Substance Abuse

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.

Conclusion

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

What Is Substance Abuse?

What Causes Substance Abuse?

What Are Some Commonly Abused Substances?

What Are Some Other Risks of Substance Abuse?

What Are the Signs of Substance Abuse?

How Is Substance Abuse Diagnosed and Treated?

Resources

Substance abuse is an unhealthy pattern of alcohol or drug use that usually leads to frequent, serious problems.

KEYWORDS

for searching the Internet and other reference sources

Drug abuse

Marijuana

Hallucinogens

Inhalants

Narcotics

Sedatives

Stimulants

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.

What Is Substance Abuse?

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.

What Causes Substance Abuse?

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
• depression
• low self-esteem
• feeling like an outsider
• poverty
• 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

What Are Some Commonly Abused Substances?

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

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

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

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

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

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

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

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

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

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

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”).

What Are Some Other Risks of Substance Abuse?

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.

What Are the Signs of Substance Abuse?

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

Violent Objections

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

How Is Substance Abuse Diagnosed and Treated?

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 therapy

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.

Group therapy

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

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

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.

See also

Addiction

Alcoholism

Consciousness

Tobacco Addiction

Resources

Book

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.

Organizations

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

Websites

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

SteroidAbuse.org. The National Institute on Drug Abuse set up this site to provide facts about anabolic steroid abuse. http://www.steroidabuse.org

Substance Abuse and Dependence

Definition

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.

Description

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:

• alcohol
• 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.

Causes and symptoms

Causes

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.

Symptoms

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.

Diagnosis

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.

Treatment

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.

Alternative treatment

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.

Prognosis

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

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.

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 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.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, DC: American Psychiatric Association, 2000.

PERIODICALS

"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

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.

BIBLIOGRAPHY

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

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

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

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

Substances of Abuse

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

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

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

Other Substances of Abuse

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

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

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

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

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

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

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

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

Treatments for Substance Abuse and Related Disorders

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

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

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

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

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

Prevention Efforts

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

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

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

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

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

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

BIBLIOGRAPHY

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

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

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

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

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

Scott C.Bates

Melanie M.Domenech-Rodríguez

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