SUBSTANCE ABUSE

SUBSTANCE ABUSE is characterized by repeated use of a substance or substances in situations where use leads to—or contributes to—markedly negative outcomes. Defining substance abuse can be difficult. "Substance" refers to the spectrum of drugs that can be potentially abused, such as illicit drugs (marijuana, heroin), licit drugs (alcohol, tobacco), and prescription drugs (Vicodin, Xanax). "Abuse" refers to the use of a substance when it is not medically indicated or when its use exceeds socially accepted levels. Technically, substance abuse is one in a spectrum of substance use disorders outlined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. In order to meet diagnostic criteria, an individual, over the course of one year, must experience one or more of the following: significant impairment in the fulfillment of role obligations due to use of a substance, continued use of a substance in dangerous situations, recurrent substance-related legal problems, or continued use of a particular substance despite having continued social or interpersonal problems caused or compounded by the use of the substance.

The continuum of substance-related disorders begins with substance use, intoxication, and withdrawal, followed by substance abuse, and then dependence. This progression marks an escalation in the use of substances that leads to numerous medical, social, and psychological difficulties. Numerous medical problems have been linked to use of substances. Cigarette smoking, for example, causes heart disease, stroke, chronic lung disease, and cancers of the lung, mouth, pharynx, esophagus, and bladder. Smokeless tobacco can lead to gum recession, an increased risk for heart disease and stroke, and cancers of the mouth, pharynx, and esophagus. Prolonged use of the drug can impair or reduce short-term memory and lead to respiratory problems, cancer, reproductive problems, and immune system problems.

Socially, substance abuse has been implicated in relational, occupational, academic, and living difficulties, such as loss of a job, housing, or a spouse; spousal and child abuse; social rejection; economic collapse; and social isolation. Psychological difficulties can occur, as the repeated misuse of substances can lead to numerous other psychiatric disorders, such as mood and anxiety disorders, sleep disorders, sexual dysfunction, delirium, dementia, amnestic disorder, and psychosis.

Substances of Abuse

In the early 2000s, the three most popular drugs of abuse were alcohol, tobacco, and marijuana. Each has an extensive history dating back thousands of years. Beer was consumed as far back as 8000 b.c. There is evidence of the production of wine as far back as 3000 b.c., and possibly even farther back to 5400 b.c. In the United States, beer tends to have an alcohol content of 3 to 5 percent; wines, 8 to 17 percent; and distilled spirits, 20 to 95 percent. These concentrations often exceed the limit imposed by nature, as alcohol concentrations in excess of 15 percent are toxic to the yeast that help produce alcohol during the fermentation process. Higher concentrations are obtained through the process of distillation. In the United States, alcohol is among the most widely used of the substances of abuse. In 2001 roughly 80 percent of U.S. high school seniors had tried alcohol. Sixty-four percent reported having been drunk at least once in their lives. Approximately 14 million Americans meet the diagnostic criteria for alcohol abuse or alcoholism. It has been estimated that on an annual basis alcohol use leads to the loss of 100,000 lives. Research has demonstrated that alcohol abuse can lead to liver disease, heart disease, cancer, and pancreatitis. Additionally, alcohol use by pregnant women can lead to fetal alcohol syndrome.

Tobacco products are the second most commonly used drug, and are the delivery system for the addictive substance called nicotine. Tobacco products are available in smokable forms such as cigarettes, cigars, and pipes, and smokeless forms such as chewing tobacco and snuff. The tobacco plant is native to the Americas; it is believed that the native peoples used tobacco, in particular during religious ceremonies, long before the arrival of the Europeans to the continent. The consumption of tobacco spread to Europe and beyond as the explorers returned to their countries of origin. Native tobacco is thought to have been much more potent than the current plant and to have contained more psychoactive substances. The Europeans, however, grew different varieties of the plant and arrived at milder versions more like those available in the early 2000s. Production of smoking tobacco was limited until the early 1800s when an American, James Bonsack, patented a machine that could produce 200 cigarettes per minute. This invention allowed for a more affordable product. The popularity of cigarette smoking spread throughout the world, as well as into lower socioeconomic classes within the United States. Tobacco is implicated in 430,000 deaths in the United States each year. In 2001, 61 percent of high school seniors had tried cigarettes and almost 20 percent had tried smokeless tobacco.

The third most commonly misused substance in the United States is marijuana. Marijuana is a plant that contains chemicals that, when smoked or ingested, lead to altered mood states. Marijuana use has been documented as far back as 2737 b.c. in China. In the United States, marijuana was used in the nineteenth century to treat migraine headaches, convulsions, pain, and to induce sleep. Recreational use has been documented to have begun in the 1920s, coinciding with the Prohibition era. At the end of Prohibition, marijuana use dwindled. The Marijuana Stamp Act (1937) required that a tax be imposed on those carrying marijuana. Late in the twentieth century, groups began advocating the legalization of marijuana for medicinal purposes. The first such legislation passed in California in 1996. Arizona, Alaska, Colorado, Hawaii, Maine, Nevada, Oregon, and Washington have since enacted similar laws. Opponents of these laws have launched fierce legal battles. In the meantime, almost half of high school seniors reported in a 2001 survey that they had used marijuana.

Other Substances of Abuse

Barbiturates and similar drugs. Introduced in 1870 as a treatment for sleep disorders, chloral hydrate was a hypnotic drug with a high potential for addiction. Other drugs—paraldehyde and bromide salts—were also used to induce sleep, but they were highly addictive and had other negative side effects. Once barbiturates were introduced in 1903 these drugs were discontinued as a treatment. Barbiturates were used as the primary line of defense against anxiety and insomnia until the introduction of benzodiazepines. Barbiturates are highly addictive, and they serve as a sedative at low doses and as a hypnotic at high doses. In the years 1950 to 1970 barbiturates were the most common drug of abuse, second to alcohol. In 2001 almost 9 percent of U.S. high school seniors reported that they had tried barbiturates.

Benzodiazepines. Drugs such as Librium, Valium, and Xanax fall into this category. When first introduced in the 1960s as an alternative treatment for sleeplessness and anxiety, benzodiazepines were well received by doctors and patients. While benzodiazepines have been popular prescription drugs to treat anxiety disorders, they are also popular drugs of abuse. Overuse of these drugs can lead to respiratory difficulties, sleeplessness, coma, and death.

Amphetamines. This class of medications is used and abused to ward off fatigue and to increase energy. First discovered in 1887, amphetamines were found to have medicinal value in 1927 for breathing disorders such as asthma. It quickly became apparent, however, that a concentrated version of the treatment drug could be used to attain an altered mental state. During World War II, amphetamines were used by soldiers—with the support of the military—to stay awake and work longer periods of time. In the mid-1960s legislation was introduced, such as amendments to the federal food and drug laws, to curb the black market in amphetamines. Many pharmaceutical amphetamine products were removed from the market altogether. More than 16 percent of high school seniors in 2001 reported having tried amphetamines.

Central nervous system stimulants. Central nervous system (CNS) stimulants, which include cocaine and drugs such as ephedrine and methylphenidate (Ritalin), have energizing effects very similar to those of amphetamines. The latter two are of particular importance given their frequent prescription in populations of children. Ephedrine has been used in Eastern medicine for thousands of years but was introduced into the United States and other Western markets much later. The first Western medical journal report of its effectiveness in treating asthma appeared in 1930. Ritalin is used in treating attention-deficit/hyperactivity disorder (ADHD) as well as narcolepsy and depression. ADHD is the most commonly diagnosed childhood disorder. Unfortunately, young children are now buying and selling Ritalin among their peers, leading to problems of abuse by young children as well as medication noncompliance among those youth who have been prescribed the drug.

Cocaine. Cocaine, a by-product of the coca plant, was isolated in the late 1850s and scientists began investigating the potential use of pure cocaine for European and U.S. populations. The leaf was used in a variety of brews, the most popular of which was the initial recipe for Coca-Cola. Reportedly, the Coca-Cola Company did not remove cocaine completely from its recipe until 1929. Sigmund Freud, the renowned psychodynamic clinician, hailed cocaine as a potential cure for depression and some addictions. Cocaine was a valuable anesthetic, providing local, fast-acting, and long-lasting effects during some surgical procedures. Outbreak of cocaine abuse in the United States in the late 1800s and similar ones abroad were thought to be related, however, to the use of cocaine in numerous medical preparations. In 1914 cocaine was officially classified as a narcotic, and its widespread use in the medical community stopped. In the early 2000s, more than 8 percent of high school seniors in the United States had tried cocaine.

Heroin. Heroin is in the opiate family, a broad and complex category that includes drugs such as morphine and codeine. Heroin abuse accounts for 90 percent of the opiate abuse in the United States. Like other substances of abuse, heroin has changed over time from an estimated 6 percent purity in the United States in the 1980s to 65 to 80 percent purity in the early 2000s. During the same period, there has been a reported decrease in price. Perhaps the greatest problem that heroin users face is the exposure to diseases, especially the HIV virus, when using dirty needles to inject the substance. In the early 2000s, almost 2 percent of high school seniors reported having tried heroin in their lifetime.

Hallucinogens. Hallucinogens are drugs that cause hallucinations. Hallucinations may be visual, auditory, or sensory and may produce rapid, intense emotional swings. Lysergic acid diethylamide (LSD) is the most commonly known hallucinogen and is the most widely used. Other hallucinogens include mescaline, psilocybin mushrooms, and ibogaine. Usually thought of as hallucinogens, PCP (phencyclidine) and ketamine were initially developed as general anesthetics for surgery. They distort visual and auditory perceptions and also produce feelings of detachment from the environment and self. They are, more accurately, dissociative anesthetics. In 2001, almost 13 percent of high school seniors had tried some form of hallucinogen.

Inhalants. An unusual class of substances, inhalants can be found among traditional household items and include gasoline, glue, felt-tip pens, pesticides, and household cleaners. The origins of inhalant use are not known for certain, although historical evidence suggests that nitrous oxide had been used recreationally as far back as the 1800s, with gasoline and glue emerging as substances for recreational use in the 1950s. The practice of glue sniffing has been traced to California adolescents who accidentally discovered the intoxicating effects of their airplane model glue. Inhalants have been referred to as "kiddie" drugs because younger rather than older adolescents use them. Of a group of U.S. eighth graders surveyed in 2001, 17 percent reported having tried inhalants.

Treatments for Substance Abuse and Related Disorders

The treatment for substance abuse varies by substance, severity of abuse, and the theoretical approach of the clinician. The main therapy approaches include biological treatments, behavioral therapy, and social treatments. Re-search findings suggest that a combination of therapy approaches is more effective than one approach by itself.

Biological treatments include detoxification, antagonist drugs, and drug maintenance therapy. Detoxification is the process by which a health professional monitors the patient's withdrawal from a drug. Detoxification involves either giving a patient smaller and smaller doses of the drug until the person is no longer taking the drug, or replacing the original drug of abuse with medications that help minimize withdrawal symptoms. Antagonist drugs interfere with the effects of other drugs. Antagonist drugs vary by drug of abuse. Disulfiram (Antabuse), for example, is used for patients trying to end alcohol abuse. Drinking any alcohol while on disulfiram produces a violent physical reaction that includes vomiting, increased heart rate, and other effects. Less common is the use of narcotic antagonists or partial antagonists in the treatment of patients who abuse or are dependent on opioids. Narcotic antagonists block opioids from attaching to endorphin receptor sites, eliminating the "high" and making the abuse pointless. These narcotic antagonists, however, are thought to be too dangerous for regular treatment and are reserved for extreme cases. Finally, drug maintenance therapy has been used primarily for treatment of heroin dependence. A drug such as methadone replaces the heroin, creating an addiction that is medically supervised. For people who are addicted to heroin, the oral medication methadone is cleaner and safer, and its availability through a clinic can eliminate dangerous drug-seeking behaviors.

In the behavioral therapy realm, aversion therapy has been used mostly to treat alcohol abuse and dependence. There are various ways to apply the therapy, which is informed by the principles of classical conditioning. That is, the stimulus, such as alcohol, is paired up with an aversive response that can be a thought or a physiological response such as that of Antabuse. Behavioral self-control training (BSCT) is a cognitive-behavioral treatment also used to treat alcohol abuse and dependence. It involves having the patient track their drinking behaviors as well as emotional, cognitive, and other important changes associated with drinking. In addition to increased awareness, the patient learns coping strategies to better manage their drinking and related cues. A similar approach, also cognitive-behavioral, is relapse-prevention training. In addition to the other BSCT tasks, patients in relapse-prevention training plan ahead, focusing on what is an appropriate amount to drink, what are acceptable drinks, and when it is all right to drink. Relapse-prevention has been used somewhat successfully to treat marijuana and cocaine abuse. Another behaviorally informed approach, contingency management treatment, has been used to treat cocaine abuse. The treatment involves developing a set of incentives that are given once a patient proves, such as through a urine sample, that they are drug-free.

Social treatments have been popular, especially Alcoholics Anonymous, a self-help group in existence since the mid-1930s. Self-help groups are often led by community members and exist outside of professional settings. Alcoholics Anonymous, for example, provides support from peers and guidelines for living with a strong spiritual component. Meetings take place often and regularly. In addition, group members are available to each other around the clock. Similar programs, such as Narcotics Anonymous, are available for other substances. Some self-help groups have expanded into more encompassing settings, offering residential treatment facilities to ease the transition into a drug-free lifestyle.

An important debate in treatment of substance abuse has centered on whether the main goal of therapy is abstinence or reduction. While the traditional approaches—supported by existing laws—advocate for complete abstinence, some people in the field advocate for reducing the harm potential of the use of a substance. Harm reduction programs arrived in the United States in the 1990s, having been successful elsewhere. Advocates of this approach view it as "humane" and "practical" in that it focuses on the effects of the drug (rather than the drug use) and seeks to minimize negative effects for people who use substances and for those around them. This debate is quite charged given that some proponents of harm reduction also support the use of marijuana for medicinal purposes. The intersection of academic perspectives on substance use and social policy makes this area of study controversial.

Prevention Efforts

While the debate on treatments for substance abuse and related disorders will likely continue for some time, both camps would agree that the best treatment for substance abuse is to prevent it altogether. Given the personal and social cost of substance abuse it is not surprising that prevention of drug abuse has, itself, become an important activity. Substance abuse prevention has generally taken the form of suppression or interdiction efforts, although more recent activities have targeted demand reduction.

Suppression efforts include the use of punitive measures to thwart substance use and abuse. Historically, suppression efforts occurred in China in the eighteenth century, when opium-den owners were executed, and in the United States during the period of Prohibition (1920– 1933) when the Eighteenth Amendment to the U.S. Constitution outlawed the production, distribution, or sale of alcoholic beverages. Suppression efforts in the early 2000s centered on enforcing existing laws and establishing new laws designed to stop drug trafficking, distribution, and use. Research has shown that public policy strategies such as raising the minimum drinking age to twenty-one and increasing alcohol prices has resulted in fewer deaths, such as from motor vehicle accidents. In 2002 the Office of National Drug Control Policy requested a budget of $19.2 billion for drug control strategies.

Demand reduction includes all efforts whose primary goal is to decrease the underlying desire for substances to abuse. Demand reduction theorists argue that if there is no market demand for substances, then their use has been effectively prevented. Demand reduction strategies for prevention of substance abuse include a broad range of activities that are designed to stop substance use before it begins, provide people with the tools to prevent relapse, or build resilience among those who are at high risk for substance use. Demand reduction prevention activities can be broadly categorized into three levels: primary, secondary, and tertiary.

Primary prevention activities are intended to reach a broad audience in an effort to avert the onset of use. An example of a primary prevention program is that of Drug Abuse Resistance Education (known as Project DARE), which was developed in the early 1980s as a prevention program targeting substance use by adolescents. In the early 2000s it was implemented in 80 percent of school districts in the United States. In the program, specially trained police officers conduct classroom lectures and discussions on how to resist peer pressure and lead drug-free lives. While Project DARE remains undeniably popular, its effectiveness in reducing substance abuse has been consistently questioned. No scientific study of the program's outcomes has revealed an impact on substance use by youth.

Generally, secondary prevention includes efforts to reduce the underlying causes of substance abuse among populations that are at risk for use. Studies have shown that substance abuse is predicted by both individual and environmental factors. Theories of problem behavior prevention identify the factors that are predictive of a particular problem behavior and target them for intervention. Such predictors are classified as risk or protective factors. Within such a model, a risk factor is any variable that increases the likelihood that a negative outcome will occur, while a protective factor is a variable that decreases the likelihood that a negative outcome will occur. By successfully targeting the appropriate risk or protective factors with a prevention/intervention program, a reduction in negative outcome behaviors may occur.

Tertiary prevention includes activities that are designed to minimize the impact of substance use. The harm reduction approach can be considered a tertiary prevention strategy, inasmuch as it attempts to minimize the harmful consequences of drug use and the high-risk behaviors associated with drug use.

BIBLIOGRAPHY

"Alcohol." National Institute on Alcohol Abuse and Alcoholism. Available at http://www.niaaa.nih.gov/publications/harm-al.htm

Doweiko, Harold E. Concepts of Chemical Dependency. 5th ed. Pacific Grove, Calif.: Brooks/Cole-Thomson Learning, 2002.

"High School and Youth Trends." National Institute on Drug Abuse. Available at http://www.nida.nih.gov/Infofax/HSYouthtrends.html

"Marijuana: Just the Facts." Texas Commission of Alcohol and Drug Abuse. Available at http://www.tcada.state.tx.us/research/facts/marijuana.html

Marlatt, G. Alan, and Gary R. Vanden Bos, eds. Addictive Behaviors: Readings on Etiology, Prevention, and Treatment. Washington, D.C.: American Psychological Association, 1997.

Scott C.Bates

Melanie M.Domenech-Rodríguez

See alsoAlcohol, Regulation of ; Drug Trafficking, Illegal ; Tobacco Industry .