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Drug abuse, also referred to as substance or chemical abuse, is the recurrent use of a drug despite the experience of problems caused by the drug use. Difficulties arising in certain areas of a user’s life are of more importance to researchers and treatment professionals than other areas for identification of a drug abuse problem. The following are types of problems that signify drug abuse: impairment meeting major responsibilities in life, such as those regarding school, work, or home; difficulties with the law and social behavior; and aggravation of physical/medical conditions due to drug use. Drug abuse is to be contrasted with drug (chemical/substance) dependence. With drug dependence, use is considered compulsive and beyond the willful control of the user. That is, someone who is drug dependent is addicted; this is thought to be a more severe condition than drug abuse. Treatment of drug abuse is accomplished primarily using a variety of counseling and psychotherapeutic techniques employed to assist the abuser to stop using the drug, to develop new behavioral and mental coping skills, and to rehabilitate his or her life from the damage caused by the substance abuse.
- Risk Factors and Causes of Drug Abuse
- Course of Drug Abuse
- Assessment of Drug Abuse
- Treatment of Drug Abuse
- Relapse Prevention
In the discussion of drug abuse, it would be easy but inaccurate to label any regular use of a substance as abusive. Drug use in the United States is commonplace. Many people are capable of consuming drugs without developing problems. Drugs such as caffeine and alcohol, as well as prescription pharmaceutical products such as pain killing agents or antianxiety medication, are routinely and openly consumed every day in the United States (and in other countries as well). The various drugs affect the body differently and are used for specific purposes. For example, caffeine is used to remain alert and to enhance concentration, and tranquilizers are used to quell anxiety and for relaxation. However, drugs of abuse all have in common the property that they are psychoactive. For the sake of discussion, drugs may be classified with respect to different properties; one commonly employed system is in terms of the effect of the drug on the central nervous system (CNS). The following is one such classification system, with examples of drugs in each category:
- CNS stimulants: Cocaine, amphetamine, and caffeine
- CNS depressants: Alcohol, barbiturates, benzodiazepines, and solvent inhalants
- Psychotomimetics (also known as psychedelics or hallucinogens): Marijuana, LSD, and mescaline
- Narcotics/Opioids: Opium, heroin, codeine, morphine, and methadone
Substance use typically begins in adolescence. Adolescent substance use does not appear to be random; that is, it follows a fairly predictable pattern. Adolescents tend to start using substances that are legal and widely available to adults: alcohol and tobacco. Due to the fact that these drugs are the starting point for substance use, they are referred to as ‘‘gateway drugs.’’ In 1975, Kandel developed a stage model of progression of drug use that has since been revised:
- Beer or wine use
- Hard liquor or cigarette use
- Marijuana experimentation
- Alcohol abuse
- Prescription drug use
- Opiates and other illegal drugs
The vast majority of adolescents experiment with the gateway drugs at least one time. However, although most individuals try alcohol and tobacco, only for a minority of adolescents does use advance to abusive levels. As the stages advance, progressively fewer adolescents are found in each category. For example, alcohol will be tried by approximately 9 out of 10 students by their senior year in high school and cigarettes by approximately 6 out of 10 students by senior year. Opiates, at the last stage of the model, will be tried by only 1 out of 100 students by senior year.
Due to the high prevalence of substance use in the United States, it should be no surprise that substance-related problems are often encountered by mental health clinicians. The relatively high frequency with which substance-related problems are encountered by mental health professionals reflects the influence of the following factors: (i) Drug abuse has the potential to create or worsen all psychological symptoms, such as anxiety, depression, impulsive behavior, and antisocial behavior; and (ii) people seeking mental health services also tend to be at elevated risk for substance abuse problems. In other words, drug abuse harms people and contributes to psychiatric symptoms, and people experiencing psychological problems are apt to use drugs abusively.
2. Risk Factors And Causes Of Drug Abuse
With any medical or mental health condition, it is desirable to determine the cause or causes of the affliction. Identifying the cause(s) helps to develop prevention strategies to limit or eliminate future cases and treatment strategies for those already affected by the condition. For example, after the discovery that an absence of insulin was responsible for type 1 diabetes, effective treatment of diabetes with externally supplied insulin became possible. In addition, research is under way to develop early identification tests for intervention strategies to prevent later development of diabetes. This research has led to the isolation of faulty antibodies believed to attack the insulin-producing cells of the pancreas. The antibodies can be detected before the person is symptomatic for diabetes; experimental treatments are being used in an attempt to prevent the development of diabetes in these high-risk individuals.
Human behavior is complex and defies easy explanation. Unlike certain physical characteristics (e.g., eye color) or physical disorders that can be traced to single genes, a disorder such as drug abuse likely represents the interaction of multiple genetic and environmental influences. Complicating things further, ethics prevents us from conducting experimental studies (involving environmental or genetic manipulation) that might help us to tease apart various possible influences. One way to attempt to identify possible causes of substance abuse is to study risk factors. Risk factors are those variables associated with increased likelihood of developing a substance use disorder. Classes of risk factors are listed here with examples in each class:
- Peer: Peer substance use, strong attachment to peers, and positive peer attitudes about substance use
- Parent/family: Parent substance use, positive attitude about substance use, parent tolerance of adolescent substance use, and family disruption (e.g., divorce)
- Personal: Early (childhood) behavior problems, poor academic performance, anxiety/depression, and low self-esteem
- Biological: Genetic predisposition to substance use (e.g., a parent is a substance abuser)
- Community/social: Low socioeconomic status, high availability of substances, and deviant norms that encourage use of substances
Risk factors help us to understand influences to use substances, but we know many more people use them than become abusers. Therefore, the question as to who will progress beyond experimentation and casual use to the level of abuse is not answered by risk factors alone. It appears that use of substances is more a function of external risk factors, such as peer, social, and family factors; abuse of substances appears to be more a function of personal factors, such as psychiatric, behavioral, and emotional problems.
The biopsychosocial disease model is the most widely accepted model of substance abuse and addiction. It should be clear after reviewing the list of risk factors that biological, psychological, and social factors contribute to substance abuse. The biopsychosocial model is sufficiently comprehensive to include all known contributants to substance abuse.
3. Course Of Drug Abuse
Disease conditions are defined by several common factors, such as having identifiable causes, characteristic symptoms, and established treatments. In addition, diseases have an observable course. It is important to describe the course of an illness in part so that the condition can be identified (i.e., for diagnostic purposes). Also, if the untreated progression of an illness was not known, there would be no way to judge the effectiveness of treatment. Treatment interventions endeavor, essentially, to change the course of a disease. Initial attempts to describe and classify the course of alcohol abuse depicted an ever-worsening condition that eventuated in death, unless the drinking was stopped altogether. As it turns out, the long-term outcome of regular alcohol use is not certain death. Some people who use alcohol never develop problems, some who develop problems (alcohol abusers) never become addicted, and a minority of alcohol abusers (approximately one-third) exhibit the progressive deteriorative pattern of drinking. The same overall trends may be expected with other substances of abuse as with alcohol. In 1995, Shaffer and Robbins developed a general model to describe the typical course of an addiction, consisting of the following stages:
- Initiation: Experimentation with a drug is begun.
- Positive consequences: At this point in the use process, only the pleasurable pharmacological and social effects of the substance are experienced.
- Negative consequences: For those individuals who continue to regularly use the substance, eventually negative consequences are experienced in terms of health, relationships, work, school, finances, or the law.
- Turning point: For abusers who continue despite negative consequences, there is some recognition of the damage the substance is causing in their lives and ambivalence ensues.
- Active quitting: For some abusers, ambivalence is resolved in the direction of stopping use.
- Relapse prevention: For those who have quit, behavior changes are maintained over time to prevent resumption of drug use.
4. Assessment Of Drug Abuse
In order to treat a condition, it must first be determined that a given individual has the condition; in other words, the diagnosis of drug abuse must be made. In medicine, objective tests via technologically advanced equipment (e.g., x-ray and magnetic resonance imagery) are often used to assist the doctor in the diagnostic process. In the evaluation of drug abuse, modern technology is hardly relevant. Biological testing, in the forms of urinalysis and evaluation of saliva and blood samples, may be used but are not the mainstay of assessment. Biological testing can determine if a specific drug or drug metabolite is present in a sample but cannot indicate anything about patterns of use, withdrawal symptoms, compulsive behavior, or consequences of use, all of which are important aspects to assess. Therefore, biological testing is confined to the role of confirming recent abstinence; this information is especially important in certain settings (e.g., criminal justice system and workplace) but of limited use in a drug abuse assessment. Since we are more interested in determining whether a pattern of abusive drug use is present or not, relevant information needs to be gathered. Therefore, the interview is the primary method by which information is acquired to make the diagnosis of drug abuse. Typically, the diagnostic interview is conducted with the person in question as well as with others in a position to observe relevant behaviors (most often family members and/or close friends). In addition to the interview, information is sometimes acquired via self-report, paper-and-pencil tests. The following information is typically obtained during a drug abuse assessment:
- List all substances ever used
- Age of first use of all substances
- How used each substance (e.g., smoke, drink, snort, etc.)
- Age of peak use, and amount used, for each substance
- Number of days use substance per week, for each substance
- Amount of substance used on a typical day of use
- Date of last use of each substance
- List all negative consequences resulting from use of substances
Diagnosing a drug abuse disorder is only one element of the assessment process. It is also necessary to determine as part of the evaluation the most appropriate setting in which treatment should take place (e.g., outpatient, halfway house, or inpatient); the proper intensity of treatment (e.g., daily treatment or monthly treatment); whether other treatment needs exist (e.g., medical and/or psychological disorders); and specific, individual treatment goals for a given person.
5. Treatment Of Drug Abuse
There is no one treatment for drug abuse. This fact is a reflection of the complexity of the condition and its diverse manifestations, and it highlights the importance of the assessment process, which is critical in helping determine the best treatment for a given individual. The treatment of drug abuse may occur in different settings, with varying degrees of professional assistance (e.g., self-help/12-step and professional help) and different modalities of professional services (e.g., individual therapy, group therapy, family therapy, and pharmacological treatment). Drug abuse treatment may be characterized as specialized treatment with one main goal: to stop the use of the substance. Treatment is primarily talking therapy—counseling and psychotherapy; in addition, medications may be employed to manage detoxification from some drugs and/or to treat coexisting psychological or medical conditions. However, regardless of the setting of treatment, the intensity of the contact schedule, or who renders the treatment, it is ultimately talking therapy that takes place. Especially early in treatment, the focus of discussion is on behavior directly related to drug use and stopping the use of the drug. Most programs and professionals recommend complete abstinence from drugs; some have the goal of harm reduction (allowing use to continue while attempting to reduce drug use to less harmful levels), but they are in the minority. As treatment progresses, and abstinence is achieved and maintained, the emphasis usually broadens to other areas of the person’s life that may need repair, such as their decision-making skills, coping skills, emotional state, and relationships. In other words, the individual suffers psychological and social damage from drug abuse and may even have had significant deficits in these areas prior to his or her drug abuse; treatment is designed to improve the psychosocial functioning of the individual once he or she is drug-free.
6. Relapse Prevention
Drug abuse has been described as a chronic, relapsing disorder. Like all chronic conditions, long-term effort must be applied for the individual to maintain abstinence from drug use. Nobody would expect the blood sugar levels of someone with diabetes to be in a healthy range if the person only complied with the prescribed care regimen for 1 month after a visit to the physician. Likewise, if a drug abuser only applies the principles of treatment for a limited period of time, resumption of abusive habits would be expected. One way to attempt to guard against a backslide into prior behavior is to extend treatment as long as possible. In addition, teaching relapse prevention skills that an abuser may use going forward in time is an integral part of drug abuse treatment. Some common elements of relapse prevention programs include identification of high-risk situations that are likely to lead to relapse, development and practice of skills to effectively cope with risky situations, enhancement of self-confidence to be able to apply coping skills when needed, learning to limit a slip to an isolated incident rather than allow it to be the beginning of a process of abuse, drug/alcohol monitoring for abstinence verification, and developing positive behaviors (e.g., working and physical exercise).
- Bukstein, O. (1995). Adolescent substance abuse: Assessment, prevention and treatment. New York: Wiley.
- Dodgen, C. E., & Shea, W. M. (2000). Substance use disorders: ssessment and treatment. San Diego: Academic Press.
- Gold, M. S. (1991). The good news about drugs and alcohol: Curing, treating and preventing substance abuse in the new age of biopsychiatry. New York: Villard.
- Kandel, D. (1975). Stages in adolescent involvement in drug use. Science, 190, 912–914.
- Schuckit, M. A. (1995). Educating yourself about alcohol and drugs: A people’s primer. New York: Plenum.
- Shaffer, H. J., & Robbins, M. (1995). Psychotherapy for addictive behavior: A stage-change approach to meaning making. In A. M. Washton (Ed.), Psychotherapy and substance abuse: A practitioner’s handbook (pp. 103–123). New York: Guilford.