Substance use and abuse

Friday, September 01, 2006

Defining Substance Use and Abuse

What is a drug?

There are various elements to this question, as the concept is heavily influenced by both the socio-cultural context and the purpose of its use. The definition of the term drug is a product of social custom and law, both of which change over time (Smith 1970). According to the World Health Organization (1981), a drug is defined as

'any chemical entity or mixture of entities, other than those required for the maintenance of normal health (like food), the administration of which alters biological function and possibly structure'

A drug, in the broadest sense, is a chemical substance which has an effect on bodily systems and behaviour. Drugs can be therapeutic, non therapeutic or both. A psychoactive drug is a drug that affects the central nervous system and alters mood, thinking, perception and behaviour. In this context, alcohol, tobacco and drugs (prescribed and illicit) are psychoactive substances. It is these drugs that psychologists are mostly concerned with. Though it is worth noting that the issue of substance abuse can also cover food, solvents, etc. Indeed anything that would be refered to as a substance and ingested into the body in some fashion can be abused and therefore of interest to psychologists.

According to the World Health Organisation (WHO) there are 4 basic forms of drug use -

  1. Unsanctioned use: a drug that is not approved by society.
  2. Hazardous use: a drug leading to harm or dysfunction.
  3. Dysfunctional use: a drug leading to impaired psychological or social functioning.
  4. Harmful use: a drug that is known to cause tissue damage or psychiatric disorders.

What is substance use and abuse?

The terms substance use and abuse are difficult concepts to define precisely. The operational use of these concepts is heavily dependent on particular ideology and clinical practice. Substance use can be defined as the ingestion of a substance which is used for therapeutic purposes or as prescribed by medical practitioners. Substance misuse is the result of a psychoactive substance being consumed in a way that it was not intended and which may cause physical, social and psychological harm. It is also used to represent the pattern of use: experimental, recreational and dependent. (Rasooll, 1998).

According to Rasool (1998) the term substance abuse, which is often associated with addiction and dependence, is considered to be value laden and has limited use in the addiction literature in the UK. In the USA, practitioners prefer the term substance abuse for problems resulting from the use of alcohol or other mood altering drugs and use addictive disorders when the problems have escalated to dependency (Sullivan 1995). Whether a substance is used or abused depends very much on the social and cultural context, the individual perspective, the pattern and mode of consumption and the perception of the observer.

The Advisory Council for the Misuse of Drugs (ACMD) prefers the term 'problem drug user, which they define as -

'any person who experiences social, psychological, physical or legal problems related to intoxication and/or regular excessive consumption and/or dependence as a consequence of his own use of drugs or other chemical substances.'

The above definition focuses on the needs and problems of the individual and places less emphasis on the substance oriented approach. It is a holistic definition in acknowledging that the problem drug user has social, psychological, physical and legal needs and the definition could be expanded to incorporate the spiritual needs of the problem drug user.

What is addiction?

A related concept to these issues is that of addiction. Addictive behaviour is a complex dynamic behaviour pattern having psychological, physical, social and behavioural components. Addictive behaviour, according to Marlatt et al. (1988) is defined as

'a repetitive habit pattern that increases the risk of diseases and/or associated personal or social problems. The individual usually has a loss of control, immediate gratification with delayed, deleterious effects, and experiences relapses when trying to quit.'

Using this type of definition one can understand that, from a psychological persepctive, any substance could be a component of addiction, for example, chocolate!

However when discussing drug addiction, rather than any other substance, or indeed behaviours, it is useful to know what we are specifically refering to. One way to refer to, and to think about, drug addiction is to use the term of drug dependence. The World Health Organisation (WHO) in 1969, defined drug dependence as -

'a state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug, characterised by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its physical effects, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present. A person may be dependent on more than one drug.'

This comprehensive definition has been widely accepted and highlights the core features of dependence such as tolerance and psychological and physical dependence -

1. According to Rassool (1998), tolerance is a behavioural state and refers to the way the body usually adapts to the repeated presence of a drug. Higher doses of the psychoactive substance are required to reproduce the original or similar effects. The drug must be taken on a regular basis and in adequate quantities for tolerance to occur. Tolerance can be subdivided into:

  • Pharmacodynamic tolerance, when higher doses of the drug are needed to produce the desired response or effect.
  • Metabolic tolerance, when there is an increased capacity to metabolise a drug.
  • Cross tolerance - when one is tolerant to one drug, there is also tolerance to other drugs of the same type or classification.

2. Psychological dependence can be described as a compulsion or a craving to continue to take a drug because of the need for stimulation, or because it relieves anxiety or depression. Psychological dependence is recognised as the most widespread and the most important (ISDD 1996). This kind of dependence is not only attributed to the use of psychoactive drugs but also to food, sex, gambling, relationships and physical activities. (Rassool, 1998)

3. Physical dependence is a state of bodily adaptation to the presence of a particular psychoactive drug. This manifests itself in physical disturbances or withdrawal symptoms following cessation of use. The withdrawal symptoms depend on the type or category of drug. For example, for nicotine, the physiological withdrawal symptoms may be relatively slight. In other dependence inducing psychoactive substances, such as opiates and depressants, the withdrawal experience can range from mild to severe. Physical withdrawal syndromes are not, however, the essence of dependence. It is possible to have dependence without withdrawal and withdrawal without dependence (Royal College of Psychiatrists, 1987). However, it is argued that many of the supposed signs of physical dependence are sometimes psychosomatic reactions triggered off, not by the chemical properties of the psychoactive drug, but by the user's fears, beliefs and fantasies about what withdrawal entails (Plant 1987).

Patterns of substance use and abuse

The patterns of drug or alcohol use and misuse for some individuals may vary over a period of time. According to Rassool (1998) substance misusers are often described as experimental, recreational and problematic -

Experimental users are described as those who use drugs, legal or illicit, on a few occasions By definition, anyone's initial use of a drug is experi- mental. The main motivation for experimental drug or alcohol use includes curiosity, anticipation of effects and availability. There is no pattern in the use of psychoactive substances but the choice of the drug misused is indiscriminate. The choice of drug use depends on factors such as availability, reputation of the drug, subculture, fashion and peer group influence. Experimental use of illicit psychoactive substances is usually a short lived experience and the majority of people may confine the consumption to drugs that are socially acceptable. Experimental users, however, are in the highest category of risk for infections (if injecting), medical complications or overdose due to the indiscriminate use of adulterated psychoactive substances.

Experimental users may or may not become recreational users of illicit psychoactive substances. The term recreational refers to a form of substance use in which pleasure and relaxation are the prime motivations. There is a strict adherence to the pattern of use so that the drug is only used on certain occasions, such as weekends, and less likely on consecutive days. There is usually a preference for a particular drug (drug of choice) - the user has leamt how to use it and appreciate its effects. Drug or alcohol use is one aspect of the user's life and tends to complement social and recreational activities.

By definition, a dependent user has progressed to regular and problematic use of a psychoactive drug or has become a polydrug user. There is the presence of psychological and/or physical dependence and it may be distinguished from experimental and recreational use. The pattern of use is more frequent and regular but less controlled. The process of obtaining the drug is more important to the user than the quality of the experience. This tends to displace rather than complement social activities.

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