and dependence cut across all lines of race, culture, education, and socioeconomic status, leaving no group untouched by their devastating effects. Substance abuse is an enormous public health problem with far-ranging effects throughout society.


In addition to the toll substance abuse can take on one’s physical health, it is considered an important factor in a wide variety of social problems, affecting rates of crime, domestic violence, sexually transmitted diseases (including HIV/AIDS), unemployment, homelessness, teen pregnancy, and failure in school.

One study estimated that 20% of the total yearly cost of health care in the United States is spent on treating the effects of drug and alcohol abuse.

A wide range of substances can be abused. The most common classes include:

• alcohol
• cocaine-based drugs
• opioids (including such prescription pain killers as morphine and Demerol as well as such illegal substances as heroin)
• benzodiazapines (including prescription drugs used for treating anxiety, such as valium)
• sedatives or “downers” (including prescription barbiturate drugs commonly referred to as tranquilizers)
• stimulants or “speed” (including prescription amphetamine drugs used as weight loss drugs and in the treatment of attention deficit disorder) and Ecstasy (which in 2001 had been tried by more than 12% of teens, up 71% over 1999 figures)
• cannabinoid drugs obtained from the hemp plant (including marijuana and hashish).
• hallucinogenic or “psychedelic” drugs (including LSD, PCP or angel dust, and other PCP-type drugs)
• inhalants (including gaseous drugs used in the medical practice of anesthesia, as well as such common substances as paint thinner, gasoline, and glue). A 2002 study found that inhalant use among youths was even higher than that of Ecstasy

Over time, the same dosage of an abused substance will produce fewer of the desired feelings. This is known as drug tolerance. In order to continue to feel the desired effect of the substance, the person must take progressively higher drug doses.

Substance dependence is a phenomenon whereby a person becomes physically addicted to a substance. A substance-dependent person must have a particular dose or concentration of the substance in his or her blood-stream at any given moment in order to avoid the unpleasant symptoms associated with withdrawal from that substance.

The common substances of abuse tend to exert either a depressive (slowing) or a stimulating (speeding up) effect on such basic bodily functions as respiratory rate, heart rate, and blood pressure.

When a drug is stopped abruptly, the person’s body will respond by overreacting to the substance’s absence. Functions slowed by the abused substance will suddenly speed up, while previously stimulated functions will slow down. This results in very unpleasant effects, known as withdrawal symptoms.

Addiction refers to the mental-state of a person who reaches a point where he/she must have a specific substance, even though the social, physical, and/or legal consequences of substance use are clearly negative (e.g., loss of relationships, employment, housing). Craving refers to an intense hunger for a specific substance, to the point where this need essentially directs the individual’s behavior.

Craving is usually seen in both dependence and addiction and can be so strong that it overwhelms a person’s ability to make any decisions that will possibly deprive him/her of the substance. Drug possession and use becomes the most important goal, and other forces (including the law) have little effect on changing the individual’s substance-seeking behavior.

Causes and symptoms

It is generally believed that there is not one single cause of substance abuse, though scientists are increasingly convinced that certain people possess a genetic predisposition that can affect the development of addictive behaviors.

One theory holds that a particular nerve pathway in the brain (dubbed the “mesolimbic reward pathway”) holds certain chemical characteristics that may increase the likelihood that substance use will ultimately lead to substance addiction.

Certainly, however, other social factors are involved, including family problems and peer pressure. Primary mood disorders (bipolar), personality disorders, and learned behaviors can be influential on the likelihood that a person will become substance dependent.

The symptoms of substance abuse may be related to its social as well as its physical effects. The social effects of substance abuse may include dropping out of school or losing a series of jobs, engaging in fighting and violence in relationships, and legal problems (ranging from driving under the influence to the commission of crimes designed to obtain the money needed to support an expensive drug habit).

Physical effects of substance abuse are related to the specific drug being abused:

• Opioid drug users may appear slowed in their physical movements and speech, may lose weight, exhibit mood swings, and have constricted (small) pupils.
• Benzodiazapine and barbiturate users may appear sleepy and slowed, with slurred speech, small pupils, and occasional confusion.
• Amphetamine users may have excessively high energy, inability to sleep, weight loss, rapid pulse, elevated blood pressure, occasional psychotic behavior, and dilated (enlarged) pupils.
• Marijuana users may be sluggish and slow to react, exhibiting mood swings and red eyes with dilated pupils.
• Cocaine users may have wide variations in their energy level, severe mood disturbances, psychosis, paranoia, and a constantly runny nose. Crack cocaine use may cause aggressive or violent behavior.
• Hallucinogenic drug users may display bizarre behavior due to hallucinations (hallucinations are imagined sights, voices, sounds, or smells which seem completely real to the individual experiencing them) and dilated pupils. LSD can cause flashbacks.

Other symptoms of substance abuse may be related to the form in which the substance is used. For example, heroin, certain other opioid drugs, and certain forms of cocaine may be injected using a needle and a hypodermic syringe.

A person abusing an injectable substance may have “track marks” (outwardly visible signs of the site of an injection, with possible redness and swelling of the vein in which the substance was injected). Furthermore, poor judgment brought on by substance use can result in the injections being made under dirty conditions.

These unsanitary conditions and the use of shared needles can cause infections of the injection sites, major infections of the heart, as well as infection with HIV (the virus which causes AIDS), certain forms of hepatitis (a liver infection), and tuberculosis.

Cocaine is often taken as a powdery substance that is “snorted” through the nose. This method of use can result in frequent nosebleeds, sores in the nose, and even erosion (an eating away) of the nasal septum (the structure that separates the two nostrils). Other forms of cocaine include smokable or injectable forms such as freebase and crack cocaine.

Overdosing on a substance is a frequent complication of substance abuse. Drug overdose can be purposeful (with suicide as a goal), or result from carelessness.

It may also be the result of the unpredictable strength of substances purchased from street dealers, mixing of more than one type of substance or of a substance and alcohol, or as a result of the ever-increasing doses the person must take of those substances to which he or she has become tolerant. Substance overdose can be a life-threatening emergency, with the specific symptoms dependent on the type of substance used.

Substances with depressive effects may dangerously slow the breathing and heart rate, lower the body temperature, and result in general unresponsiveness. Substances with stimulatory effects may dangerously increase the heart rate and blood pressure, increase body temperature, and cause bizarre behavior. With cocaine, there is a risk of stroke.

Still other symptoms may be caused by unknown substances mixed with street drugs in order to “stretch” a batch. A healthcare worker faced with a patient suffering extreme symptoms will have no idea what other substance that person may have unwittingly put into his or her body. Thorough drug screening can help with diagnosis.

Diagnosis

The most difficult aspect of diagnosis involves over coming the patient’s denial. Denial is a psychological trait whereby a person is unable to allow him- or herself to acknowledge the reality of a situation. This may lead a person to completely deny his or her substance use, or may cause the person to greatly underestimate the degree of the problem and its effects on his or her life.

One of the simplest and most common screening tools practitioners use to begin the process of diagnosing substance abuse is the CAGE questionnaire. CAGE refers to the first letters of each word that forms the basis of each of the four questions of the screening exam:

• Have you ever tried to cut down on your substance use?
• Have you ever been annoyed by people trying to talk to you about your substance use?
• Do you ever feel guilty about your substance use?
• Do you ever need an eye opener (use of the substance first thing in the morning) in order to start your day?

Other lists of questions may be used to assess the severity and effects of a person’s substance abuse. Certainly, it is also relevant to determine whether anybody else in the user’s family has ever suffered from substance or alcohol addiction.

A physical examination may reveal signs of substance abuse in the form of needle marks, tracks, trauma to the inside of the nostrils from snorting drugs, or unusually large or small pupils.

With the person’s permission, substance use can also be detected by examining an individual’s blood, urine, or hair in a laboratory. Drug testing is limited by sensitivity, specificity, and the time elapsed since the person last used the drug.

Treatment

Treatment has several goals, which include helping a person deal with the uncomfortable and possibly life threatening symptoms associated with withdrawal from an addictive substance (called detoxification), helping an abuser deal with the social effects that substance abuse has had on his or her life; and efforts to prevent relapse (resumed use of the substance). Individual or group psychotherapy may be helpful.

Ridding the body of toxins is believed to be aided by hydrotherapy (bathing regularly in water containing baking soda, sea salt, or Epsom salts).

Hydrotherapy can include a constitutional effect where the body’s vital force is stimulated and all organ systems are revitalized. Herbalists or naturopathic physicians may prescribe such herbs as milk thistle (Silybum marianum), burdock (Arctium lappa, a blood cleanser), and licorice (Glycyrrhizaglabra) to assist in detoxification.

Anxiety brought on by substance withdrawal is thought to be lessened by using other herbs, which include valerian (Valeriana officinalis), vervain (Verbena officinalis), skullcap (Scutellaria baicalensis), and kava (Piper methysticum).

Other treatments aimed at reducing the stress a person suffers while attempting substance withdrawal and throughout an individual’s recovery process include acupuncture, hypnotherapy, biofeedback, guided imagery, and various meditative arts (including yoga and t’ai chi).

Use of acupuncture to treat addiction is becoming more common. In 2002, a study was undertaken in Maine to treat substance abuse users who were dually diagnosed with chronic mental illness and substance abuse problems with ear acupuncture.

The technique appears to cleanse organs and to aid in relaxation, which eases many of the stresses believed to lead these patients to maintain their reliance on the drugs. Another clinical trial in the same year, however, found that acupuncture was not effective alone for treating cocaine-dependent adults.

However, the study did conclude that acupuncture may be effective for these patients when used in combination with other treatments. New research also suggests that qigong therapy may be an effective alternative for patients with heroin addiction.

Allopathic treatment

Detoxification may take from several days to many weeks. Detoxification can be accomplished “cold turkey,” by complete and immediate cessation of all substance use, or by slowly decreasing (tapering) the dose which a person is taking, to minimize the side effects of withdrawal.

Some substances absolutely must be tapered, because “cold turkey” methods of detoxification are potentially life-threatening. Alternately, a variety of medications may be utilized to combat the unpleasant and threatening physical symptoms of withdrawal.

A substance (such as methadone in the case of heroin addiction) may be substituted for the original substance of abuse, with gradual tapering of this substituted drug. In practice, many patients may be maintained on methadone and lead a reasonably normal life.

Because of the rebound effects of wildly fluctuating blood pressure, body temperature, heart and breathing rates, as well as the potential for bizarre behavior and hallucinations, a person undergoing withdrawal must be carefully monitored.

Expected results

After a person has successfully withdrawn from substance use, the even more difficult task of recovery begins. Recovery refers to the lifelong efforts of a person to avoid returning to substance use. The craving can be so strong even years and years after initial withdrawal that a previously addicted person is in danger of slipping back into substance use.

Triggers for such a relapse include any number of life stresses (problems on the job or in the marriage, loss of a relationship, death of a loved one, financial stresses), in addition to seemingly mundane exposure to a place or an acquaintance associated with previous substance use.

While some people remain in counseling indefinitely as a way of maintaining contact with a professional who can help monitor behavior, others find that various support groups or 12-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are most helpful in monitoring the recovery process and avoiding relapse.

Another important aspect of treatment for substance abuse concerns the inclusion of close family members in treatment.

Because substance abuse has severe effects on the functioning of the family, and because research shows that family members can unintentionally develop behaviors that inadvertently serve to support a person’s substance habit, most good treatment will involve all family members.

Prevention

Prevention is best aimed at teenagers, who are at very high risk for substance experimentation. Education regarding the risks and consequences of substance use, as well as teaching methods of resisting peer pressure, are both important components of a prevention program.

Furthermore, it is important to identify children at higher risk for substance abuse (including victims of physical or sexual abuse; children of parents who have a history of substance abuse, especially alcohol; and children with school failure and/or attention deficit disorder).

These children will require a more intensive prevention program. A 2002 report demonstrated that prevention programs worked with high-risk youth in reducing rates of alcohol, tobacco, and marijuana use.