Substance abuse and dependence

Substance abuse involves the use of drugs, alcohol or other chemicals in a way that interferes with normal healthy functioning. Substance abuse cuts across all lines of race, culture, educational and socioeconomic status. Substanceabuse is an enormous public health problem, with far-ranging effects. In addition to the health problems substance abuse can cuase, it is also consideredto 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. 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 amphetamine drugs used as weight loss drugs and in the treatment of attention deficit disorder)
  • Cannabinoid drugs obtained from the hemp plant (including marijuana)
  • Cocaine-based drugs
  • Hallucinogenicor "psychedelic" drugs (including LSD, PCP or angel dust)
  • Inhalants(including anesthetics as well as paint thinner, gas or glue)
  • Alcohol

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 will 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. Most substances of abuse tend toeither slow or a speed up basic body functions such as breathing, heart rate, blood pressure. When a drug is stopped abruptly, the person's body will respond by over-reacting. 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.

Scientists don't think there is just one single cause of substance abuse, although it does seem as if certain people have a genetic tendency to develop addictive behaviors. However, other social factors are most likely involved aswell, including social problems and peer pressure. Other mental disorders canincrease the chance that a person will become addicted.

The symptoms of substance abuse may be related to both its social effects andits 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 move slowly, lose weight, have mood swings, and have 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, sleep problems, weight loss, rapid pulse, high blood pressure, occasional psychotic behavior and 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, and a constantly runny nose. "Crack" cocaine may cause aggressive orviolent behavior.
  • Hallucinogenic drug users may display bizarre behavior due to hallucinations and dilated pupils. LSD can cause flashbacks.

Other symptoms may depend on the type of substance being abused. For example,heroin, 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 needle marks on arms or legs, with redness and swelling of the vein in which the substance was injected. Furthermore, poor judgment brought onby 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, aswell as infection with HIV, certain forms of hepatitis (a liver infection), and tuberculosis.

Cocaine is often taken as a powdery substance which is "snorted" through thenose. This can result in frequent nose bleeds, sores in the nose, and even aneating away of the nasal septum (the structure which separates the two nostrils). Other forms of cocaine include smokable or injectable forms of cocainesuch as free base and crack cocaine.

Overdosing on a substance is a frequent complication of substance abuse. Drugoverdose 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 of a substance and alcohol, or as aresult 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. Substances with depressive effects may dangerously slow the breathing and heart rate, drop the body temperature, and result in a general unresponsiveness. Stimulants may dangerously boost the heart rate and blood pressure, increase body temperature, and cause bizarre behavior. With cocaine, there is also 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 will 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.

The most difficult aspect of diagnosis involves overcoming the patient's refusal to acknowledge the problem. This may cause the person to completely denythe substance use or underestimate the degree of the problem and its effects.

One of the simplest and most commonly used screening tools used by doctors todiagnose substance abuse is called the CAGE questionnaire:

  • 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 youever feel Guilty about your substance use?
  • Do you ever need an Eyeopener (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. A family history is another helpful tool in diagnosing substance abuse.

A physical exam may reveal signs of substance abuse in the form of needle marks, tracks, damage to the inside of the nostrils from snorting drugs, or unusually large or small pupils. Substance use also can be detected by examiningthe 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 has several goals, which include helping a person deal with the uncomfortable and possibly life-threatening symptoms associated with withdrawalfrom an addictive substance, helping a person deal with the social effects which substance abuse has had on his or her life, and efforts to prevent relapse. Individual or group psychotherapy is sometimes helpful.

Detoxification may take from several days to many weeks, and can either focuson "cold turkey" (complete and immediate ending of all substance use) or byslowly decreasing the dose which a person is taking to minimize the side effects of withdrawal. Some substances absolutely must be tapered, because "coldturkey" methods of detoxification are potentially deadly. 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 ofthe rebound effects of wildly fluctuating blood pressure, body temperature,heart and breathing rates, as well as the potential for bizarre behavior andhallucinations, a person undergoing withdrawal must be carefully monitored.

Alternative treatments for substance abuse include treatments 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.

Treatments thought to improve a person's ability to stop substance use include acupuncture and hypnotherapy. Ridding the body of toxins is believed to beaided by hydrotherapy (bathing regularly in water containing baking soda, seasalt or Epsom salts). Herbs also may help, including milk thistle, burdock,and licorice. Anxiety brought on by substance withdrawal is thought to be lessened by using other herbs, which include valerian, vervain, skullcap and kava.

Other treatments aimed at reducing the stress during detox include biofeedback, guided imagery, and various meditations such as (yoga and tai chi).

After a person has successfully withdrawn from substance use, the even more difficult task of recovery begins. Recovery refers to the life-long efforts ofa 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 stresses such as problems on the job or in the marriage, loss of a relationship, death of a loved one, financial stresses. While some people remain in counseling indefinitely, others find that various support groups or 12-Step Programssuch as Narcotics Anonymous and Alcoholic Anonymous are the most helpful wayof monitoring the recovery process and avoiding relapse.

Another important aspect of treatment is the involvement of close family members. Because substance abuse has severe effects on the functioning of the family, and because research shows that family members can accidentally developbehaviors which inadvertently serve to support a person's substance habit, most good treatment will involve all family members.

Prevention is best aimed at teenagers, who are at very high risk for substance experimentation. Data compiled in 1987 showed that 25% 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 asteaching methods of resisting peer pressure, are both important components of a prevention program. Furthermore, it is important to identify children athigher 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. Thesechildren will require a more intensive prevention program.

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