Substance abuse has a substantial and reciprocal impact upon families. There are many definitions of substance abuse and dependence but two authoritative sources are the fourth edition of the Diagnostic and Statistical Manual (DSM-IV-TR) (American Psychiatric Association 1994), commonly used in the United States, and the tenth edition of the International Classification of Diseases (ICD-10) (World Health Organization 1992). The criteria for alcohol abuse in the DSM-IV-TR include drinking despite recurrent and significant adverse consequences due to alcohol use. A diagnosis of alcohol dependence emphasizes a set of psychological symptoms (e.g., craving); physiological signs (e.g., tolerance and withdrawal); and behavioral indicators (e.g., use of alcohol to relieve discomfort due to withdrawal). Unlike the DSM-IV-TR, the ICD-10 does not include a category alcohol abuse, but rather uses the term harmful use, created so that problems related to alcohol use would not be underreported. Harmful use implies use that causes physical or mental damage in the absence of dependence (National Institute on Alcohol Abuse and Alcoholism 1995).
One of the limitations of these classifications (particularly with the DSM-IV-TR) is the lack of attention to cultural variations in the diagnosis of substance abuse (Tang and Bigby 1996). Around the world, substance use and abuse take on different meaning and importance. For example, there are different cultural norms about the legal drinking age. The legal age for purchasing alcohol in many European countries is sixteen years (in Denmark it is fifteen) (Eurocare 2001). Among indigenous groups, alcohol and other drugs may be integrated parts of tribal and community existence (Charles et al. 1994) where conventional definitions of abuse and dependence may be not be held. The definitions of substance abuse used in this entry tend to reflect the conventions of the nonindigenous cultures of North America because most of the research cited tends to use the DSM in its various editions. However, to maximize a cross-cultural perspective, multicultural and international studies are also referenced.
The emphasis in this entry is on reporting the evidence base for understanding substance abuse and the family. Popular but evidence-limited notions of the cause, effect, or treatment of substance abuse will not be included.
Prevalence and Incidence
International data suggest widespread and serious substance use and abuse. Within the United States, the annual National Household Survey on Drug Abuse (NHSDA) collects data on substance use patterns and trends among the general population. According to the 2001 NHSDA, 6.3 percent (14 million) of the U.S. population reported current use of illicit drugs (i.e., used an illicit drug at least once during the thirty days before the interview) (Substance Abuse and Mental Health Services Administration 2001). Among major racial/ethnic groups, the current rates for illicit drug use were 6.4 percent each for whites and African Americans and 5.3 percent for Hispanics/Latinos. The rate was highest among American Indian/Alaska Natives (12.6%), with Asians reporting the lowest rate (2.7%). Almost half (46.6%, approximately 104 million) of the U.S. population reported current use of alcohol. Almost 6 percent of the population (5.6%, 12.6 million) were heavy drinkers, consuming five or more drinks on one occasion in five or more days during the thirty days prior to interview.
Although trends in the United States and in other developing countries indicate either flat or declining alcohol use, rates are rising in many developing countries and in Central and Eastern Europe (World Health Organization 2001). One source has noted that "dangerous patterns of heavy drinking exist in most countries" (World Health Organization 2001, p. 1). With respect to illicit drug use, estimates for 1999 indicate 3 percent (180 million people) of the world's population consumed illicit substances (United Nations Office for Drug Control and Crime Prevention 2001). The most commonly consumed substance was cannabis, used by 2.4 percent (144 million people) of the world's population.
Because of the widespread abuse of substances among the world's population, there are likely to be substantial family effects. The next section reviews some of these findings.
Effects of Substance Abuse on Families
The effects of substances on couple and family relationships are both direct and indirect—and substantial. Due to limitations of the research designs, many findings are correlational and not causal. Thus, although many effects are associated with substance use, it is sometimes unclear whether the substance use is the cause or the effect.
Financial effects on families. Substance abuse by family members can have a substantial negative effect on the financial viability of caregivers. Substance-abusing caregivers may spend money allocated for food or clothing for children. Substance abusers may divert money from rent or mortgages to buy substances. Noncustodial parents who abuse alcohol are less likely to provide financial support for their children (Dion et al. 1997). In Yemen and Somalia, users may spend as much on khat (a type of stimulant) as they spend on food (Abdul Ghani et al. 1987). Additionally, families are often unwitting accomplices to their relative's substance abuse as the substance use is often financed by immediate family members (Gearon et al. 2001).
Fetal exposure to alcohol and other drugs. There is considerable evidence for the effects of maternal substance use on the development of the fetus. Specifically, childhood developmental problems have been associated with maternal substance use. For example, prenatal alcohol exposure can lead to mental retardation, behavioral and neurological problems that may lead to poor academic performance, and legal and employment problems in youth and adulthood (National Institute on Alcohol Abuse and Alcoholism 2000). However, researchers do not know how much alcohol produces adverse fetal consequences. Thus, experts recommend that pregnant women should not consume alcohol (National Institute on Alcohol Abuse and Alcoholism 2000).
Early family environment. In addition to the direct effects of substances on the unborn child, the early social environment of children with substance-abusing parents adds potential risks. A high percentage of children in contact with the child welfare system have substance-abusing parents ( Jones-Harden 1998). Reviews have consistently documented the association between parental substance abuse and poor parenting skills ( Jones-Harden 1998). The type of child maltreatment often associated with these cases includes physical, medical, and emotional neglect (Hawley et al. 1995; Jones-Harden 1998). Research in Israel documented the ill effects of severe environmental deprivation when both parents are heroin-addicted and noted that the early home environment has a greater influence than in-utero exposure on developmental outcomes, as long as there is no significant neurological damage (Ornoy et al. 1996). Other research has found that a positive postnatal caregiving environment can attenuate some of the negative effects of prenatal exposure to substances ( Jones-Harden 1998; McNichol and Tash 2001).
Child and adolescent problems. Children with family histories of substance abuse differ from children without such histories in higher levels of aggression, delinquency, sensation-seeking, hyperactivity, impulsivity, negative affectivity (Dore et al. 1996; Giancola and Parker 2001), anxiety, and lower levels of differentiation of self (Maynard 1997). Family history of alcohol dependence, through a moderating influence of adolescent drug dependence, has predicted poor adolescent neuropsychological functioning (i.e., language and attention functioning) (Tapert and Brown 2000). On the other hand, youth without family histories of alcohol dependence seemed to be protected from poorer neuropsychological functioning (Tapert and Brown 2000).
Relational distress, partner and family violence. A nationwide study of married and cohabiting couples found that partners tend to share similar drinking patterns and when there are differences in the amounts of alcohol consumed, couples tend to have serious relationship problems including alcohol-related arguments and physical violence (Leadley, Clark, and Caetano 2000). Alcohol frequently plays a role in intimate partner violence. National surveys in the United States have reported that 30 to 40 percent of men and 27 to 34 percent of women who perpetrated partner violence were drinking at the time (Caetano, Schafer, and Cunradi 2001). The study also revealed that alcohol-related problems were related to partner violence among African Americans and whites, but not among Hispanics/Latinos.
In sum, there appear to be substantial effects of substance abuse on family and couple relationships. The next section reviews the evidence for factors that contribute to or protect from the risk for substance abuse.
Family Factors Contributing to Risk and Resiliency
Substance abuse is the result of a complex interaction of individual, family, peer, community, and societal factors (United Nations Office for Drug Control and Crime Prevention 2000). A consistent global finding is that substance abuse runs in families. A family history of drug abuse and dependence substantially increases the risk for such problems among members (Madianos et al. 1995; Wester-meyer and Neider 1994; Wu et al. 1996). The same pattern occurs with alcohol abuse and dependence (Curran et al. 1999; Jauhar and Watson 1995). Although genetics plays a substantial role in both alcohol (Bierut, Dinwiddie, and Regleiter 1998) and drug dependence (Tsuang et al. 1996), the family environment plays a role in both promoting and protecting from substance abuse and dependence. This section reviews some of these factors. Due to the limitations of the research designs, many of these findings are correlational and not causal.
Child physical and sexual abuse. Although much of the research is limited in design (e.g., retrospective designs, clinical samples), childhood abuse appears to be a risk factor for substance abuse. Women who were physically or sexually abused as children are at risk for alcohol abuse as adults (Langeland and Hartgers 1998; Rice et al. 2001) but the evidence for males is contradictory (e.g., contrast Galaif et al. 2001 and Langeland and Hartgers 1998). Childhood sexual abuse may also increase the risk for adolescent drug abuse among females ( Jarvis, Copeland, and Walton 1998). Tracey Jarvis and colleagues speculated that the use of drugs might be an effort to self-medicate the emotional pain associated with the abuse.
Family attitudes and practices about substance abuse. Although peer influences are important in explaining substance use among youth (Lane et al. 2001), family attitudes and practices are also significant. Among Hispanic/Latino youth in particular, parents have been more influential than peers (Coombs, Paulson, and Richardson 1991). Family members' attitudes about and use of substances influence youth substance use. For example, an analysis of the 1997 household survey on substance use found that youth ages twelve to seventeen who perceived that their parents would be "very upset" with marijuana, cigarettes, and binge drinking reported the lowest prevalence of use of these substances in the past year (Lane et al. 2001). Similarly, the protective influence of strong family sanctions against alcohol use reduced the use of that substance among girls in Hungary (Swaim, Nemeth, and Oetting 1995). The level of influence seems to extend to siblings. In one household study in Canada, older sibling drug use, more than parental drug use, was the dominant influence of substance use among youth (Boyle et al. 2001).
Problematic family and partner relations. Family and partner conflict tends to increase risk for substance abuse. The national household survey in the United States found that adolescents who argued with their parents at least several times a week were more likely to have used marijuana in the past year than those who argued with their parents only once a week to once a month (Lane et al. 2001). Internationally, family conflict and lower perceived family caring increases the risk for adolescent substance abuse (Al-Umran, Mahgoub, and Qurashi 1993; Nappo, Galduroz, and Noto 1996; Swaim, Nemeth, and Oetting 1995).
Marital and family conflict appear to increase risk for alcoholism among women in Zagreb (Breitenfeld et al. 1998). Over three-quarters of 100 males admitted for alcohol abuse in Scotland ascribed their marital breakdown or family neglect to their drinking ( Jauhar and Watson 1995).
Family structure. Studies of family structure around the world have found that youth who live with both biological parents are significantly less likely to use substances, or to report problems with their use, than those who do not live with both parents (Challier et al. 2000; Johnson, Hoffman, and Gerstein 1996). However, family structure alone does not appear to explain substance abuse. The characteristics of these family structures offer some clues. For example, boys who are in care of their mothers and whose fathers are drug abusers are at increased risk for drug abuse but this is due to the genetic transmission of risk and lack of resources for effective parenting for single mothers (Tarter et al. 2001). Studies in Brazil and Saudi Arabia have noted that the quality of family relationships was more important than structure in explaining substance use (Al-Umran, Mahgoub, and Qurashi 1993; Carvalho et al. 1995).
Disruptions in the family life cycle seem to characterize these single-parent households. An unstable family environment (i.e., father absence, one or both parents who had immigrated, or death of parents) was associated with substance abuse among a nationwide sample of youth in Greece (Madianos et al. 1995). White non-Hispanics/Latinos and African Americans in changed families (e.g., those that changed from two parents to single parents during the study) had the highest rates of substance initiation (Gil, Vega, and Biafora 1998). Moreover, deteriorating family environments were stronger influences of drug initiation among Hispanic/Latino immigrants than nonimmigrants to the United States. Among African Americans, family structure and environment had the weakest effect on substance use and African-American youth in the care of their mothers or other adult family members, had the lowest proportion of drug onset (Gil, Vega, and Biafora 1998).
Thus, family structure along with characteristics of these families seems to account for substance abuse. More research is needed on the quality of the relationships within these family structures and on the time-order of the onset of substance use among youth with different family structures ( Johnson, Hoffman, and Gerstein 1996).
Protective family factors that mitigate risk for substance abuse. Although they may place members at risk of substance abuse, family factors may also be protective. As noted above, two-parent households appear protective. High levels of perceived support from family members seems to protect against youth alcohol use (Foxcroft and Lowe 1991) and drug use among Hispanics/Latinos (Frauenglass et al. 1997) and African Americans (Sullivan and Farrell 1999). Researchers have found that effective family relationships (e.g., family involvement and communication, proactive family management, or attachment to family) protect against adolescent substance abuse across racial and cultural groups (Carvalho et al. 1995; Stronski et al. 2000; Williams et al. 1999). Further, the positive effects of family support during adolescence seem long lasting. Greater family support and bonding during adolescence has predicted less problem alcohol use in adulthood (Galaif et al. 2001).
In families with substance-abusing parents, there may be influences that protect from abuse. Preliminary research has suggested that a factor that provides some protection for children in homes with substance-abusing parents is the availability of a stable, nurturing relative such as grandmothers or aunts ( Jones-Harden 1998). In research in Colombia, the adverse effects of parental substance abuse were buffered by effective parent-child rearing practices (Brook et al. 2001).
Protection extends beyond parents to siblings. One study reported that older brother abstinence from drugs, as well as strong attachment to parents, explained reduced drug use among younger brothers (Brook, Brook, and Whiteman 1999).
In sum, the risk and protective factors suggest that family relationships have a significant impact on substance abuse and dependence. However, the research is not sufficiently developed to indicate which or how much of these protective factors are necessary to reduce risk. There are variations across groups and in timing in their importance for preventing or reducing risk (Gil, Vega, and Biafora 1998). Further, the risk and protective factors at other levels, such as community or societal, may mitigate or attenuate risk.
Treatment for Substance Abuse
A common reason for seeking treatment for substance abuse is a problem with interpersonal relationships (Tucker and Gladsojo 1993). Given the evidence showing the influence of family and social relationships on substance abuse, cited above, treatment attempts to improve the quality of inter-personal relationships and to teach problem solving skills to couples and families with a substanceabusing member. Interactions between family members are important in the etiology and maintenance of substance use. Family interactions are interdependent and, over time, become patterns of behavior that the family maintains. Family interventions focus on identifying and changing the patterns that support the problematic substance use. Some family-based interventions also acknowledge that the family system is maintained in a broader context of peers, work, school, and neighborhood and attempt to engage elements from these systems in therapy. Although there are different models of family-based interventions, the common focus is on changing the patterns of interaction within the family (Robbins and Szapocznik 2001).
Reviews of the substance abuse treatment literature in the mid-1990s noted that modest benefits could be ascribed to family-based interventions (Edwards and Steinglass 1995; Liddle and Dakof 1995). The reviews concluded that although the research at that time indicated the promise of family-based interventions, there were not enough randomized clinical trials to warrant an endorsement of efficacy, defined as a high degree of confidence that the intervention reduced or eliminated substance abuse.
Treatment of alcohol abuse and alcohol dependency. Three interventions that effectively reduce alcohol abuse and dependency among adults are Behavioral Couples (or marital) Therapy (BCT), Behavioral Family Therapy (BFT), and the Community Reinforcement Approach (CRA). BCT is highly structured and guided by a treatment manual principally developed by Timothy O'Farrell, Barbara McCrady, and their colleagues (Fals-Stewart, Birchler, and O'Farrell 1996; McCrady 2000; O'Farrell, Van Hutton, and Murphy 1999). Early sessions focus on helping the couple to increase positive verbal exchanges and behaviors. Later sessions build skills at positive marital communication and problem solving. Sessions include review of disulfiram (an alcohol antagonist) contracts, homework assignments, and the client's drinking or urges to drink. Sessions continue with the introduction of new material, modeling of new skills by the therapist, and rehearsal of the skills by the couple. To complement the approach, a module of fifteen sessions is used to establish and maintain a relapse prevention plan that includes how to identify and manage warning signs of lapses.
BFT, an efficacious and promising intervention across groups and substances (Azrin et al. 1996; Edwards and Steinglass 1995; Stanton and Shadish 1997), is based on the assumption that behaviors are maintained by consequences. Change is unlikely to occur unless more rewarding consequences result from different behaviors. For example, parent skills training, a feature of BFT, teaches parents to increase reward for positive behaviors and ignore negative behaviors to produce change. A strategy often used is to improve communication between the parents and the adolescent.
CRA is an efficacious and comprehensive intervention that involves spouses, family members, and others in the drinker's social network to change the marital, familial, and social reinforcers that support the drinker's behavior (Kirby et al. 1999; Miller, Meyers, and Hiller Sturmhoefel 1999). Beginning with a functional analysis of the drinking behavior (i.e., a review of persons, places, and contexts that act as triggers for substance use behavior), significant others are trained to help the drinker to engage in treatment and to remove positive reinforcers during drinking episodes. Drink refusal skills, relaxation, control of drinking urges, and methods to deal with risky social situations are taught. Often disulfiram contracts are included.
Two other interventions that show promise in reducing alcohol abuse and dependency are Functional Family Therapy (FFT) and Multi Systemic Family Therapy (MSFT). FFT is a manually guided intervention involving eight to thirty sessions spread over a three-month period (Stanton and Shadish 1997; Weinberg et al. 1998). The approach evolved from the need to serve at-risk adolescents and their families with few resources or who were difficult to treat. FFT has phases that consist of engagement and motivation, behavior change, and generalization. Each phase involves assessment and intervention. For example, in the engagement and motivation phase, assessment focuses on the level of negativity and blaming in family exchanges. The intervention in this phase would target the development of behaviors and communication that reduce negativity and blaming. Similarly, in the generalization phase, assessment identifies the range of situations to which the family can apply new behaviors. The objective of intervention in this phase would be to maximize the functional range of the family's new behavior(s).
MSFT views substance abuse as antisocial behavior that develops from a complex network of interconnected systems: the individual, the family, and extrafamilial factors such as peers, school, and neighborhood (Henggeler, Pickrel, and Brondino 1999; Schoenwald et al. 1996). The intervention is primarily targeted to adolescents. MSFT attempts to alter parenting skills and resources as well as improve the adolescent's coping skills. The intervention integrates strategic family therapy, structural family therapy, behavioral parent training, and cognitive-behavioral therapy. The home-based intervention is designed to reduce service barriers, increase family retention in treatment, allow for the provision of intensive therapy, and enhance treatment gains. MSFT is designed for approximately sixty hours of contact with the family, but family needs determine the frequency and duration of contact.
Treatment of drug abuse and drug dependency. Although some of the interventions described above are useful in treating drug abuse and dependency, Brief Strategic Family Therapy (BSFT), Multidimensional Family Therapy (MDFT) and the Matrix model (MM) are also promising. BSFT and MDFT target adolescent drug abuse. BSFT is a short-term, problem-focused intervention based partly on classical and operant conditioning (Stanton and Shadish 1997; Szapocznik and Williams 2000). Substance abuse is viewed as the result of problematic family interactions that are rewarding based on familiarity and habit. The focus of the intervention is on improving family interactions so that new behaviors are rewarded and replace the substance abuse by the family member. The techniques used in this process are joining (engaging and entering the family system), diagnosing (identifying the maladaptive interactions as well as the family strengths), and restructuring (transforming maladaptive family interactions). BSFT is delivered in twelve to fifteen sessions over three months. BFST was developed for application with inner city Hispanic/Latino and African-American families. Therapists are trained to assess and facilitate healthy family interactions based on the cultural norms of the family.
MDFT views the development of adolescent drug use as the result of individual, family, peer, and community influences (Liddle and Dakof 1995; Schmidt, Liddle, and Dakof 1996). Reducing unwanted behavior and increasing desirable behavior occurs in multiple ways and within different settings (e.g., in the home, school, and community). MDFT interventions typically include individual sessions held in parallel with family sessions. In the individual sessions, adolescents learn effective decision making, negotiation, and problem-solving skills. In the family sessions, parents identify their parenting style and learn positive developmentally appropriate skills to influence their child's behavior.
The MM recognizes the important influence of the family on the development, maintenance and consequences of drug abuse (Rawson et al. 1995; Shoptaw et al. 1994). The intervention includes family education groups to assist families in understanding the effects of the drug abuse of the member. The intervention requires therapists to use nonconfrontational methods to promote the individual's self-esteem, dignity, and self-worth. Sessions include early recovery skills groups, conjoint sessions, family education groups, twelve-step programs, relapse analysis, and social support groups.
Much progress has been made in understanding the relationship between substance abuse and the family. Family factors have an important role in explaining the onset, development, and amelioration of substance abuse. Encouraging gains have been made in treating couples and families with substance abuse problems. More research is needed involving diverse and international populations, but efficacious treatments are growing in type and number that bodes well for improving the lives of millions worldwide.
See also:Child Abuse: Physical Abuse and Neglect; Child Abuse: Sexual Abuse; Childhood, Stages of: Adolescence; Children of Alcoholics; Chronic Illness; Codependency; Conduct Disorder; Developmental Psychopathology; Family Rituals; Health and Families; Homeless Families; Juvenile Delinquency; Therapy: Couple Relationships
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MARK J. MACGOWAN
CHRISTOPHER P. RICE
Substance abuse is an unhealthy pattern of alcohol or drug use that usually leads to frequent, serious problems.
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The statistics are startling: In 1998, 1 out of every 10 young people ages 12 through 17 in the United States said they were a current user of illegal drugs. In that same year, over 10 million Americans under age 21 reported that they drank alcohol. Of this group, 5 million were binge drinkers, meaning they drank five or more drinks at one time. This group also included 2 million who were heavy drinkers, meaning they drank five or more drinks on five or more days during the previous month.
Substance abuse is an unhealthy pattern of alcohol or drug use that usually leads to frequent, serious problems at home, school, or work. Substance abuse also can cause stress in relationships. For example, a teenager might get into frequent arguments with parents or fights with friends. Substance abuse can even lead to trouble with the law. For example, a young person might be arrested for underage drinking or disorderly conduct. People who abuse substances also may put themselves in dangerous situations, such as driving under the influence of alcohol or drugs or having unsafe sex.
Substance abuse is one step along the path from occasional drinking or drug use to outright addiction (ad-DIK-shun). When people are addicted, they develop a strong physical or psychological need for a substance. One hallmark of addiction is tolerance (TOL-er-uns). This means that over time, people start to need more and more of a substance to get drunk or feel high. Another is withdrawal, which means that people who are addicted will have physical symptoms and feel sick if they stop using the substance.
Drugs and alcohol cause intoxication (in-TOK-sih-KAY-shun), the medical term for a temporary feeling of being high or drunk that occurs just after using a drug. Intoxication leads to changes in the way people think and act. For example, people may become angry, moody, confused, or uncoordinated. These changes increase the risk that people will make poor choices, have accidents that hurt themselves or others, or behave in a way that they will later regret.
People give many reasons for starting to drink alcohol or use drugs. Some teenagers are looking for an easy way to escape stress at home, school, or elsewhere. Others hope that alcohol or drugs will help them fit in or make them seem older. Some may be using substances to“treat” or“self-medicate”depression or boredom. Still others are simply curious. Whatever the original reason, no one can say for sure which teenagers will go on to have a serious substance abuse problem. However, certain factors raise the risk that this will happen. Risk factors for substance abuse include:
Everyone Isn’t Doing It
Sometimes it can seem as if everybody else is drinking alcohol, smoking cigarettes, or using drugs. Monitoring the Future is a yearly survey, funded by the U.S. National Institute on Drug Abuse, that aims to find out just how common substance abuse really is among teenagers in eighth through twelfth grades. The facts are:
- 1999 was the third year in a row that drug use in this age group stayed the same or went down for most substances.
- Among eighth-graders, half had never drunk alcohol, 3 out of 5 had never smoked cigarettes, and 4 out of 5 had never used marijuana.
- Among twelfth-graders, 9 out of 10 had never tried cocaine or LSD, and 98 percent had never tried heroin.
- family history of substance abuse
- using alcohol or tobacco at a young age
- low self-esteem
- feeling like an outsider
- child abuse or neglect
- family stress
Some of these factors can be changed or controlled by the teenagers themselves, but others cannot. However, that does not mean that those who come from stressed families or poor neighborhoods are doomed. Certain other factors raise the odds that young people will be able to cope with problems without turning to alcohol or drugs. These factors include:
- learning to do something well
- being active at school or in church
- having a caring adult to talk to
People abuse an amazing variety of drugs, both legal and illegal. Legally available substances include alcohol, tobacco, chemicals in certain household products, drugs bought in a drugstore, and medicines prescribed by a doctor. Illegally sold substances include numerous street and“party”drugs.
Alcohol affects virtually every organ in the body, and longtime use can lead to a number of medical problems. The immediate effects of drinking too much include slurred speech, poor coordination, unsteady walking, memory problems, poor judgement, and the inability to concentrate. Drinking too much alcohol at one time can cause alcohol poisoning and sudden death. The recklessness that comes from drinking too much also is a leading cause of traffic accidents and other injuries. In addition, alcohol drinking by pregnant women is the cause of the most common preventable birth defect, called fetal alcohol syndrome. Long-term risks of heavy drinking include liver damage, heart disease, sexual problems for men, and trouble getting pregnant for women.
Tobacco contains nicotine (NIK-o-teen), a highly addictive chemical. Nicotine is readily absorbed from tobacco smoke in the lungs, whether the smoke comes from cigarettes, cigars, or pipes. Smoking is the number one cause of preventable death in the United States. The longterm health risks include cancer, lung disease, heart disease, and stroke. Smoking by pregnant women also has been linked to miscarriage*, stillbirth* premature* birth, low birth weight*, and infant death. Nicotine is readily absorbed from smokeless tobacco as well. Like smoking, dipping or chewing tobacco can have serious longterm effects, including cancer of the mouth, gum problems, loss of teeth, and heart disease.
- * miscarriage
- is the loss of a fetus before birth.
- * stillbirth
- is the birth of a dead baby or fetus.
- * premature (pre-muh-CHOOR) birth
- means born too early. In humans, it means being born after a pregnancy term of less than 37 weeks.
- * low birth weight
- means born weighing less than normal. In humans, it refers to a baby weighing less than 5.5 pounds.
Inhalants (in-HALE-ants) are substances that a person can sniff (“huff”) or inhale to get an immediate “rush” or high. They include a varied group of chemicals that are found in household products such as aerosol sprays and cleaning fluids. Using inhalants even one time can lead to suffocation, severe mood swings, seeing or hearing things that are not really there, and numbness or tingling of the hands and feet, and even sudden death. Long-term use can lead to permanent brain damage, headache, muscle weakness, stomach pain, loss of the sense of smell, nosebleeds, liver disease, kidney damage, lung disease, violent behavior, irregular heartbeat, dangerous chemical imbalances in the body, and loss of control over urination.
Marijuana (mar-ih-HWAH-nuh; nicknames: pot, herb, weed, blunts, Mary Jane) is the most widely used illegal drug. It is typically the first illegal drug tried by teenagers. It is a mixture of dried, shredded flowers and leaves from the cannabis plant. Marijuana usually is smoked in a cigarette, pipe, or water pipe, but some users also mix it with foods or use it to brew tea. Short-term effects of marijuana use include euphoria*, sleepiness, increased hunger, trouble keeping track of time, memory problems, inability to concentrate, poor coordination, increased heart rate, paranoia* and anxiety. Long-term risks include lung disease, changes in hormone levels, lower sperm counts in men, and trouble getting pregnant in women.
- * euphoria
- is an abnormal, exaggerated feeling of well-being.
- * paranoia
- refers to either an unreasonable fear of harm by others (delusions of persecution) or an unrealistic sense of self-importance (delusions of grandeur).
Hallucinogens (huh-LOO-sih-no-jenz) are drugs that distort a person’s view of reality. They include LSD (short for lysergic acid diethylamide; nickname: acid), PCP (short for phencyclidine; nicknames: angel dust, loveboat), psilocybin (SY-lo-SY-bin; nickname: magic mushrooms), mescaline (MES-kuh-len), and peyote (pay-YO-tee or payYO-tay). People who use these drugs may lose all sense of time, distance, and direction. They also may behave strangely or violently, which can lead to serious injuries or death. Since everyone reacts differently to hallucinogens, however, there is no way to tell in advance who will have a bad experience.
- LSD is one of the most potent of all mind-altering drugs. It may be taken in pills. A drop may be placed on a square of paper and eaten. LSD can last a long time in the body—up to 12 hours. The physical effects of LSD use include dilated (widened) pupils, increased heart rate, higher blood pressure, sweating, loss of appetite, trouble sleeping, dry mouth, and shaking. The psychological effects are much more dramatic, however. Users may feel several different emotions at once, or they may swing from one emotion to another, euphoria to paranoia. They may have bizarre or terrifying thoughts, or they may see things that are not really there, like walls melting. Some users later have flashbacks, in which they relive part of what they experienced while taking the drug, even though the drug use has stopped.
Same Problem, Different Solution
In the United States, using and selling drugs such as marijuana and heroin is illegal, and people who break the drug laws go to jail. In the Netherlands, the government is trying a different approach that stresses treatment rather than punishment.
In the mid-1970s, the Netherlands was hit by a sharp upswing in heroin use. In response, the government launched a policy called harm reduction, which aims to lower the harmful effects of drug use for both users and society. The policy is based on the belief that“soft”drugs, such as marijuana and the related drug hashish (hah-SHESH), are less dangerous than“hard”drugs, such as heroin, cocaine, amphetamines, and MDMA. To encourage people not to try hard drugs, the government allows the sale of small amounts of marijuana and hashish in adults-only coffee shops, much the way alcohol is sold in bars. Hard drugs are still banned, but users are treated as people with an illness rather than as criminals.
There is much debate over how well this policy works. However, the number of drug addicts in the Netherlands is lower than in many countries. In addition, the average age of addicts is rising, which suggests that fewer young people are getting hooked. On the other hand, the rate of marijuana and hashish use has gone up in recent years, although it is still lower than in the United States. Another problem is the rise of Dutch crime gangs that are selling illegal drugs throughout Europe.
- PCP can be snorted through the nose, smoked, or eaten. It has a bad reputation for causing bizarre and sometimes violent behavior. Other possible effects of PCP use include increased or shallow breathing rate, higher blood pressure, flushing, sweating, numbness, poor coordination, and confused or irrational thinking. High doses can lead to seeing or hearing things that are not really there, paranoia, seizures, coma, injuries, and suicidal behavior.
Stimulants (STIM-yoo-lunts) are drugs that produce a temporary feeling of euphoria, alertness, power, and energy. As the high wears off, however, depression and edginess set in. Stimulants include cocaine (ko-KANE; nicknames: coke, snow, blow, nose candy),“crack”cocaine, amphetamine (am-FET-uh-mean), methamphetamine (METH-am-FETuh-mean; nicknames: speed, meth, crank), and crystallized methamphetamine (nicknames: ice, crystal, glass).
- Cocaine is a white powder that is either snorted into the nose or injected into a vein. Crack is a form of cocaine that has been chemically changed so that it can be smoked. Both forms are very addictive. Possible physical effects of cocaine and crack use include increased heart rate, higher blood pressure, increased breathing rate, heart attack, stroke, trouble breathing, seizures, and a reduced ability to fight infection. Possible psychological effects include violent or strange behavior, paranoia, seeing or hearing things that are not really there, feeling as if bugs are crawling over the skin, anxiety, and depression. In the end, cocaine addicts often wind up losing interest in food, sex, friends, family—everything except getting high.
- Methamphetamine is taken in pills, or it can be snorted or injected. Crystallized methamphetamine is a more powerful form of the drug that is smoked. Both forms are highly addictive. Possible physical effects of methamphetamine use are similar to those of cocaine. Possible psychological effects include trouble sleeping, crankiness, confusion, anxiety, paranoia, and violent behavior. In the 1960s and 1970s there was a popular expression,“Speed kills.”This saying was meant to alert users to the sad end of methamphetamine addiction.
Narcotics (nahr-KOT-iks) are addictive painkillers that produce a relaxed feeling and an immediate high, followed by restlessness and an upset stomach. They can also be deadly. Drugs in this class include heroin (HAIR-oh-in; nicknames: smack, H, skag, junk), morphine (MORfeen), opium (OH-pee-um), and codeine (KO-deen).
In Amsterdam, the Netherlands, marijuana use is legal. The city has coffee shops such as this one, in which people are free to purchase and use the drug. Corbis
- Heroin is made from morphine, a natural substance that comes from the poppy plant. It is a powder that is injected, snorted, or smoked, and it is highly addictive. Immediate effects of heroin use include a heavy feeling in the arms and legs, warm flushing of the skin, dry mouth, clouded thinking, and going back and forth between being wide awake and feeling drowsy. In addition, street heroin varies in strength, and users never know if they are getting a particularly strong dose. If they do, they can easily overdose (“OD”), resulting in coma or death. Long-term effects include collapsed veins, infection of the heart lining and valves, liver disease, and HIV/AIDS from sharing needles.
Sedatives (SED-uh-tivz), sometimes called as tranquilizers (TRANK-will-LY-zerz) or sleeping pills, include barbiturates or“downers.”They are drugs that produce a calming effect or sleepiness. Physicians prescribe them to relieve anxiety, promote sleep, and treat seizures. When they are abused or taken at high doses, however, many of these drugs can lead to loss of consciousness or even death. Combining sedatives with alcohol is particularly dangerous. Possible effects of sedative abuse include poor judgment, slurred speech, staggering, poor coordination, and slow reflexes.
Club drugs are drugs that are mainly used by young people at parties, clubs, and bars. While users may think these are harmless fun drugs, research has shown that they can cause serious health problems and sometimes even death. When combined with alcohol, they can be particularly dangerous. Drugs in this category include MDMA (nicknames: ecstasy, Adam, XTC) GHB (nicknames: liquid ecstasy, Georgia home boy), Rohypnol (nicknames: roofies, roach), and ketamine (nickname: special K).
Cocaine is a mood-altering drug that interferes with normal transport of the neurotransmitter dopamine, which carries messages from neuron to neuron. When cocaine molecules block dopamine receptors, too much dopamine remains active in the synaptic gaps between neurons, creating feelings of excitement and euphoria.
- MDMA or XTC combines some of the properties of hallucinogens and stimulants. Possible effects include euphoria, confusion, paranoia, increased heart rate, higher blood pressure, blurred vision, faintness, chills, and sweating. Because this drug is increasingly abused at dances, kids may forget to drink, become dehydrated, and need to be rushed to the emergency room for immediate treatment. Possible psychological effects include confusion, depression, sleep problems, anxiety, and paranoia. Recent research also has linked MDMA to long-term damage in parts of the brain that are critical for thought, memory, and pleasure.
- GHB, Rohypnol, and ketamine are often colorless, tasteless, and odorless, which makes it easy for someone to slip one of these drugs into another person’s drink. As a result, these substances are sometimes called“date rape”drugs, because they have been used in rapes against women who were drugged unknowingly. To make matters worse, people may be unable to remember what happened to them while they were under the influence of one of these drugs.
C. J. Hunter, world shotput champion, breaks down during a press conference at the 2000 Summer Olympic Games. It had just been revealed that Hunter was using a steroid banned for all Olympic athletes. AFP/Corbis
Anabolic steroids (AN-uh-BOL-ik STER-oidz) are drugs that are related to testosterone (tes-TOS-tuh-rone), the major male sex hormone. While these drugs have medical uses, many athletes and bodybuilders today are abusing them because they can increase muscle build-up with weight lifting or strength training. Although steroids may seem like a shortcut to improved sports performance and a more muscular body, they carry serious health risks. In boys and men, steroids can reduce sperm production, shrink the testicles, enlarge the breasts, and cause problems with sexual performance. In girls and women, they can lead to unwanted body hair, a deep voice, and irregular periods. Steroids also can damage the heart, liver, and kidneys. In teenagers, they can stunt bone growth, making the person reach a shorter final height than he or she would have otherwise. High doses of testosterone can also cause outbursts of aggressive or violent behavior (“steroid rage”).
One thing most abused drugs have in common is that they can lead to unclear thinking and unpredictable behavior. Many also cause poor coordination and slow reflexes. It is little wonder, then, that substance abuse is closely tied to accidents and injuries. Alcohol and other drugs play a role in half of all fatal car crashes, which are the leading cause of death in young people. Alcohol also is involved in nearly 60 percent of fatal falls and at least half of adult drownings.
Substance abuse is also now the single biggest factor in the spread of infection with HIV (human immunodeficiency virus), the virus that causes AIDS, in the United States. It is a direct cause, because many drugs are injected into a vein, and people can catch HIV by using or sharing unclean needles. It is also an indirect cause, because people whose thinking is clouded by alcohol or other drugs are more likely to have unsafe sex, which increases their risk of catching HIV from an infected partner.
Substance abuse can lead to physical and psychological problems that affect people’s relationships and everyday lives. Typical warning signs of substance abuse in young people include:
- Physical: tiredness, unexplained health problems, red and glazed eyes, long-lasting cough
Anyone who needs one more reason to avoid substance abuse should consider the latest statistics on alcohol, drugs, and violence.
- Alcohol is a key factor in more than 60 percent of assaults and over half of murders or attempted murders in the United States.
- Over 40 percent of convicted rapists say they were under the influence of alcohol or other drugs at the time of their crime.
- Almost two-thirds of reported child abuse and neglect cases in New York City have been linked to alcohol or drug use by the parent.
- Up to 35 percent of suicide victims have a history of alcohol abuse or were drinking shortly before they killed themselves.
- Psychological: personality changes, sudden mood swings, crankiness, carelessness, low self-esteem, poor judgment, depression, loss of interest in friends and activities
- Social: new friends who abuse alcohol or drugs, problems with the law, changes in dress or appearance
- Home: starting arguments, breaking rules, withdrawing from family life
- School: loss of interest, bad attitude, drop in grades, frequent absences, getting into trouble
People who abuse alcohol or other drugs often need help to get help, since they may be tempted to deny the problem or feel as if their situation is hopeless. However, they should know that help is out there for those who seek it. The first step is to see a physician, psychologist, or counselor, or visit a health center for screening. To make a diagnosis, the health care professional will ask about present and past alcohol and drug use. If possible, the clinician also will talk to the person’s family or friends. In addition, the clinician may sometimes order blood or urine tests for drugs.
Treatment for people who abuse alcohol or drugs but are not yet addicted to them usually centers around“talk”therapy. Several kinds of therapy may be used, either individually or in a group.
Cognitive (COG-nih-tiv) therapy targets the faulty thinking patterns that lead to alcohol and drug use. One approach helps people understand and change the poor decision making that leads to a relapse (RE-laps), a slip back into their old, bad habits.
Individual therapy involves only the person and a therapist, while group therapy involves the person, a therapist, and other people with similar concerns. Group therapy often is used in substance abuse treatment, because it lets people get emotional support and practical tips from others who are struggling with the same kinds of problems.
Family therapy works on problems at home that may play a role in a person’s alcohol or drug abuse. It may be especially helpful when there is severe conflict within the family or when there are other family members who are themselves depressed or abusing substances.
Self-help groups can be very helpful to both people with substance abuse problems and their family members. Many are 12-step groups, patterned on the 12 steps that are the guiding principles of Alcoholics Anonymous. Those who take part in such groups receive personal support from other people who have faced the same kinds of difficult situations.
Packer, Alex J. Highs! Over 150 Ways to Feel Really REALLY Good . . . Without Alcohol or Other Drugs. Minneapolis: Free Spirit, 2000. For ages 13 and up.
U.S. National Clearinghouse for Alcohol and Drug Information, P.O. Box 2345, Rockville, MD 20847-2345. This government clearinghouse is the world’s largest resource for current information and materials on substance abuse and addiction. Telephone 800-729-6686 http://www.health.org
U.S. National Institute on Alcohol Abuse and Alcoholism, 6000 Executive Boulevard, Bethesda, MD 20892-7003. This government institute provides in-depth information on alcohol abuse and addiction. Telephone 301-443-3860 http://www.niaaa.nih.gov
U.S. National Institute on Drug Abuse, 6001 Executive Boulevard, Bethesda, MD 20892-9561. This government institute provides detailed information about drug abuse and addiction. Telephone 301-443-1124 http://www.drugabuse.gov
ClubDrugs.org. The National Institute on Drug Abuse launched this site to provide reliable information about popular club drugs. http://www.clubdrugs.org
Join Together Online. This site, a project of the Boston University School of Public Health, features the latest news on substance abuse. http://www.jointogether.org
Substance Abuse and Dependence
Substance Abuse and Dependence
Substance abuse and dependence refer to any continued pathological use of a medication, non-medically indicated drug (called drugs of abuse), or toxin. They normally are distinguished as follows.
Substance abuse is any pattern of substance use that results in repeated adverse social consequences related to drug-taking—for example, interpersonal conflicts, failure to meet work, family, or school obligations, or legal problems. Substance dependence, commonly known as addiction, is characterized by physiological and behavioral symptoms related to substance use. These symptoms include the need for increasing amounts of the substance to maintain desired effects, withdrawal if drug-taking ceases, and a great deal of time spent in activities related to substance use.
Substance abuse is more likely to be diagnosed among those who have just begun taking drugs and is often an early symptom of substance dependence. However, substance dependence can appear without substance abuse, and substance abuse can persist for extended periods of time without a transition to substance dependence.
Substance abuse and dependence are disorders that affect all population groups although specific patterns of abuse and dependence vary with age, gender, culture, and socioeconomic status. According to data from the National Longitudinal Alcohol Epidemiologic Survey, 13.3% of a survey group of Americans exhibited symptoms of alcohol dependence during their lifetime, and 4.4% exhibited symptoms of alcohol dependence during the past 12 months. According to the 1997 National Household Survey on Drug Abuse, 6.4% of those surveyed had used an illicit drug in the past month.
Although substance dependence can begin at any age, to people aged 18 to 24 have relatively high substance use rates, and dependence often arises sometime during the ages of 20 to 49. Gender proportions vary according to the class of drugs, but substance use disorders are in general more frequently seen in men. A 2004 report revealed that in a 2002 national survey, more than 2.6 million youths age 12 to 17 had used inhalants more than once.
In addition to being an individual health disorder, substance abuse and dependence may be viewed as a public health problem with far-ranging health, economic, and adverse social implications. Substance-related disorders are associated with teen pregnancy and the transmission of sexually transmitted diseases (STDs), as well as failure in school, unemployment, domestic violence, homelessness, and crimes such as rape and sexual assault, aggravated assault, robbery, burglary, and larceny. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the estimated cost of alcohol-related disorders alone (including health care expenditures, lost productivity, and premature death ) was $166.5 billion in 1995.
The term substance, when discussed in the context of substance abuse and dependence, refers to medications, drugs of abuse, and toxins. These substances have an intoxicating effect, desired by the user, which can have either stimulating (speeding up) or depressive/sedating (slowing down) effects on the body. Substance dependence and/or abuse can involve any of the following 10 classes of substances:
- amphetamines (including "crystal meth," some medications used in the treatment of attention deficit disorder [ADD], and amphetamine-like substances found in appetite suppressants)
- cannibis (including marijuana and hashish)
- cocaine (including "crack")
- hallucinogens (including LSD, mescaline, and MDMA ["ecstasy"])
- inhalants (including compounds found in gasoline, glue, and paint thinners)
- nicotine (substance dependence only)
- opioids (including morphine, heroin, codeine, methadone, oxycodone [Oxycontin (TM)])
- phencyclidine (including PCP, angel dust, ketamine)
- sedative, hypnotic, and anxiolytic (anti-anxiety) substances (including benzodiazepines such as valium, barbiturates, prescription sleeping medications, and most prescription anti-anxiety medications)
Caffeine has been identified as a substance in this context, but as yet there is insufficient evidence to establish whether caffeine-related symptoms fall under substance abuse and dependence.
Substances of abuse may thus be illicit drugs, readily available substances such as alcohol or glue, over-the-counter drugs, or prescription medications. In many cases, a prescription medication that becomes a substance of abuse may have been a legal, medically indicated prescription for the user, but the pattern of use diverges from the use prescribed by the physician.
|Frequency Of Substance Abuse By Gender And Age|
|Ages 18 to 29||17 to 24 percent|
|Ages 30 to 44||11 to 14 percent|
|Ages 45 to 64||6 to 8 percent|
|Over age 65||1 to 3 percent|
|Ages 18 to 29||4 to 10 percent|
|Ages 30 to 44||2 to 4 percent|
|Ages 45 to 64||1 to 2 percent|
|Over age 65||less than 1 percent|
Causes and symptoms
The causes of substance dependence are not well established, but three factors are believed to contribute to substance-related disorders: genetic factors, psychopathology, and social learning. In genetic epidemiological studies of alcoholism, the probability of identical twins both exhibiting alcohol dependence was significantly greater than with fraternal twins, thus suggesting a genetic component in alcoholism. It is unclear, however, whether the genetic factor is related to alcoholism directly, or whether it is linked to other psychiatric disorders that are known to be associated with substance abuse. For example, there is evidence that alcoholic males from families with depressive disorders tend to have more severe courses of substance dependence than alcoholic men from families without such family histories.
These and other findings suggest substance use may be way to relieve the symptoms of a psychological disorder. In this model, unless the underlying pathology is treated, attempts to permanently stop substance dependence are ineffective. Psychopathologies that are associated with substance dependence include antisocial personality disorder, bipolar disorder, depression, anxiety disorder, and schizophrenia.
A third factor related to substance dependence is social environment. In this model, drug-taking is essentially a socially learned behavior. Local social norms determine the likelihood that a person is exposed to the substance and whether continued use is reinforced. For example, individuals may, by observing family or peer role models, learn that substance use is a normal way to relieve daily stresses. External penalties, such as legal or social sanctions, may reduce the likelihood of substance use.
At the level of neurobiology, it is believed that substances of abuse operate through similar pathways in the brain. The chemical changes induced by the stimulation of these pathways by initial use of the substance lead to the desire to continue substance use, and eventual substance dependence.
The DSM-IV-TR identifies seven criteria (symptoms), at least three of which must be met during a given 12-month period, for the diagnosis of substance dependence:
- Tolerance, as defined either by the need for increasing amounts of the substance to obtain the desired effect or by experiencing less effect with extended use of the same amount of the substance.
- Withdrawal, as exhibited either by experiencing unpleasant mental, physiological, and emotional changes when drug-taking ceases or by using the substance as a way to relieve or prevent withdrawal symptoms.
- Longer duration of taking substance or use in greater quantities than was originally intended.
- Persistent desire or repeated unsuccessful efforts to stop or lessen substance use.
- A relatively large amount of time spent in securing and using the substance, or in recovering from the effects of the substance.
- Important work and social activities reduced because of substance use.
- Continued substance use despite negative physical and psychological effects of use.
Although not explicitly listed in the DSM-IV-TR criteria, "craving," or the overwhelming desire to use the substance regardless of countervailing forces, is a universally-reported symptom of substance dependence.
Symptoms of substance abuse, as specified by DSM-IV-TR, include one or more of the following occurring during a given 12-month period:
- Substance use resulting in a recurrent failure to fulfill work, school, or home obligations (work absences, substance-related school suspensions, neglect of children).
- Substance use in physically hazardous situations such as driving or operating machinery.
- Substance use resulting in legal problems such as drug-related arrests.
- Continued substance use despite negative social and relationship consequences of use.
In addition to the general symptoms, there are other physical signs and symptoms of substance abuse that are related to specific drug classes:
- Signs and symptoms of alcohol intoxication include such physical signs as slurred speech, lack of coordination, unsteady gait, memory impairment, and stupor, as well as behavior changes shortly after alcohol ingestion, including inappropriate aggressive behavior, mood volatility, and impaired functioning.
- Amphetamine users may exhibit rapid heartbeat, elevated or depressed blood pressure, dilated (enlarged) pupils, weight loss, as well as excessively high energy, inability to sleep, confusion, and occasional paranoid psychotic behavior.
- Cannibis users may exhibit red eyes with dilated pupils, increased appetite, dry mouth, and rapid pulse; they may also be sluggish and slow to react.
- Cocaine users may exhibit rapid heart rate, elevated or depressed blood pressure, dilated pupils, weight loss, in addition to wide variations in their energy level, severe mood disturbances, psychosis, and paranoia.
- Users of hallucinogens may exhibit anxiety or depression, paranoia, and unusual behavior in response to hallucinations (imagined sights, voices, sounds, or smells that appear real). Signs include dilated pupils, rapid heart rate, tremors, lack of coordination, and sweating. Flashbacks, or the re-experiencing of a hallucination long after stopping substance use, are also a symptom of hallucinogen use.
- Users of inhalants experience dizziness, spastic eye movements, lack of coordination, slurred speech, and slowed reflexes. Associated behaviors may include belligerence, tendency toward violence, apathy, and impaired judgment.
- Opioid drug users exhibit slurred speech, drowsiness, impaired memory, and constricted (small) pupils. They may appear slowed in their physical movements.
- Phencyclidine users exhibit spastic eye movements, rapid heartbeat, decreased sensitivity to pain, and lack of muscular coordination. They may show belligerence, predisposition to violence, impulsiveness, and agitation.
- Users of sedative, hypnotic, or anxiolytic drugs show slurred speech, unsteady gait, inattentiveness, and impaired memory. They may display inappropriate behavior, mood volatility, and impaired functioning.
Other signs are 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. A person using 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 dangerously unhygienic conditions. These unsanitary conditions and the use of shared needles are risk factors for major infections of the heart, as well as infection with HIV (the virus that causes AIDS ), certain forms of hepatitis (a liver infection), and tuberculosis.
Cocaine is often taken as a powdery substance which is "snorted" through the nose. This 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).
Overdosing on a substance is a frequent complication of substance abuse. Drug overdose can be purposeful (with suicide as a goal), or due to carelessness, the unpredictable strength of substances purchased from street dealers, mixing of more than one type of substance, or as a result of the increasing doses that a person must take to experience intoxicating effects. Substance overdose can be a life-threatening emergency, with the specific symptoms depending on the type of substance used. Substances with depressive effects may dangerously slow the breathing and heart rate, drop the body temperature, and result in a general unresponsiveness. Substances with stimulatory effects may dangerously increase the heart rate and blood pressure, produce abnormal heart rhythms, increase body temperature, induce seizures, and cause erratic behavior.
Tools used in the diagnosis of substance dependence include screening questionnaires and patient histories, physical examination, and laboratory tests. A simple and popular screening tool 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?
A "yes" answer to two or more of these questions is an indication that the individual should be referred for more thorough work-up for substance dependency or abuse.
In addition to CAGE, other screening questionnaires are available. Some are designed for particular population groups such as pregnant women, and others are designed to more thoroughly assess the severity of substance dependence. These questionnaires, known by their acronyms, include AUDIT, HSS, HSQ, PRIME-MD, ACE, TWEAK, s-MAST, and SADD. There is some variability among questionnaires in terms of how accurately and comprehensively they can identify individuals as substance dependent.
Patient history, as taken through the direct interview, is important for identifying physical symptoms and psychiatric factors related to substance use. Family history of alcohol or other substance dependency is also useful for diagnosis.
A physical examination may reveal signs of substance abuse. These signs are specific to the substances used, as well as needle marks, tracks, or nasal erosion.
With the individual's permission, substance use can be detected through laboratory testing of his or her blood, urine, or hair. Laboratory testing, however, may be limited by the sensitivity and specificity of the testing method, and by the time elapsed since the person last used the drug.
One of the most difficult aspects of diagnosis involves overcoming the patient's denial. Denial is a psychological state during which a person is unable to acknowledge the (usually negative) circumstances of a situation. In this case, denial leads a person to underestimate the degree of substance use and of the problems associated with substance use.
According to the American Psychiatric Association, there are three goals for the treatment of people with substance use disorders: (1) the patient abstains from or reduces the use and effects of the substance; (2) the patient reduces the frequency and severity of relapses; and (3) the patient develops the psychological and emotional skills necessary to restore and maintain personal, occupational, and social functioning.
In general, before treatment can begin, many treatment centers require that the patient undergo detoxification. Detoxification is the process of weaning the patient from his or her regular substance use. 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 must be tapered because "cold turkey" methods of detoxification are potentially life threatening. In some cases, medications may be used to combat the unpleasant and threatening physical and psychological symptoms of withdrawal. For example, methadone is used to help patients adjust to the tapering of heroin use.
Treatment itself consists of three parts: (1) assessment; (2) formulation of a treatment plan; (3) psychiatric management. The first step in treatment is a comprehensive medical and psychiatric evaluation of the patient. This evaluation includes:
- a history of the patient's past and current substance use, and its cognitive, psychological, physiological, and behavioral effects
- a medical and psychiatric history and examination
- a history of psychiatric treatments and outcomes
- a family and social history
- screening of blood, breath, or urine for substances
- other laboratory tests to determine the presence of other conditions commonly found with substance use disorders
After the assessment is made, a treatment plan is formulated. Treatment plans vary according to the needs of the specific patient and can change for the same patient as he or she undergoes different phases of the disorder. Plans typically involve the following elements: (1) a strategy for the psychiatric management of the patient; (2) a strategy for reducing effects or use of substances, or for abstinence; (3) efforts to ensure compliance with the treatment program and to prevent relapse; (4) treatments for other conditions associated with substance use. Initial therapy and treatment setting (hospital, residential treatment, partial hospitalization, outpatient) decisions are made as part of the treatment plan, but because substance use disorders are considered a chronic condition requiring long-term care, these plans can and do change through the course of treatment.
The third step, psychiatric management of the patient, is the implementation of the treatment plan. Psychiatric management of the patient includes establishing a trusting relationship between clinician and patient; monitoring the patient's progress; managing the patient's relapses and withdrawal; diagnosing and treating associated psychiatric disorders; and helping the patient adhere to the treatment plan through therapy and the development of skills and social interactions that reinforce a drug-free lifestyle.
As part of the treatment process, patients typically undergo psychosocial therapy and, in some cases, pharmacologic treatment. Psychosocial therapeutic modalities include cognitive-behavioral therapy, behavioral therapy, individual psychodynamic or interpersonal therapy, group therapy, family therapy, and self-help groups. Pharmacologic treatment may include medications that ease withdrawal symptoms, reduce craving, interact negatively with substances of abuse to discourage drug-taking, or treat associated psychiatric disorders.
The efficacy of alternative treatments for substance use disorders remains for the most part ambiguous. One treatment that has been recently shown to have variable success is the use of acupuncture in treating substance dependence. In 2000, a randomized controlled trial of the effect of acupuncture on cocaine addiction reported that acupuncture significantly reduced the cocaine use of study participants. A 1999 meta-analysis (summary analysis of studies), however, reported that acupuncture had no statistically significant effect on smoking cessation.
There has been movement toward examining some touted treatments in more rigorous clinical trials. In particular, there has been some interest in Pueraria lobata, or kudzu, an herb that has reputedly been used in Chinese medicine to treat alcoholism. Preclinical trials of an herbal formula with kudzu have shown that increased consumption of the herbal formula is associated with decreased consumption of alcohol. Toxicity studies show few ill effects of the formula, and human trials are currently being undertaken to more fully evaluate the efficacy of this treatment.
The effectiveness of electroacupuncture (the practice of acupuncture accompanied by the application of low levels of electrical current at acupuncture points) in alleviating opiate withdrawal symptoms is also being examined. Preclinical trials suggest that electroacupuncture treatment given prior to the administration of naxolone seems to alleviate the withdrawal effects of naxolone.
Recovery from substance use is notoriously difficult, even with exceptional treatment resources. Although relapse rates are difficult to accurately obtain, the NIAAA cites evidence that 90% of alcohol dependent users experience at least one relapse within the 4 years after treatment. Relapse rates for heroin and nicotine users are believed to be similar. Certain pharmacological treatments, however, have been shown to reduce relapse rates.
Relapses are most likely to occur within the first 12 months of having discontinued substance use. Triggers for relapses can 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.
The development of adaptive life skills and ongoing drug-free social support are believed to be two important factors in avoiding relapse. The effect of the support group Alcoholics Anonymous has been intensively studied, and a 1996 meta-analysis noted that long-term sobriety appears to be positively related to Alcoholics Anonymous attendance and involvement. Support for family members in addition to support for the individual in recovery is also important. Because substance dependence has a serious impact on family functioning, and because family members may inadvertently maintain behaviors that initially led to the substance dependence, ongoing therapy and support for family members should not be neglected.
Prevention is best aimed at teenagers and young adults aged 18-24 who are at very high risk for substance experimentation. Prevention programs should include an education component that outlines the risks and consequences of substance use and a training component that gives advice on how to resist peer pressure to use drugs.
Furthermore, prevention programs should work to identify and target children who are at relatively higher risk for substance abuse. This group includes victims of physical or sexual abuse, children of parents who have a history of substance abuse, and children with poor school performance and/or attention deficit disorder. These children may require more intensive intervention.
Addiction— The state of being both physically and psychologically dependent on a substance.
Dependence— A state in which a person requires a steady concentration of a particular substance to avoid experiencing withdrawal symptoms.
Detoxification— A process whereby an addict is withdrawn from a substance.
Intoxication— The desired mental, physical, or emotional state produced by a substance.
Street drug— A substance purchased from a drug dealer; may be a legal substance, sold illicitly (without a prescription, and not for medical use), or it may be a substance that is illegal to possess.
Tolerance— A phenomenon whereby a drug user becomes physically accustomed to a particular dose of a substance, and requires increasing dosages in order to obtain the same effects.
Withdrawal— Those side effects experienced by a person who has become physically dependent on a substance, upon decreasing the substance's dosage or discontinuing its use.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, DC: American Psychiatric Association, 2000.
"Inhalant Abuse Becomes Focus of SAMHSA Guidelines, Prevention Effors." Alcoholism & Drug Abuse Weekly March 22, 2004: 1-4.
Schneider, Robert K., James L. Levenson, and Sidney H. Schnoll. "Update in Addiction Medicine." Annals of Internal Medicine 134 (March 6, 2001): 387-395.
Substance abuse in the workplace is a subject of concern to many small business owners, to one degree or another. Oftentimes the issue is a sensitive one to confront, but business owners and researchers alike agree that if left unchecked, substance abuse has the capacity to cripple or destroy a company.
IMPACT IN THE WORKPLACE
Substance abuse is a hard problem to eradicate in any business setting, but it can be particularly difficult to address in small business settings. After all, many small business owners develop close—or at least friendly—relationships with their employees because they often work together on projects and share smaller work areas. "Because many small business owners have one-on-one relationships with each employee, dealing with an employee who is addicted to alcohol or drugs is a personal as well as a personnel problem," wrote Barbara Mooney in Crain's Cleveland Business.
But substance abuse experts and business researchers alike warn that substance abuse problems are not the sort of problems that tend to go away by themselves. Rather, they often continue to grow and fester, further strangulating the business's productivity and profitability. Indeed, substance abuse often ends up being a tremendous drain on a company's fiscal well-being. This drain takes many forms, including decreased productivity, increased absences, rising numbers of accidents, use of sick leave, and jumps in workers' compensation claims. Indeed, HR Focus reported in 1997 that "alcohol and drug abusers are absent from work two-and-a-half times more frequently than nonusers; they use three times the amount of sick leave as nonusers; their worker's compensation claims are five times higher; and they are generally less productive." This latter factor—what HR Focus termed "the less dramatic, day-to-day financial losses that accrue in a company when its workers are impaired and performing below potential"—can be particularly deadly to a business precisely because its impact is so hard to detect and quantify. Finally, substance abusers often compromise the efficiency of other workers within the business. Co-workers are often hampered by the substandard work of the abuser, and in many cases their effectiveness may be further curtailed by a sense of obligation to cover for their co-workers—who, after all, are often their friends as well.
Substance abuse problems also open companies up to greater legal liability. According to Occupational Medicine, Studies indicate that 1) alcohol and drug abusers are two to four times as likely to have an accident as people who do not use drugs and alcohol, and 2) substance abusers can be linked to approximately 40 percent of American industrial fatalities. Moreover, business consultant Tim Plant indicated to HR Focus that drug- or alcohol-addled employees can also wreak harm on people and places outside the company: "When drivers come to work under the influence of drugs or alcohol," he said, "accidents could happen, causing the disruption of deliveries or other activities. Vehicles could be damaged; people could be hurt or killed. These have an immediate impact on the bottom line for a small- or medium-sized company."
Finally, in situations where a partner or owner of the business is the one with the substance abuse problem, the very life of the company is often jeopardized. Such people obviously wield a tremendous amount of influence over a company, and if their ability to make reasonable, intelligent decisions in a timely manner is compromised, the financial health of the company will likely deteriorate as well.
CHARACTERISTICS OF SUBSTANCE ABUSERS
Substance abuse experts and business owners who have been forced to deal with drug and/or alcohol abusers in their workplace cited a variety of warning signs that owners and managers should look for if they suspect a problem:
- Increased absenteeism and tardiness, especially immediately before and after weekends and holidays
- Deteriorating work performance, as manifested in big changes in work quality and/or productivity
- Frequent colds, flus, headaches, and other ailments
- High rates of mishaps, both on and off the job
- Unusually high medical claims
- Excessive mood swings, which may manifest themselves in immoderate levels of talking, anxiety, or moodiness
- Overreactions to criticism, both real or imagined
- Avoidance of supervisors
- Deterioration in physical appearance or grooming
- Financial problems
Researchers also note that certain industries and business dynamics seem especially prone to substance abuse problems. One substance abuse counselor flatly told Barbara Mooney of Crain's Cleveland Business that the extent of substance abuse problems in small businesses often depends on the makeup of its work force: "It's a problem prevalent among employers who hire a lot of entry-level people in industries with high turnover rates and high stress levels." Such conditions can be found in some retail establishments and especially in the restaurant industry, where late working hours, proximity to liquor, and demographic characteristics (prevalently young and single) provide a fertile atmosphere for substance abuse. Family-owned businesses are also cited as being particularly vulnerable to substance abuse problems, in part because family members may have a more difficult time being objective about a relative's work performance.
POLICIES AND STRATEGIES TO CURB SUBSTANCE ABUSE
Although tackling the problem of substance abuse can be a daunting one for small business enterprises, substance abuse experts and business researchers note that affected businesses can utilize a variety of steps that have a track record of effectiveness in curbing workplace drug and alcohol abuse.
One of the most commonly practiced policies employed by businesses of all sizes is random drug testing, wherein employees (and prospective employees) are required to submit to scientific tests to determine whether they have been using illegal drugs. Many experts cite the growing popularity of such policies for the apparent downturn in workplace substance abuse incidents in recent years. Drug testing remains controversial, however, as opponents argue that it violates individual privacy rights and sometimes hurts employee morale.
Another option for small business owners is to actively utilize the hiring/interviewing process to screen for substance abusers. "You get what you ask for," contended Gregory Lousig-Nont and Paul Leckinger in Security Management. "If you want people who are free from substance abuse problems—just ask for them in your ad." They point out that studies and anecdotal evidence suggests that want ads that include phrases like "Applicant must have a clean drug history" effectively dissuade many applicants with substance abuse problems from submitting an application. "Another commonsense approach to screening applicants," say Lousig-Nont and Leckinger, "is to broach the subject on the application form" by bluntly inquiring whether the applicant has used illicit drugs in the past. "Surprisingly, many people will actually list the drugs they have used. People who use drugs but do not want to tell you about it will leave the answer blank or put a dash on the answer line. People who have not used drugs will usually write a bold 'NONE' in the space provided." They note, however, that even though federal laws do not restrict asking questions about drug abuse, companies should check with their state employment commission to see if any state laws might apply in this area.
With current employees, business owners are encouraged to establish clear, written guidelines that explicitly detail the company's stance on substance abuse. "The policy should take a clear stand against the use, possession, sale or distribution (particularly on company time) of any mood altering substances," stated HR Focus. "It should also outline a very clear sequence of events that will ensue if the rules are broken." Small business owners need to make sure that their substance abuse policies abide by various state and federal laws.
Small business owners should also make an effort to enlist the support of employees in establishing a drug-free workplace. "Everyone … has an interest in securing a safe workplace and making sure that colleagues pull their loads," commented HR Focus. "One of the most effective ways to fight substance abuse is for employees to unite against it," concurred W.H. Weiss in Supervisor's Standard Reference Handbook. "Supervisors can spur such a move by making it clear to their people that alcohol or drug use on the job is absolutely unacceptable."
Business owners should also consider providing an employee assistance program (EAP) for its workers. "Adopting an employee assistance program is viewed favorably by both management and employees," wrote Lousig-Nont and Leckinger. "Under such a policy, the company agrees to assist employees who have a substance abuse problem. Assistance generally comes in the form of granting the employee sick leave and paying for a rehabilitation program, and a promise by the company that there will be no retribution against the employee." The responsibility for initiating enrollment in such programs, however, rests with the employee. If management discovers that a worker who has not pursued help through an EAP has a substance abuse problem, he or she may face termination. Employee assistance programs have been hailed by substance abuse experts and businesspeople alike as an effective tool in curbing workplace drug and alcohol abuse, and proponents point out that the cost of such programs is usually far less than the costs that often accrue when a substance-abusing employee is not dealt with.
Finally, when confronted with evidence of workplace substance abuse, managers and owners of small companies are urged to intervene immediately and determine whether a problem exists. If a problem is found, then the business needs to document the performance of the employee. This will offer the company a greater measure of legal protection in case they need to fire the employee or the employee's performance spurs legal claims from outside parties.
Carr, Elena. "Re-Energizing the Roots of Employee Assistance: Tapping federal workplace substance abuse efforts." The Journal of Employee Assistance. January-March 2006.
"Drug Trends: A Shot in the Arm?" Security Management. August 1996.
Gray, George R., and Darrel R. Brown. "Issues in Drug Testing for the Private Sector." HR Focus. November 1992.
Humphreys, Richard M. "Substance Abuse: The Employer's Perspective." Employment Relations Today. Spring 1990.
Lousig-Nont, Gregory M., and Paul M. Leckinger. "Alternatives to Drug Testing." Security Management. May 1990.
Martin, Lynn. "Drug Free Policy: Key to Success for Small Businesses." HR Focus. September 1992.
Mooney, Barbara. "Addiction: A Downer for All; Substance Abuse can be an Owner's Toughest Problem." Crain's Cleveland Business. August 8, 1994.
"Substance Abuse in the Workplace." HR Focus. February 1997.
Hillstrom, Northern Lights
updated by Magee, ECDI
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.
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.
"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.
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
|FREQUENCY OF SUBSTANCE ABUSE BY GENDER AND AGE|
|Ages 18 to 29||17 to 24 percent|
|Ages 30 to 44||11 to 14 percent|
|Ages 45 to 64||6 to 8 percent|
|Over age 65||1 to 3 percent|
|Ages 18 to 29||4 to 10 percent|
|Ages 30 to 44||2 to 4 percent|
|Ages 45 to 64||1 to 2 percent|
|Over age 65||less than 1 percent|
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:
- 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 bloodstream at any given moment in order to avoid the un-pleasant 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 over-whelms 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 & 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.
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 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 (Glycyrrhiza glabra ) 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.
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.
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.
- —A phenomenon whereby a drug user becomes physically accustomed to a particular dose of a substance and requires ever-increasing dosages in order to obtain the same effects.
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.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association, 1994.
O'Brien, C.P. "Drug Abuse and Dependence." In Cecil Textbook of Medicine, edited by J. Claude Bennett and Fred Plum. Philadelphia: W.B. Saunders, 1996.
Imperio, Winnie A. "Substance Abuse Prevention Works." Clinical Psychiatry News (March 2002):41.
"Inhalant Use More Popular than Ecstasy, OxyContin." Alcoholism & Drug Abuse Weekly (March 25, 2002):8.
Margolin, Arthur, et al. "Acupuncture for the Treatment of Cocaine Addiction: A Randomized Controlled Trial." JAMA, The Journal of the American Medical Association (January 2, 2002):55–59.
Monroe, Judy. "Recognizing Signs of Drug Abuse." Current Health (September 1996):16+.
O'Brien, Charles P. and A. Thomas McLellan. "Addiction Medicine." Journal of the American Medical Association (18 June 1997): 1840+.
"Qigong Therapy Evaluated for Detoxification." The Brown University Digest of Addiction Theory and Application (March 2002):S1.
Rivara, et al. "Alcohol and Illicit Drug Abuse and the Risk of Violent Death in the Home." Journal of the American Medical Association (20 August 1997): 569+.
Savage, Lorraine. "Grant to Study Acupuncture's Effectiveness on Patients Suffering from Substance Abuse." Healthcare Review (March 19, 2002): 16.
"Survey Finds Rise in Ecstasy Use Among Teens." Alcoholism & Drug Abuse Weekly. (February 25, 2002): 3.
Al-Anon, Alanon Family Group, Inc. P.O. Box 862, Midtown Station, New York, NY 10018-0862. (800) 356-9996. http://www.recovery.org/aa.
National Alliance On Alcoholism and Drug Dependence, Inc. 12 West 21st St., New York, NY 10010. (212) 206-6770.
National Clearinghouse for Alcohol and Drug Information. http://www.health.org.
Parent Resources and Information for Drug Education (PRIDE). 10 Park Place South, Suite 340, Atlanta, GA 30303. (800) 853-7867 or (404) 577-4500.
Teresa G. Odle
Substance Abuse and Dependence
Substance abuse and dependence
Substance abuse is a pattern of behavior that displays many adverse results from continual use of a substance. Substance dependence is a group of behavioral and physiological symptoms that indicate the continual, compulsive use of a substance in self-administered doses despite the problems related to the use of the substance.
The characteristics of abuse are a failure to carry out obligations at home or work, continual use under circumstances that present a hazard (such as driving a car), and legal problems such as arrests. Use of the drug is persistent despite personal problems caused by the effects of the substance on the self or others. In substance dependence, as the patient's tolerance for the drug increases, increased amounts of a substance are needed to achieve the desired effect or level of intoxication. Withdrawal is a physiological and psychological change that occurs when the body's concentration of the substance declines in a person who has been a heavy user.
Substance abuse and dependence cuts across all lines of race, culture, educational, and socioeconomic status, leaving no group untouched by its devastating effects. An estimated 13 million Americans abuse or are dependent on an illegal substance. 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, substance abuse is considered to be 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. An estimated 20 percent of the total yearly cost of health care in the United States is spent on the effects of drug and alcohol abuse.
A wide range of substances can be abused. The most common classes include the following:
- opioids, including such prescription pain killers as morphine and demerol, as well as illegal substances such 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
- cannabinoid drugs obtained from the hemp plant, including marijuana and hashish
- cocaine-based drugs, including cocaine and "crack"
- hallucinogenic or psychedelic drugs, including lysergic acid diethylamide (LSD) or "acid," phencyclidine (PCP) or "angel dust," 3-4 methylenedioxymethamphetamine (MDMA) or "ecstasy," 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
- alcoholic drinks
- cigarettes, cigars, and other tobacco products
Those substances of abuse that are actually prescription medications may have been obtained on the street by fraudulent means or may have been a legal, medically indicated prescription that a person begins to use without regard to the directions of his or her physician.
A number of important terms must be defined in order to have a complete discussion of substance abuse. Drug tolerance refers to a person's body being accustomed to the symptoms produced by a specific quantity of a substance. When a person first begins taking a substance, he or she will note various mental or physical reactions brought on by the drug (some of which are the very changes in consciousness that the individual is seeking through substance use). Over time with repeated use, the same dosage of the substance produces fewer of the desired feelings. In order to continue to feel the desired effect of the substance, progressively higher drug doses must be taken.
The National Survey on Drug Use and Health (NSDUH) is conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services. In 2003, the study found the rate of substance dependence or abuse was 8.9 percent for youths aged 12 to 17 and 21 percent for persons aged 18 to 25. Among persons with substance dependence or abuse, illicit drugs accounted for 58.1 percent of youths and 37.2 percent of persons aged 18 to 25. In 2003, males were almost twice as likely to be classified with substance dependence or abuse as females (12.2% versus 6.2%). Among youths aged 12 to 17, however, the rate of substance dependence or abuse among females (9.1%) was similar to the rate among males (8.7%). The rate of substance dependence or abuse was highest among Native Americans and Alaska Natives (17.2%). The next highest rates were among Native Hawaiians and other Pacific Islanders (12.9%) and persons reporting mixed ethnicity (11.3%). Asian Americans had the lowest rate (6.3%). The rates among Hispanics (9.8%) and whites (9.2%) were higher than the rate among blacks (8.1%).
Rates of drug use showed substantial variation by age. For example, in 2003, 3.8 percent of youths aged 12 to 13 reported current illicit drug use compared with 10.9 percent of youths aged 14 to 15 and 19.2 percent of youths aged 16 to 17. As in other years, illicit drug use in 2003 tended to increase with age among young persons, peaking among 18 to 20-year-olds (23.3%) and declining steadily after that point with increasing age. The prevalence of current alcohol use among adolescents in 2003 increased with increasing age, from 2.9 percent at age 12 to a peak of about 70 percent for persons 21 to 22 years old. The highest prevalence of both binge and heavy drinking was for young adults aged 18 to 25, with the peak rate of both measures occurring at age 21. The rate of binge drinking was 41.6 percent for young adults aged 18 to 25 and 47.8 percent at age 21. Heavy alcohol use was reported by 15.1 percent of persons aged 18 to 25 and 18.7 percent of persons aged 21. Among youths aged 12 to 17, an estimated 17.7 percent used alcohol in the month prior to the survey interview. Of all youths, 10.6 percent were binge drinkers, and 2.6 percent were heavy drinkers, similar to the 2002 numbers.
In 2003 rates of illicit drug use varied significantly among the major racial-ethnic groups. The rate of illicit drug use was highest among Native Americans and Alaska Natives (12.1%), persons reporting two or more races (12%), and Native Hawaiians and other Pacific Islanders (11.1%). Rates were 8.7 percent for African Americans, 8.3 percent for Caucasians, and 8 percent for Hispanics. Asian Americans had the lowest rate of illicit drug use at 3.8 percent. These rates were unchanged from 2002. Native Americans and Alaska Natives were more likely than any other racial-ethnic group to report the use of tobacco products in 2003. Among persons aged 12 or older, 41.8 percent of Native Americans and Alaska Natives reported using at least one tobacco product in the past month. The lowest current tobacco use rate among racial-ethnic groups in 2003 was observed for Asian Americans (13.8%), a decrease from the 2002 rate (18.6%).
Young adults aged 18 to 25 had the highest rate of current use of cigarettes (40.2%), similar to the rate in 2002. Past month cigarette use rates among youths in 2002 and 2003 were 13 percent and 12.2 percent, respectively, not a statistically significant change. However, there were significant declines in past year (from 20.3% to 19%) and lifetime (from 33.3% to 31%) cigarette use among youths aged 12mto 17 between 2002 and 2003. Among persons aged twelve or older, a higher proportion of males than females smoked cigarettes in the past month in 2003 (28.1% versus 23%). Among youths aged 12 to 17, however, girls (12.5%) were as likely as boys (11.9%) to smoke in the past month. There was no change in cigarette use among boys aged 12 to 17 between 2002 and 2003. However, among girls, cigarette use decreased from 13.6 percent in 2002 to 12.5 percent in 2003.
Causes and symptoms
There is not thought to be a single cause of substance abuse, though scientists are as of 2004 increasingly convinced that certain people possess a genetic predisposition which 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 which can 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 the role of learned behavior can influence the likelihood that a person will become substance dependent.
The symptoms of substance abuse may be related to its social effects 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).
When to call the doctor
The earlier one seeks help for their child or teen's substance abuse or dependence problems, the better. Regarding the matter of determining if a teen is experimenting or moving more deeply into the drug culture, parents must be careful observers, particularly of the little details that make up a teen's life. Dramatic change in appearance, friends, or physical health may be signs of trouble. If parents believe their child may be drinking or using drugs, they should seek help through a substance abuse recovery program, family physician, or mental health professional.
The most difficult aspect of diagnosis involves overcoming the patient's denial. Denial is a psychological trait that prevents a person from acknowledging the reality a situation. Denial may cause a person to be completely unaware of the seriousness of the substance use or may cause the person to greatly underestimate the degree of the problem and its effects on his or her life. 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, unusually large or small pupils. With the person's permission, substance use can also be detected by examining in a laboratory an individual's blood, urine, or hair. This drug testing is limited by sensitivity, specificity, and the time elapsed since the person last used the drug.
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 a person deal with the social effects which substance abuse has had on his or her life, and efforts to prevent relapse (resumed use of the substance). Individual or group psychotherapy is sometimes helpful.
Detoxification may take from several days to many weeks. Detoxification can be accomplished suddenly, by complete and immediate cessation of all substance use or by slowly decreasing (tapering) the dose that 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. Alternatively, a variety of medications may be used to combat the unpleasant and threatening physical symptoms of withdrawal. A substance (such as methadone in the case of heroine 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 style. 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.
Alternative treatments thought to improve a person's ability to stop substance use include acupuncture and hypnotherapy. 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. Elimination of toxins is aided as well as by such herbs as milk thistle, burdock, and licorice. Anxiety brought on by substance withdrawal is thought to be lessened by using other herbs, for example valerian, vervain, skullcap, and kava.
After a person has successfully withdrawn from substance use, the even more difficult task of recovery begins. Recovery refers to the life-long efforts of a person to avoid returning to substance use. The craving can be so strong, even years and years after initial withdrawal has been accomplished, that a previously addicted person may be virtually forever 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 twelve-step programs such as Narcotics Anonymous and Alcoholics Anonymous are the most helpful ways of monitoring the recovery process and avoiding relapse.
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 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 or attention deficit disorder). These children may require a more intensive prevention program.
Parents and guardians need to be aware of the power they have to influence the development of their kids throughout the teenage years. Adolescence brings a new and dramatic stage to family life. The changes that are required are not just the teen's to make; parents need to change their relationship with their teenager. It is best if parents are proactive about the challenges of this life cycle stage, particularly those that pertain to the possibility of experimenting with and using alcohol and drugs. Parents should not be afraid to talk directly to their kids about drug use, especially if they have had problems with drugs or alcohol themselves. Parents should give clear, no-use messages about smoking , drugs, and alcohol. It is important for kids and teens to understand that the rules and expectations set by parents are based on parental love and concern for their well-being. Parents should also be actively involved and demonstrate interest in their teen's friends and social activities. Spending quality time with teens and setting good examples are essential. Even if problems such as substance abuse already exist in the teen's life, parents and families can have a positive influence on their teen's behavior.
Addiction —The state of being both physically and psychologically dependent on a substance.
Dependence —A state in which a person requires a steady concentration of a particular substance to avoid experiencing withdrawal symptoms.
Detoxification —The process of physically eliminating drugs and/or alcohol from the system of a substance-dependent individual.
High —The altered state of consciousness that a person seeks when abusing a substance.
Street drug —A substance purchased from a drug dealer. It may be a legal substance, sold illicitly (without a prescription, and not for medical use), or it may be a substance which is illegal to possess.
Tolerance —A condition in which an addict needs higher doses of a substance to achieve the same effect previously achieved with a lower dose.
Withdrawal —The characteristic withdrawal syndrome for alcohol includes feelings of irritability or anxiety, elevated blood pressure and pulse, tremors, and clammy skin.
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Genevieve Pham-Kanter, Ph.D. Ken R. Wells
In the 2000 U.S. census, approximately 4.1 million people reported their race as “American Indian or Alaska Native.” While that constitutes only 1.5 percent of the United States population, the U.S. Department of Health and Human Services reports that American Indians and Alaska Natives account for 2.1 percent of all admissions to publicly funded substance–abuse treatment facilities, with 40 percent of these individuals being referred to such programs by the criminal justice system. This clearly demonstrates that substance abuse continues to be a persistent and growing issue among the Native American population.
Historically, the introduction of intoxicating substances, especially alcohol, among indigenous populations often served the colonial designs of European nations. Alcohol became an important vehicle with which to appropriate resources, weaken the structure of indigenous societies, and destroy indigenous resistance to European colonialism. The overconsumption of alcohol also served to reinforce European beliefs about the inferiority of indigenous peoples, thereby bolstering the belief in “white” racial superiority. As Robert Berkhofer points out in The White Man’s Indian (1979), alcohol abuse provided concrete evidence of Indian degeneracy and criminality, leading to the public stereotype of the “drunken Indian.”
According to Gilbert Quintero, associate professor of anthropology, University of Montana, nonnative beliefs about Indian drunkenness constitute:
A form of colonial knowledge … that creates standardized categories and oppositional differences that distinguish the colonizers from the colonized. In addition, colonial knowledge functions to keep the colonized in a subjugated position relative to the colonizer. It does so primarily by attributing devalued characteristics and features to a specific group of people that is usually recognized as somehow distinct, usually in racial, cultural, or historical terms. (Quintero 2001, p. 57)
Despite the proliferation of scientific research about American Indian drinking, the myth persists that indigenous peoples are predisposed to addiction and that there are biophysical reasons for their inability to control their addictive behaviors. In some respects, the argument that there is a genetic basis to explain excessive alcohol consumption among Native Americans continues to serve the stereotypes of racial inferiority and degeneracy, especially when held up against reported data and beliefs about white alcohol consumption and behaviors. In addition, for some this argument can ostensibly be extended to other forms of substance abuse. There is, in fact, data to establish genetic contributions to alcoholism and other substance abuse addictions. This biogenetic predisposition is not exclusive to Native populations, however, but also exists among all ethnic populations. Evidence specific to American Indian addictions, especially alcohol, reveals that there is more in–group variation than between–group variation, indicating that environmental variables play a significant role in the manifestation of Native substance abuse (May 1994; Mancall 1995). Despite any biogenetic predispositions, however, the amount of substance abuse within a given population, much like the rate of Type II diabetes mellitus, is a reflection of social and economic conditions, not a sign of inferior racial biology. The health status of Native Americans and Alaska Natives, including substance abuse, is directly related to the socioeconomic conditions that exist in indigenous communities. Health levels, therefore, are directly linked to extant social, political, and economic forces.
Substance abuse and other afflictions are directly related to an array of socioeconomic conditions affecting indigenous communities. According to U.S. 2000 census data, 25.7 percent of American Indians and Alaska Natives live in poverty—twice the national average. Among selected tribes, poverty rates range from 18 percent to 38.9 percent. Paralleling poverty rates, the labor–force participation rate for American Indians and Alaska Natives is lower than among the general U.S. population. In addition, earnings
among full–time, year–round Native workers are substantially lower than the earnings of all U.S. workers. This is particularly true for indigenous men, who also experience higher unemployment and underemployment rates.
Level of education is clearly associated with labor–force participation and earnings. According to the Census Bureau, “the educational levels of American Indians and Alaska Natives were below those of the total population in 2000.” In particular, 71 percent “had at least a high school education, compared with 80 percent of the total population” (U.S. Census Bureau 2006). As a result of this educational disparity the distribution of employment for Native peoples is heavily concentrated in the nonmanagerial positions and professions, clustering them in a particular class and economic sector.
American Indians and Alaska Natives have a higher percentage of single–parent homes than the total population. According to Census 2000, slightly more than 28 percent of Native households are single–parent homes, compared to 15.5 percent of total U.S. households. The vast majority of these households are headed by a woman with no husband present (20.7% of Native households). This percentage increases by 4.1 percent if the household is located on reservation lands, trust lands, or other tribally designated lands. Moreover, the average household size is 22.6 percent larger on tribally designated lands than among the total U.S. population.
It is estimated that Native Americans have six times the number of substandard homes as the rest of the United States. Many homes do not have water or adequate sewage systems. More than 30 percent of low–income American Indians live in overcrowded homes, as there is at least a 200,000 unit housing shortage across Indian country. Moreover, the construction of cluster housing on many reservations has created a particular type of residential segregation that contributes to elevated risks of violence, substance abuse, and other community health problems.
Finally, no other U.S. ethnic group has the lives of its people, including their health care, so heavily dictated by federal laws, policies, and treaties. As early as 1820, Western medical services became an integral component of U.S. Indian policy. As of 2007, the Indian Health Service (IHS), located within the Department of Health and Human Services, administers primary and preventive care to eligible Native peoples within their established service areas. The IHS largely operates on annual congressional appropriations, but the per capita expenditure for indigenous patients is only 61.3 percent of the per capita personal healthcare expenditures for the total U.S. population. This results in a rationing of health care, an inequitable distribution of healthcare resources, and limited primary treatment and prevention services. The U.S. Congress Office of Technology Assessment reports that these disparities pose significant risks for the development of health problems, particularly behavioral health issues such as substance abuse.
Substance abuse mortality rates continue to exceed the rates for the general U.S. population. In 1995, the age–adjusted drug–related death rate for American Indians and Alaskan Natives was 65 percent higher than for the total population. In addition, the National Institute of Drug Abuse (NIDA) reported in 2003 that American Indians and Alaska Natives exhibit the highest estimated prevalence of past–month tobacco smoking and heavy alcohol consumption of any recognized racial/ethnic minority population. Age–adjusted lung cancer rates among this population increased 184 percent between 1973 and 2006.
Between 1985 and 2000, age–adjusted alcohol death rates among the Native population increased 28 percent, seven times the rate for the total population. The IHS reported in 1998–1999 that first diagnosis of alcoholic psychosis, alcoholism, alcohol–related chronic liver disease, and cirrhosis was 1.6 times higher in IHS and tribal hospitals than in U.S. general short–stay hospitals.
In addition to alcohol and cigarette abuse, illicit drug use and nonmedical prescription drug abuse is also becoming a plague among American Indian and Alaskan Native communities. A 2003 NIDA survey measuring prevalence of past–month drug use revealed that indigenous peoples consume illicit drugs, marijuana, and cocaine at significantly higher rates than any other racial/ethnic population. This data is corroborated by the 2003 National Household Survey on Drug Abuse Report, which recorded that American Indians or Alaska Natives aged twelve or older had a higher rate of past–year substance dependence or abuse than any other racial/ethnic population.
Mortality attributed to drug use is also increasing at a steady pace among Native peoples. Drug–related death rates for this population increased 164 percent between 1979 and 1998, when it was 1.8 times higher the U.S. all–races rate. Within the Native population, there is a large disparity in drug–related deaths between males and females. For the 1996–1998 period, the peak male age–specific drug–related death rate was 111 percent higher than the peak female rate, according to the IHS’s report Trends in Indian Health, 2000–2001.
Methamphetamine (meth) abuse is causing havoc among Native Americans and Alaska Native communities. According to IHS data, the number of recorded patient services related to meth use rose 2.5 times from 2000 until 2005. Robert McSwain, the deputy director of the IHS reported to Congress in 2006 that the age cohort most affected by the use of this drug is age 15 to age 44. The social effects of methamphetamine addiction reach beyond the individual user. Addicted parents neglect their children, leading to child abuse, a rise in child placements, and more broken homes. The use and selling of this drug also fuels increases in homicides, aggravated assaults, rape, domestic violence, and possibly suicides. Statistics from a southwestern reservation indicate the extent of the crisis. In 2004 there were 101 suicide attempts on the reservation, with eight out of ten involving methamphetamine. That same year, 64 out of 256 babies born on the reservation were born to addicted mothers. Kathleen Kitcheyan, the chairwoman of the San Carlos Apache Tribe, has testified that of the child neglect and abuse cases reported in 2005 to Tribal Child Protective Services, 80 percent involved illicit drug use, alcohol use, or both.
Methamphetamine also is straining tribal law enforcement, health–care resources, and funding for tribal housing. For example, it is estimated that the elimination of hazardous material from a home used as a meth laboratory can cost $10,000. With IHS and tribal health programs funded at less than 60 percent of the level necessary to meet adequate levels of care, methamphetamine abuse is crippling an already overtaxed healthcare system.
There is an intimate and growing relationship between violent crimes and substance abuse. In 2004, the U.S. Department of Justice reported that American Indians experience a per capita rate of violence twice that of the U.S. resident population, with an average of one violent crime per ten residents aged twelve or older. Seventy–five percent of all investigations in Indian country by the Federal Justice system involve violent crimes. Significantly, indigenous victims of violence report that 62 percent of offenders were under the influence of alcohol at the time of the attack, with drugs being involved about 9 percent of the time. Fourteen percent of victims report that the offender was using both alcohol and drugs.
Similar to the introduction of alcohol centuries ago, methamphetamine is being injected into native communities by non–native drug cartels. On a Great Plains reservation, for example, a Mexican meth cartel attempted to introduce the drug to the reservation. In an Oklahoma Native community, the Satan’s Disciples, a violent Chicago street gang, organized a methamphetamine trafficking operation targeting indigenous peoples.
Paralleling the rise in drug use and drug trafficking is a rise in youth gang activities. The onset of gang activity is associated with a variety of factors, including the frequency with which families move off and onto the reservation; poverty, substance abuse, and family dysfunction; the development of reservation cluster housing; and a waning connection to tribal cultural traditions. According to a 2004 report titled “Youth Gangs in Indian Country,” drug sales account for 22 percent of criminal offenses by gang members, with aggravated assault accounting for 15 percent of offenses. Communities surveyed cited substance abuse, particularly alcohol (96%) and drugs (88%), as a significant problem contributing to antisocial behavior among youth and adults.
As a result of high levels of substance abuse, many racial minorities, including Native Americans, are disproportionately imprisoned for numerous offenses. According to data for 1999–2000, American Indians and Alaska Natives are incarcerated at a higher rate than any other racial/ethnic minority, except African Americans. Despite being the smallest racial/ethnic population, more than 4 percent of Native peoples are under correctional supervision, and this percentage is rising, due in large part to an increase in different forms of illicit substance abuse. The 2001 alcohol–related arrest rate for the American Indian and Alaska Native population was higher than the rate for all races.
Indigenous peoples experience significantly higher rates of violent crime. Between 1992 and 2002, “among American Indians age 25 to 34, the rate of violent crime victimizations was more than 2½ times the rate for all persons the same age” (U.S. Department of Justice 2004). In 2001, 54.9 percent of American Indians entering the federal prison system had been convicted of violent crimes, while only 4.1 percent of whites and 13.3 percent of African Americans in prison had committed violent crimes. The Justice Department notes, however, that “approximately 60% of American Indian victims of violence, about the same percentage as of all victims of violence, described the offender as white” (U.S. Department of Justice 2004). Arrests for drug offenses accounted for 12.1 percent of American Indians entering the prison system.
Substance abuse, like other health challenges faced by American Indian and Native Alaska communities, is rooted in political economic conditions. Social and economic conditions that are prevalent in many indigenous communities provide fertile ground not only for the initiation of substance abuse, but also for its perpetuation. Substance abuse is only one component of the larger spectrum of health disparities that reflect race and class. Native peoples share the same racial and class landscape as other racial minorities and poor people.
Agency for Healthcare Research and Quality. 2005. 2004 National Healthcare Disparities Report. Rockville, MD: U.S. Department of Health and Human Services.
Berkhofer, Robert. 1979. The White Man’s Indian: Images of the American Indian from Columbus to the Present. New York: Vintage Press.
Enoch, Mary–Anne, and David Goldman. 1999. “Genetics of Alcoholism and Substance Abuse.” Psychiatric Clinics of North America 22 (2): 289–299.
Indian Health Service. 2000. Trends in Indian Health, 1998–1999. Rockville, MD: U.S. Department of Health and Human Services. Available from http://www.ihs.gov/PublicInfo/Publications.
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President, National Congress of American Indians, before the United States Senate Committee on Indian Affairs: Oversight Hearing on the Problem of Methamphetamine in Indian Country, April 25, 2006.” Washington DC: National Congress of American Indians. Available from http://www.ncai.org/Methamphetamine_Resources.195.0.html.
Kitcheyan, Kathleen. 2006. “Testimony of Chairwoman Kathleen Kitcheyan of the San Carlos Apache Tribe before the United States Senate Committee on Indian Affairs: Oversight Hearing on the Problem of Methamphetamine in Indian Country, April 25, 2006.” Washington DC: National Congress of American Indians. Available from http://www.ncai.org/Methamphetamine_Resources.195.0.html.
Major, Aline K., et al. 2004. “Youth Gangs in Indian Country.” Juvenile Justice Bulletin. Washington DC: U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention. http://www.ncjrs.gov/pdffiles1/ojjdp/202714.pdf.
Mancall, Peter. 1995. Deadly Medicine: Indians and Alcohol in Early America. Ithaca, NY: Cornell University Press.
May, Phillip. 1994. “The Epidemiology of Alcohol Abuse among American Indians.” American Indian Culture and Research Journal 18 (2): 121–143.
McSwain, Robert. 2006. “Statement of Robert McSwain, Deputy Director, Indian Health Service, before the Senate Committee on Indian Affairs: Oversight Hearing on the Problem of Methamphetamine in Indian Country, April 25, 2006.” Washington DC: National Congress of American Indians. Available from http://www.ncai.org/Methamphetamine_Resources.195.0.html.
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Gregory R. Campbell
Adolescent substance abuse and its resulting harms are major concerns of parents, policymakers, teachers, and public health officials. Nevertheless, experimentation with substances, particularly alcohol and tobacco, is progressively more common behavior from pre- to late adolescence. When adolescents try substances a few times, with peers, this experimentation is generally not associated with any long-term impairment of functioning. Experimentation is considered problematic when substance use occurs at a very young age, with increasing frequency, while the child is alone, or in the context of behavioral or emotional difficulties. If use becomes more frequent, negative consequences can develop, including impairment at school or work, legal problems, accidents, and interpersonal difficulties. Substance use becomes abuse when an adolescent suffers negative and harmful consequences because of the use of substances—and yet continues using. Substance abuse has been strongly linked to risky sexual behavior, delinquent behavior, and low school achievement. Heavy and prolonged substance use can result in drug dependence, with a syndrome of significant distress if the drug use is stopped or reduced.
Adolescents tend to follow a particular pattern of involvement with drugs. Typically, the first substance an adolescent uses is one that is legal for adults (tobacco or alcohol). The next stage is often experimentation with marijuana. Tobacco, alcohol, and marijuana have been labeled "gateway drugs" because they precede the use of other harder drugs. High frequency of use and early age of initiation are both associated with movement to higher stages of substance use.
Early initiation of substance use is linked to substance abuse and dependence. A 1997 study by Bridget Grant and Deborah Dawson found that more than 40 percent of individuals who began drinking before age fourteen developed a dependence on alcohol. In comparison, only 10 percent of those who began drinking at age twenty or older developed alcohol dependence. Similarly, individuals who began using drugs at an early age tend to experience greater drug problems. A 1993 study conducted by Denise Kandel and Kazuo Yamaguchi found that adolescents who use harder drugs, such as cocaine or crack, began using one of the gateway drugs (cigarettes, alcohol, or marijuana) two years earlier than adolescents who did not advance to harder drugs. Most smokers begin smoking as teenagers. More than 90 percent of individuals who become regular smokers begin before the age of nineteen.
Trends in Substance Use
The Monitoring the Future study, conducted by Lloyd Johnston, Patrick O'Malley, and Jerald Bachman, tracked the prevalence of adolescent substance use among American eighth, tenth, and twelfth grade students each year from the mid-1970s into the twenty-first century. The study focused on three categories of substances: illicit drugs, alcohol, and cigarettes. It also examined gender and racial/ethnic differences in substance use.
Illicit drug use peaked in the 1970s, decreased steadily until the early 1990s, and then increased during the 1990s, with a slight decline and leveling off at the close of the decade. Marijuana is the most common illicit drug used. In 2000, more than half (54%) of American high school seniors reported using some type of illicit drug in their lifetimes. Reported prevalence rates among tenth and eighth grade students that year were lower (46% and 27%, respectively). In 2000, one-quarter of twelfth grade students reported using an illicit drug during the previous month, followed by 23 percent of tenth graders and 12 percent of eighth grade students.
Alcohol use increased throughout the 1970s, peaking at the end of the decade; it then steadily decreased in the 1980s and remained fairly stable during the 1990s. In the 2000 survey, 80 percent of twelfth grade students reported having tried alcohol at least once, and 62 percent reported having been drunk at least once. Seventy-one percent of tenth grade students had tried alcohol (49 percent had been drunk at least once), and 52 percent of eighth grade students had tried alcohol (25 percent had been drunk at least once). One-half of high school seniors, 41 percent of tenth graders, and 22 percent of eighth graders reported drinking alcohol in the previous thirty days.
Cigarette use peaked in the mid-1970s, declined substantially for a few years, remained relatively stable in the mid-1980s and early 1990s, increased during the mid-1990s, and experienced a slight decrease in the last few years of the twentieth century for eighth and tenth graders. According to results from 2000, over half of twelfth graders (63%) and tenth graders (55%) reported smoking a cigarette in their lifetimes, while 41 percent of eighth graders had smoked. The reported prevalence rates for smoking during the previous thirty days were 31 percent of twelfth grade students, 24 percent of tenth graders, and 15 percent of eighth graders.
Gender and Racial/Ethnic Differences
Male students have higher lifetime and thirty-day prevalence rates than their female counterparts for marijuana use for all grades reported. Senior males report more illicit drug use of other types in the previous thirty days than females, but there is little gender difference in tenth or eighth grade. Males also tend to use alcohol more than females, which becomes more apparent by twelfth grade. Across all grades, males and females seem to have almost equal rates of daily cigarette smoking. African-American students report lower lifetime, annual, thirty-day, and daily illicit drug use prevalence rates than white and Hispanic students. African-American students also have the lowest prevalence rates of alcohol use, being drunk, and binge drinking.
Approaches to Preventing Substance Abuse
In order to prevent substance abuse among young people, both supply and demand reduction strategies are critical. Supply reduction strategies include any method used to reduce the availability of drugs, such as border patrols, confiscation of drug shipments, and penalties for drug use and drug dealing. In recent years, "community" police officers have been increasingly used in neighborhood and secondary school settings to prevent the local sale and distribution of drugs. Within the realm of legal substances, such as alcohol and tobacco, effective supply reduction strategies include increasing taxes, increasing the legal age of use, increasing law enforcement, reducing product advertising, reducing the number of sales outlets, and imposing penalties for sales of these products to minors.
Demand reduction strategies are designed to reduce the demand for drugs. Prevention and treatment are part of demand reduction. Prevention attempts to reduce demand by decreasing risk factors and increasing protective factors associated with substance abuse, while treatment is designed to decrease demand by stopping substance abuse in addicted or abusing individuals.
Prevention programs are organized along a targeted audience continuum—that is, the degree to which any person is identified as an individual at risk for substance abuse. Universal prevention strategies address the entire population (e.g., national, local community, school neighborhood) with messages and programs aimed at preventing or delaying the use of alcohol, tobacco, and other drugs. Selective prevention strategies target subsets of the total population that are deemed to be at risk for substance abuse by virtue of their membership in a particular population segment—for example, children of adult alcoholics, dropouts, or students who are failing academically. Indicated prevention strategies are designed to prevent the onset of substance abuse in individuals who do not meet medical criteria for addiction but who are showing early danger signs, such as truancy, falling grades, and cigarette smoking.
Research shows that there are many risk factors for drug abuse, each having a different impact depending on the phase of development. Risk factors can be associated with individual characteristics as well as social contexts. Individual risk factors include: genetic susceptibility to addiction, high sensation seeking, impulsive decision making, conduct problems, shyness coupled with aggression in boys, rebelliousness, alienation, academic failure, and low commitment to school.
Family risk factors include: substance abusing or emotionally disturbed parents; perceived parent permissiveness toward drug/alcohol use; lack of or inconsistent parental discipline; negative communication patterns and conflict; stress and dysfunction caused by death, divorce, incarceration of parents or low income; parental rejection; lack of adult supervision; poor family management and communication; and physical and/or sexual abuse. School risk factors include: ineffective classroom management, failure in school performance, truancy, affiliations with deviant peers, peers around deviant behaviors, and perceptions of approval of drug using behaviors in the school, peer, and community environments.
Certain protective factors have also been identified. These factors are not always the opposite of risk factors, and their impact varies along the developmental process. The most salient protective factors include: strong bonds with the family; experience of parental monitoring with clear rules of conduct within the family unit and involvement of parents in the lives of their children; success in school performance; and strong bonds with prosocial institutions such as the family, school, and religious organizations. Other factors—such as the availability of drugs, alcohol, and tobacco, and beliefs that substance use by young people is generally tolerated—also influence a number of youth who start to use drugs.
During the 1990s, the federal government made a concerted effort to test and disseminate prevention programs that met rigorous scientific standards for effectiveness. For example, school districts had to select effective programs and evaluate their progress toward specific goals for reduction of substance use by students, in order to receive funding through the Safe and Drug Free Schools program. Agencies such as the National Institute on Drug Abuse and the Center for Substance Abuse Prevention funded national and local studies to test whether youth who participate in prevention programs actually experience a reduction in risk factors, an increase in protective factors, and/or reductions in substance use. Federal agencies, scientific societies, and private foundations developed criteria for assessing the evidence about the effectiveness of various approaches and programs, and many provided recommendations to the public about particular programs and approaches through web sites and print media. Changing behavior is exceedingly complex, but informed efforts by parents, schools, and communities can help protect young people from the harms of substance abuse.
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Johnston, Lloyd D., Patrick M. O'Malley, and Jerald G. Bachman."Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2000." Available from http://www.monitoringthefuture.org; INTERNET.
Kandel, Denise B., and Kazuo Yamaguchi. "From Beer to Crack:Developmental Patterns of Drug Involvement." American Journal of Public Health 83 (1993):851-855.
Kandel, Denise B., Kazuo Yamaguchi, and Kevin Chen. "Stages of Progression in Drug Involvement from Adolescence to Adulthood: Further Evidence for the Gateway Theory." Journal of Studies on Alcohol 53 (1992):447-457.
Political interest in regulating alcohol consumption in the United States emerged in the mid‐nineteenth century, when eighteen states passed prohibition laws. Temperance organizations subsequently made drinking a national issue. In 1862, the traditional rum ration for naval personnel was discontinued, and in 1914, drinking by officers aboard navy ships was prohibited. The Prohibition Amendment was ratified in 1919. After Prohibition was repealed in 1933, drinking in the armed services became an almost obligatory social ritual. Command‐sponsored club happy hours, airborne forces' “Prop Blast” parties, and naval aviators' Tailhook Conventions were organized around heavy drinking.
In 1970, PL 91‐616, the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act, defined alcoholism as a disease and mandated that military alcohol abusers receive treatment in a nondiscriminatory and confidential context. The following year, Title V of the Selective Service Act, PL 92‐129, required DoD to identify, treat, and rehabilitate alcoholics to prevent the loss of experienced personnel. The medical departments treated physiological and psychiatric conditions associated with drinking, and command conducted rehabilitation programs.
In 1980, DoD announced that alcohol abuse was incompatible with military discipline, performance, and readiness. Commanders were to deglamorize drinking, educate service members on its harmful effects, punish drunken driving severely, and deemphasize alcohol at social functions. The 1986 DoD Health Promotion Program, designed to improve the quality of service members' lives and to enhance readiness, included programs to reduce the use of alcohol, tobacco, and drugs. By 1987, the services were operating the world's largest integrated occupational health program, with 47,000 enrollees. But alcoholic service members, suspecting that their careers would be compromised, were reluctant to ask for rehabilitation.
The DoD‐sponsored Worldwide Survey of Substance Abuse and Health Behaviors Among Military Personnel began in 1980. Between 1980 and 1992, the proportion of drinkers among service members declined from 86.5 percent to 79.6 percent, and heavy drinkers declined from 20.8 percent to 14.5 percent. In contrast, 9.5 percent of civilians in 1991 were heavy drinkers.
Cigarettes became a ritual of relaxation during World War II. In 1964, Surgeon General Luther Terry made public the deleterious effects of smoking on health. In 1982, DoD began to track smoking on its Worldwide Surveys. As part of the 1986 Health Promotion Program, DoD limited smoking in workplaces; in 1994, it banned smoking indoors. Between 1980 and 1992, the proportion of military smokers declined from 51 percent of the force to 35 percent. During the same period, civilian smoking declined from 30 percent to 25 percent.
Use of illegal drugs and abuse of medicinal drugs became a problem in the armed forces in the late 1960s as a consequence of expanding drug use in the civil sector and easy availability of drugs in Vietnam. During the Vietnam War, drug users were classified as addicts and evacuated through medical channels. In 1971, treatment and rehabilitation of drug as well as alcohol abusers was mandated.
The Boys in the Barracks, a landmark study of drug use in the U.S. Army in 1973–74 by L. H. Ingraham and F. J. Manning, revealed the psychological purposes served by drug abuse. Soldiers in dysfunctional units used drugs as a basis for establishing trust among themselves and bonding against authority. These findings led to initiatives to enhance cohesion around military values and to train leaders to care for and empower their subordinates. The first Worldwide Survey (1980) indicated that drug abuse was volitional rather than addictive behavior, and a 1980 DoD directive made commanders rather than the medical departments responsible for its control.
In 1984, random urinalysis made it difficult for drug users to escape detection, and in 1986 the Health Promotion Program introduced zero tolerance for drug use. Officers and noncommissioned officers caught using drugs were eliminated from the service. Commanders had discretion to give junior enlisted personnel a second chance by authorizing rehabilitation. Drug use fell from 27.6 percent of military personnel in 1980 to 3.4 percent in 1992. The latter figure compares favorably with 10 percent use in 1991 in the general population.
Since the mid‐1980s, substance abuse has declined as commanders, supported by the medical departments, have assumed responsibility for promoting healthy behavior. Emphasis on cohesion, focus on wartime missions, and improved leadership have reduced the psychosocial needs for drugs, alcohol, and tobacco. The military population has become older and better educated, and more members are married—demographic characteristics negatively correlated with substance abuse. Drug abuse has been almost eliminated. But both drinking and smoking—which military traditions define as characteristics of a fighting man—persist, particularly among the young, unmarried, and poorly educated.
Marvin R. Burt , et al., Worldwide Survey of Nonmedical Drug Use and Alcohol Use Among Military Personnel: 1980, 1982.
Robert M. Bray , et al., 1982 (1985, 1988, 1992) Worldwide Survey of Substance Abuse and Health Behaviors Among Military Personnel, titles vary; 1983, 1986, 1989, 1992.
Larry H. Ingraham and and Frederick J. Manning , The Boys in the Barracks, 1984.
U.S. Department of the Army , Alcohol and Drug Abuse Prevention and Control Program, Army Regulation 600–85, 1988.
Henry J. Watanabe,, Paul T. Harig,, Nicholas J. Rock,, and and Ronald J. Koshes , Alcohol and Drug Abuse and Dependence in Franklin D. Jones, et al., eds., Textbook of Military Medicine, Part I, Vol. 7: Military Psychiatry—Preparing in Peace for War, 1994.
Robert M. Bray,, Larry A. Kroutil,, and and Mary Ellen Marsden , Trends in Alcohol, Illicit Drug, and Cigarette Use Among U.S. Military Personnel: 1980–1992, Armed Forces and Society, 21 (Winter 1995), pp. 271–93.
Faris R. Kirkland