Drug Dependence

and Substance
Abuse

Submitted by:
Jessa Mae R. Baylin
Charmaine V. Bañes
Cherrylot B. Bermoy
Aldren Geyrozaga

[October 2009]
MAPEH 1b
Personal, Community and Environmental Health

Definition of Drug abuse and Dependence:

Drug addiction (dependence) is compulsively using a

substance, despite its negative and sometimes dangerous effects.
 A physical dependence on a substance (needing the drug to function) is not
always part of the definition of addiction. Some drugs (for example, some blood pressure
medications) don't cause addiction but do cause physical dependence. Other drugs
cause addiction without physical dependence (cocaine withdrawal, for example, doesn't
have symptoms like vomiting and chills; it mainly involves depression). Substance abuse
is the continued compulsive use of mind-altering substances despite personal, social,
and/or physical problems caused by the substance use. Abuse may lead to dependence,
in which increased amounts are needed to achieve the desired effect or level of
intoxication and the patient's tolerance for the drug increases.

Substance abuse and dependence refer to any continued

pathological use of a medication, non-medically indicated drug
(called drugs of abuse), or toxin. Although there are on-going
debates on the exact distinctions between substance abuse and
substance dependence, the current practice standard—
distinguishes between the two by defining substance dependence
in terms of physiological and behavioral symptoms of substance
use, and substance abuse in terms of the social consequences of
substance use. Substance dependence, commonly known as
addiction, is characterized by physiological and behavioral
symptoms related to substance use.

Substance abuse is more likely to be diagnosed among those who have just
begun drug-taking 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.

A single definition for drug dependence is elusive. Concepts that aid in defining
drug dependence are tolerance and psychologic and physical dependence.

Tolerance describes the need to progressively increase the drug dose to produce
the effect originally achieved with smaller doses.

Psychologic dependence includes feelings of satisfaction and a desire to repeat

the drug experience or to avoid the discontent of not having it. This anticipation of effect
is a powerful factor in the chronic use of psychoactive drugs and, with some drugs, may
be the only obvious reason for intense craving and compulsive use. Craving and
compulsion to use a drug lead to using it in larger amounts, more frequently, or over a
longer period than was intended when use began. Psychologic dependence involves
giving up social, occupational, or recreational activities because of drug use, as well as
persistent use despite knowing that the drug is likely causing a physical or mental
problem. Drugs that cause psychologic dependence often have ≥ 1 of the following
effects:

• Reduced anxiety and tension

• Elation, euphoria, or other pleasurable mood changes
• Feelings of increased mental and physical ability
 • Altered sensory perception
• Changes in behavior

Drugs that cause chiefly psychologic dependence include marijuana,

amphetamine, 3,4-methylenedioxymethamphetamine (MDMA), and hallucinogens, such
as lysergic acid diethylamide (LSD), mescaline, and psilocybin.

Physical dependence is manifested by a withdrawal (abstinence) syndrome, in

which untoward physical effects occur when the drug is stopped or when its effect is
counteracted by a specific antagonist. Drugs that cause strong physical dependence
include heroin, alcohol, benzodiazepines, and cocaine. Abstinence syndromes are drug-
or drug class–specific and may vary considerably based on the amount and frequency of
use and on patient characteristics, which may affect how patients experience withdrawal.

Description

Although substance dependence can begin at any age, persons aged 18 to 24

have relatively high substance use rates, and that 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.

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.

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 (antianxiety) substances
(including benzodiazepines such as valium, barbiturates,
prescription sleeping medications, and most prescription anti-
anxiety medications)

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

FREQUENCY OF SUBSTANCE ABUSE BY GENDER AND AGE

Men
Ages 18 to 29 17 to 24 percent
Ages 30 to 44 11 to 14 percent
Ages 45 to 64 6 to 8 percent
Over age 65 1 to 3 percent
Women
Ages 18 to 29 4 to 10 percent
Ages 30 to 44 2 to 4 percent
Ages 45 to 64 1 to 2 percent
Over age 65 less than 1 percent

Substance dependence is a phenomenon whereby a person becomes physically

addicted to a substance. A substance-dependent person must have a particular dose or
concentration of the substance in his or her bloodstream at any given moment in order to
avoid the un-pleasant symptoms associated with withdrawal from that substance. The
common substances of abuse tend to exert either a depressive (slowing) or a stimulating
(speeding up) effect on such basic bodily functions as respiratory rate, heart rate, and
blood pressure. When a drug is stopped abruptly, the person's body will respond by
overreacting to the substance's absence. Functions slowed by the abused substance will
suddenly speed up, while previously stimulated functions will slow down. This results in
very unpleasant effects, known as withdrawal symptoms.

Addiction refers to the mental-state of a person who reaches a point where he/she
must have a specific substance, even though the social, physical, and/or legal
consequences of substance use are clearly negative (e.g., loss of relationships,
employment, housing). Craving refers to an intense hunger for a specific substance, to
the point where this need essentially directs the individual's behavior. Craving is usually
seen in both dependence and addiction and can be so strong that it over-whelms a
person's ability to make any decisions that will possibly deprive him/her of the substance.
Drug possession and use becomes the most important goal, and other forces (including
the law) have little effect on changing the individual's substance-seeking behavior.

Causes, incidence, and risk factors:

Drug abuse can lead to drug dependence or addiction. People who use drugs for
pain relief may become dependent, although this is rare in those who don't have a history
of addiction.

The exact cause of drug abuse and dependence is not known. However, the
person's genes, the action of the drug, peer pressure, emotional distress, anxiety,
depression, and environmental stress all can be factors.

Children who grow up in an environment of illicit drug use may first see their
parents using drugs. This may put them at a higher risk for developing an addiction later
in life for both environmental and genetic reasons.

Signs of drug use in children include but are not limited to:

• A change in the child's friends

• Withdrawn behavior
• Long unexplained periods away from home
• Lying
• Stealing
• Involvement with the law
• Problems with family relations
• Acting drunk or high (intoxicated), confused, impossible to
understand, or unconscious
• Distinct changes in behavior and normal attitude
• Decreased school performance

Commonly abused substances include:

• Opiates and narcotics are powerful painkillers that cause drowsiness (sedation)
and feelings of euphoria. These include heroin, opium, codeine, meperidine
(Demerol), hydromorphone (Dilaudid), and Oxycontin.
• Central nervous system stimulants include amphetamines, cocaine,
dextroamphetamine, methamphetamine, and methylphenidate (Ritalin). Caffeine
and nicotine are the most commonly used stimulants. These drugs have a
stimulating effect, and people can start needing higher amounts of these drugs to
feel the same effect (tolerance).
 • Central nervous system depressants include barbiturates (amobarbital,
pentobarbital, secobarbital), benzodiazepine (Valium, Ativan, Xanax), chloral
hydrate, and paraldehyde. The most commonly used, by far, is alcohol. These
substances produce a soothing sedative and anxiety-reducing effect and can lead
to dependence.
• Hallucinogens include LSD, mescaline, psilocybin ("mushrooms"), and
phencyclidine (PCP or "Angel Dust"). They can cause people to see things that
aren't there (hallucinations) and can lead to psychological dependence.
• Tetrahydrocannabinol (THC) is the active ingredient found in marijuana
(cannabis) and hashish. Although used for their relaxing properties, THC-derived
drugs can also lead to paranoia and anxiety.

People may become high on drugs or overdose by accident or on purpose. Drug

withdrawal symptoms can occur when a person stops or reduces their use of a
substance. Withdrawal symptoms vary, depending on the abused substance. When
withdrawal symptoms begin depends on the length of time the drug normally stays within
the body. Drug intoxication, overdose, and withdrawal can sometimes be life-threatening.

Causes & Symptoms

Certainly, other social factors are involved, including family problems and peer
pressure. Primary mood disorders (bipolar), personality disorders, and learned behaviors
can be influential on the likelihood that a person will become substance dependent.

The symptoms of substance abuse may be related to its social as well as its
physical effects. The social effects of substance abuse may include dropping out of
school or losing a series of jobs, engaging in fighting and violence in relationships, and
legal problems (ranging from driving under the influence to the commission of crimes
designed to obtain the money needed to support an expensive drug habit).

Physical effects of substance abuse are related to the specific drug being abused:

• Opioid drug users may appear slowed in their physical movements and speech,
may lose weight, exhibit mood swings, and have constricted (small) pupils.
• Benzodiazapine and barbiturate users may appear sleepy and slowed, with slurred
speech, small pupils, and occasional confusion.
• Amphetamine users may have excessively high energy, inability to sleep, weight
loss, rapid pulse, elevated blood pressure, occasional psychotic behavior, and
dilated (enlarged) pupils.
• Marijuana users may be sluggish and slow to react, exhibiting mood swings and
red eyes with dilated pupils.
• Cocaine users may have wide variations in their energy level, severe mood
disturbances, psychosis, paranoia, and a constantly runny nose. Crack cocaine
use may cause aggressive or violent behavior.
• Hallucinogenic drug users may display bizarre behavior due to hallucinations
(hallucinations are imagined sights, voices, sounds, or smells which seem
 completely real to the individual experiencing them) and dilated pupils. LSD can
cause flashbacks.

Diagnosis

The most difficult aspect of diagnosis involves over-coming the patient's denial.
Denial is a psychological trait whereby a person is unable to allow him- or herself to
acknowledge the reality of a situation. This may lead a person to completely deny his or
her substance use, or may cause the person to greatly underestimate the degree of the
problem and its effects on his or her life.

One of the simplest and most common screening tools practitioners use to begin
the process of diagnosing substance abuse is the CAGE questionnaire. CAGE refers to
the first letters of each word that forms the basis of each of the four questions of the
screening exam:

• Have you ever tried to cut down on your substance use?

• Have you ever been annoyed by people trying to talk to you about your substance
use?
• Do you ever feel guilty about your substance use?
• Do you ever need an eye opener (use of the substance first thing in the morning)
in order to start your day?

Treatment

Treatment has several goals, which include helping a person deal with the
uncomfortable and possibly life-threatening symptoms associated with withdrawal from
an addictive substance (called detoxification), helping an abuser deal with the social
effects that substance abuse has had on his or her life; and efforts to prevent relapse
(resumed use of the substance). Individual or group psychotherapy may be helpful.

Ridding the body of toxins is believed to be aided by hydrotherapy (bathing

regularly in water containing baking soda, sea salt, or Epsom salts). Hydrotherapy can
include a constitutional effect where the body's vital force is stimulated and all organ
systems are revitalized. Herbalists or naturopathic physicians may prescribe such herbs
as milk thistle (Silybum marianum), burdock (Arctium lappa, a blood cleanser), and
licorice (Glycyrrhiza glabra) to assist in detoxification.

Other treatments aimed at reducing the stress a person suffers while attempting
substance withdrawal and throughout an individual's recovery process include
acupuncture, hypnotherapy, biofeedback, guided imagery, and various meditative arts
(including yoga and t'ai chi).

Use of acupuncture to treat addiction is becoming more common. In 2002, a study

was undertaken in Maine to treat substance abuse users who were dually diagnosed with
chronic mental illness and substance abuse problems with ear acupuncture. The
technique appears to cleanse organs and to aid in relaxation, which eases many of the
stresses believed to lead these patients to maintain their reliance on the drugs. Another
clinical trial in the same year, however, found that acupuncture was not effective alone for
treating cocaine-dependent adults. However, the study did conclude that acupuncture
may be effective for these patients when used in combination with other treatments. New
research also suggests that qigong therapy may be an effective alternative for patients
with heroin addiction.

Expected Results

After a person has successfully withdrawn from substance use, the even more
difficult task of recovery begins. Recovery refers to the lifelong efforts of a person to
avoid returning to substance use. The craving can be so strong even years and years
after initial withdrawal that a previously addicted person is in danger of slipping back into
substance use. Triggers for such a relapse include any number of life stresses (problems
on the job or in the marriage, loss of a relationship, death of a loved one, financial
stresses), in addition to seemingly mundane exposure to a place or an acquaintance
associated with previous substance use.

Prevention

Prevention is best aimed at teenagers, who are at very high risk for substance
experimentation. Education regarding the risks and consequences of substance use, as
well as teaching methods of resisting peer pressure, are both important components of a
prevention program.

Treatment

Treatment for drug abuse or dependence begins with recognizing the problem.
Though "denial" used to be considered a symptom of addiction, recent research has
shown that people who are addicted have far less denial if they are treated with empathy
and respect, rather than told what to do or "confronted."

Treatment of drug dependency involves stopping drug use either gradually or

abruptly (detoxification), support, and staying drug free (abstinence). People with acute
intoxication or drug overdose may need emergency treatment. Sometimes, the person
loses consciousness and might need to be on a breathing machine (mechanical
respirator) temporarily. The treatment depends on the drug being used.

Detoxification is the withdrawal of an abused substance in a controlled

environment. Sometimes a drug with a similar action is taken instead, to reduce the side
effects and risks of withdrawal. Detoxification can be done on an inpatient or outpatient
basis.

If the person also has depression or another mood disorder, it should be treated.
Very often, people start abusing drugs in their effort to self-treat mental illness.
 For narcotic dependence, some people are treated with methadone or similar
drugs to prevent withdrawal and abuse. The goal is to enable the person to live as normal
a life as possible.

Outlook (Prognosis)

Drug abuse and dependence may lead to a fatal drug overdose. Some people
start taking the drugs again after they have stopped. Relapses can lead to continued
dependence.

Possible Complications

The complications of drug abuse and dependence include:

• Depression
• Relapse of drug abuse
• Drug overdose
• Bacterial endocarditis, hepatitis, thrombophlebitis, pulmonary emboli, malnutrition,
or respiratory infections, caused by drug use through a vein (intravenous)
• Infection with HIV through shared needles
• Unsafe sexual practices, which may result in unwanted pregnancies, sexually
transmitted diseases, HIV, or hepatitis.
• Problems with the law
• Increase in various cancer rates, for example, lung and pharynx cancer are linked
to nicotine use, mouth and stomach cancer are associated with alcohol abuse and
dependence
• Problems with memory and concentration, for example with hallucinogen use,
including marijuana (THC)