Substance Abuse and Dependence

Definition

Substance abuse is a pattern of drug, alcohol, or other substance use that creates many adverse results from its continual use. 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 self or others.

Substance dependence has been defined medically as 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 this substance. Sometimes Increased amounts are needed to achieve the desired effect or level of intoxication. Consequently the patient's tolerance for the drug increases. 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.

Description

Substance abuse and dependence cross all lines of race, culture, education, and socioeconomic status, leaving no group untouched by its devastating effects. A recent survey estimated that about 16 million citizens of the United States had used an illegal substance in the month preceding the study. Substance abuse is an enormous public health problem, with far-ranging effects throughout society. In addition to the toll substance abuse can take on one's physical health, it is considered an important factor in a wide variety of social problems, affecting rates of crime, domestic violence, sexually transmitted diseases (including HIV/AIDS), unemployment, homelessness, teen pregnancy, and failure in school. One study estimated that 20% of the total yearly cost of health care in the United States is spent on the effects of drug and alcohol abuse.

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

• 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 amphetamines used for weight loss and in the treatment of attention deficit disorder
• cannabinoid drugs obtained from the hemp plant, including marijuana ("pot") and hashish
• cocaine-based drugs
• 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, glue
• alcoholic drinks, including beer, liquor, and wine

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/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 becoming accustomed to the symptoms produced by a specific quantity of a substance. When a person first begins taking a substance, he/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, the same dosage of the substance may produce fewer of the desired feelings. In order to continue to feel the desired effect of the substance, progressively higher drug doses must be taken.

Substance dependence is the 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 their bloodstream at any given moment in order to avoid the unpleasant symptoms associated with withdrawal from that substance. The common substances of abuse tend to exert either a depressive (slowing) or a stimulating (speeding up) effect on such basic bodily functions as respiratory rate, heart rate, and blood pressure. When a drug is stopped abruptly, the person's body will respond by overreacting to the substance's absence. Functions slowed by the abused substance will be suddenly speeded up, while previously stimulated functions will be suddenly slowed. This results in very unpleasant symptoms, known as withdrawal symptoms.

Addiction refers to the mind-state of a person who reaches a point where he/she must have a specific substance, even though the social consequences of substance use are clearly negative (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. Such craving can be so strong that it overwhelms a person's ability to make any decisions which will possibly deprive him/her of the substance. Drug possession and use becomes the most important goal, and other forces (including the law) have little effect on changing the individual's substance-seeking behavior.

Causes and symptoms

There is not thought to be a 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 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, such as bipolar disorder, 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 committed 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 may cause aggressive or violent behavior.
• Hallucinogenic drug users may display dilated pupils and bizarre behavior due to hallucinations.(Hallucinations are imagined sights, voices, sounds, or smells which seem completely real to the individual experiencing them.) 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 horrifyingly 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 human immunodeficiency virus (HIV) (the virus that causes acquired immunodefiency syndrome, or AIDS ), certain forms of hepatitis (a liver infection), and tuberculosis.

Cocaine is often taken as a powdery substance which is inhaled or "snorted" through the nose. This can result in frequent nose bleeds, sores in the nose, and even erosion of the nasal septum, the structure that separates the two nostrils. Cocaine can also be smoked.

Overdosing on a substance is a frequent complication of substance abuse. Drug overdose can be purposeful (with suicide as a goal), or caused by carelessness, the unpredictable strength of substances purchased from street dealers, mixing of more than one type of substance, or as a result of the ever-increasing doses which a 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, drop the body temperature, and result in a 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 health care worker faced with a patient suffering extreme symptoms may have no idea what other substance that person may have unwittingly put into his or her body. Thorough drug screening can help with this problem.

Diagnosis

The most difficult aspect of diagnosis involves addressing and overcoming 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 commonly used screening tools used by nursing staff or allied health professionals to begin the process of diagnosing substance abuse is called 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, longer lists of questions exist in order to try to determine the severity and effects of a person's substance abuse. Certainly, it is also relevant to determine whether anybody else in a person'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, 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. This drug testing is limited by sensitivity, specificity and the time elapsed since the person last used the drug.

Treatment

Treatment has several goals, which include helping a person deal with the uncomfortable and possibly life-threatening symptoms associated with withdrawal from an addictive substance (called detoxification), helping 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 "cold turkey," 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 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 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 and treated appropriately.

A recent discovery for the treatment of opiate addiction is a medication called naltrexone. This medication blocks the receptors involved with the "high" produced by heroin. The drug is useful for many patients since it is does not produce physical dependence and has virtually zero potential for abuse. Scientists have found that unfortunately, many heroin addicts do not like to take naltrexone quite possibly because they enjoy the effects of opiates. Since the medication eliminates the craving for opiates, in one recent study only 15% of heroin addicts were still taking the drug after one month.

Alternative treatments for substance abuse include those specifically designed to aid a person who is suffering from the effects of withdrawal and the toxicities of the abused substance, as well as treatments which are intended to decrease a person's stress level, thus hopefully decreasing the likelihood that he or she will relapse.

Additional 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 by hydrotherapy as well as by such herbs as milk thistle (Silybum marianum), burdock (Arctium lappa), a blood cleanser, and licorice (Glycyrrhiza glabra). 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 biofeedback, guided imagery, and various meditative arts, including yoga and tai chi. Alternative medicine also places a great emphasis on proper nutrition, for detoxification, healing, and sustained recovery.

Prognosis

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 has been accomplished, that a previously addicted person is virtually forever in danger of slipping back into substance use. Triggers for such a relapse include any number of life stressors: problems on the job or in the marriage, loss of a relationship, death of a loved one, and 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 Narcotics Anonymous are the most successful and useful way of monitoring the recovery process and avoiding relapse. Research indicates that a good prognosis is more likely for individuals who have a strong support than for those who have little or no support.

Another important aspect of treatment for substance abuse is 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 accidentally develop behaviors that inadvertently serve to support a person's substance habit, most good treatment programs will involve all family members.

Health care team roles

Nursing staff and allied health professionals can assist in the treatment of substance abuse and dependence by understanding the disease model of alcoholism and addiction.

During the treatment phase, nursing staff and allied health professionals can help patients by providing them with appropriate educational materials and referrals for supportive services such as Alcoholics Anonymous or Narcotics Anonymous.

KEY TERMS

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 in order to avoid experiencing withdrawal symptoms.

Detoxification— A process whereby an addict is withdrawn from a substance.

Disease model of alcoholism— Also known as the Minnesota model, the disease model contends that alcoholism is a disease that alcoholism is chronic, progressive, and frequently fatal.

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 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.

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.

Prevention

Prevention is best aimed at teenagers, who are at very high risk for substance experimentation. Data compiled in 1999 revealed that 14% of high school seniors had used an illegal substance other than marijuana in the preceding year. 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.

Resources

BOOKS

Allen, Frances, et al. Diagnostic and Statistical Manual of Mental Disorders. Washington, D. C.: 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.

Shealy, C. Norman. The Complete Family Guide to Alternative Medicine. New York: Barnes and Noble, 1996.

Volpicelli, Joseph. Recovery Options: The Complete Guide. New York: John Wiley & Sons, 2000.

ORGANIZATIONS

Al-Anon, Alanon Family Group, Inc. PO 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.