SUBSTANCE USE DISORDERS – ABUSE AND DEPENDENCE
Regardless of what people may experience as positive effects of drugs and alcohol, they both have negative effects on our health and ability to function, especially when used repeatedly. This recurrent use may result in a substance use disorder.
Symptoms
There are two substance use disorders – abuse and dependence. Substance abuse is defined entirely on the criterion of impairment.If someone’s repeated use of a substance causes significant impairment in even one area of life, he can be described as a substance
abuser. Common impairments include: failure to fulfil major role obligations – e.g. constantly late to or absent from work; recurrent use in dangerous situations – e.g. while driving; frequent substance-related legal problems – e.g. arrests for disorderly conduct; and social and interpersonal problems – e.g. conflict with partner or other family members.Substance dependence is indicated by physical or psychological dependence or addiction. Physical dependence includes: tolerance – the need for increased amounts of the substance or diminished effect with same amount; and withdrawal – the experience of physical symptoms when the substance is stopped, or turning to another substance to relieve or avoid those symptoms. Psychological dependence is indicated by: taking substances in larger amounts or over longer periods of time than intended; a persistent desire to use or unsuccessful efforts to cut down or control use; spending a great deal of time trying to obtain, use or recover from the substance; giving up important activities; and continued use, despite knowledge of a problem that is exacerbated by the substance.The course of substance use disorders Substance abuse and dependence can be chronic, progressive, degenerative problems with severe negative outcomes. But the course they take varies, depending on the substance being used.Alcoholism in particular can have tragic outcomes, includinghealth problems, interpersonal problems and early death. People who use substances frequently will often use more than one kindof substance.Substance disorders can begin at any age and are becoming more prevalent, particularly among adolescents. Althoughmost adult substance abusers began using in adolescence, most adolescents who try drugs don’t progress to severe abuse. So experimentation doesn’t necessarily lead to lifelong addiction or adverse consequences.Some people with substance use disorders show remission, especially late in life, but relapse is frequent, particularly in response to high-risk situations, such as negative emotional states, social pressure and interpersonal conflict. Unfortunately, because of the high relapse rates, few people fully recover from substance disorders.
Causes of substance use disorders and factors affecting their course
1 Genetic and biological factors
Most research into substance abuse involves alcohol, as alcohol is legal and very widely available. So evidence of genetic transmission comes primarily from alcoholism research. This research supports the role of heredity, particularly among men (e.g. Goodwin, 1979). Consistent with a biological approach, substance use disorders are considered by some to be diseases (e.g. Jellinek, 1960). Some theorists have suggested that alcoholics may be biologically sensitive to alcohol, which may lead to progressive and irreversible alcoholism (e.g. Pollock, 1992). The body’s ability to metabolize alcohol is another possible explanation. The liver produces an enzyme called aldehyde dehydrogenase, which breaks down alcohol in the body. If alcohol isn’t broken down, it can build up and lead to illness. In some groups of East Asians, this enzyme is absent or reduced – a possible reason for the relatively lower rates of alcoholism in these groups (e.g. Higuchi et al., 1992). We know very little about other biological causes of substance abuse, but researchers continue to study the effects of neurotransmitter functioning, brain-wave functioning and biological sensitivities to substances in order to elucidate relevant mechanisms and relationships.
2 Psychosocial factors
Numerous psychosocial factors have been implicated in the onset and course of substance problems. Reinforcement certainly plays an important role. Consistent with the tension-reduction hypothesis, continued substance use is reinforced because substances often lead to positive feelings and help people escape negative feelings through use of these substances (Conger,1956). Substance users are said to engage in ‘self-medication’,using substances to help relieve tension or temporarily eliminate feelings of anxiety or depression.People also learn to use substances through observation. Those whose families or peers use substances are at high risk for substance use disorders (e.g. Jessor & Jessor, 1975). Learned associations also affect the course of substance use. If someone comes to associate particular people, places or circumstances with substance use, they are more likely to use the substance in similar circumstances (Collins & Marlatt, 1981). That is why people whoget treatment for substance problems often relapse when they return to their former environment and social group. Cognitive factors also play a role in the development and course of substance problems, at least in the case of alcoholism. People who expect positive results from using alcohol (e.g. they think it will make them feel good or improve their social standing) are more likely to use it and to develop alcohol problems (Marlatt, 1987; Smith, 1980).In addition, people who fall prey to the abstinence violation effect are more likely to relapse than are others (Marlatt, 1978). This effect occurs when a minor relapse (a violation of abstinence) leads to guilt, which then leads to a more severe relapse. So if an abstinent alcoholic has one drink, she may feel guilty and decide that, having already failed at abstinence, she may as well drink more. She ends up having a fullblown relapse instead of a momentary one. The notion of an ‘addictive’ personality has been suggested. This is a controversial topic. So far, there is no evidence for its existence, but research does indicate that some aspects of personality may contribute to substance problems. A disinhibited personality style that includes impulsivity and antisocial traits may be the best personality predictor of substance problems (e.g. Shedler & Block, 1990). Consistent with the tension-reduction hypothesis discussed earlier, it is also possible that substance problems are masking some other form of psychopathology. But the research on this topic is mixed and suggests that problems such as depression are as likely to follow from substance problems as they are to precede them (e.g. Schuckit, 1994). There are also broader environmental factors that may contribute to substance abuse, such as the extent to which substance use is condoned by a particular culture (e.g. Westermeyer,1999; Yeung & Greenwald, 1992). For example, groups whose religious values prohibit or limit the use of alcohol (e.g.Muslims, Mormons, Orthodox Jews) show relatively low rates ofalcoholism. Perhaps the best way to approach substance use disorders is from a multiple risk factor perspective, which suggests that the more risk factors someone experiences, the more likely he is to develop a problem (e.g. Bry, McKeon & Pandina, 1982). In addition to the risk factors already discussed, many others for substance abuse have been identified, including low socio-economic status, family dysfunction, peer rejection, behaviour problems, academic failure and availability of substances. Of course, because of the nature of the research in this field, some of these factors may be consequences of substance abuse instead of (or as well as) being risk factors.
Regardless of what people may experience as positive effects of drugs and alcohol, they both have negative effects on our health and ability to function, especially when used repeatedly. This recurrent use may result in a substance use disorder.
Symptoms
There are two substance use disorders – abuse and dependence. Substance abuse is defined entirely on the criterion of impairment.If someone’s repeated use of a substance causes significant impairment in even one area of life, he can be described as a substance
abuser. Common impairments include: failure to fulfil major role obligations – e.g. constantly late to or absent from work; recurrent use in dangerous situations – e.g. while driving; frequent substance-related legal problems – e.g. arrests for disorderly conduct; and social and interpersonal problems – e.g. conflict with partner or other family members.Substance dependence is indicated by physical or psychological dependence or addiction. Physical dependence includes: tolerance – the need for increased amounts of the substance or diminished effect with same amount; and withdrawal – the experience of physical symptoms when the substance is stopped, or turning to another substance to relieve or avoid those symptoms. Psychological dependence is indicated by: taking substances in larger amounts or over longer periods of time than intended; a persistent desire to use or unsuccessful efforts to cut down or control use; spending a great deal of time trying to obtain, use or recover from the substance; giving up important activities; and continued use, despite knowledge of a problem that is exacerbated by the substance.The course of substance use disorders Substance abuse and dependence can be chronic, progressive, degenerative problems with severe negative outcomes. But the course they take varies, depending on the substance being used.Alcoholism in particular can have tragic outcomes, includinghealth problems, interpersonal problems and early death. People who use substances frequently will often use more than one kindof substance.Substance disorders can begin at any age and are becoming more prevalent, particularly among adolescents. Althoughmost adult substance abusers began using in adolescence, most adolescents who try drugs don’t progress to severe abuse. So experimentation doesn’t necessarily lead to lifelong addiction or adverse consequences.Some people with substance use disorders show remission, especially late in life, but relapse is frequent, particularly in response to high-risk situations, such as negative emotional states, social pressure and interpersonal conflict. Unfortunately, because of the high relapse rates, few people fully recover from substance disorders.
Causes of substance use disorders and factors affecting their course
1 Genetic and biological factors
Most research into substance abuse involves alcohol, as alcohol is legal and very widely available. So evidence of genetic transmission comes primarily from alcoholism research. This research supports the role of heredity, particularly among men (e.g. Goodwin, 1979). Consistent with a biological approach, substance use disorders are considered by some to be diseases (e.g. Jellinek, 1960). Some theorists have suggested that alcoholics may be biologically sensitive to alcohol, which may lead to progressive and irreversible alcoholism (e.g. Pollock, 1992). The body’s ability to metabolize alcohol is another possible explanation. The liver produces an enzyme called aldehyde dehydrogenase, which breaks down alcohol in the body. If alcohol isn’t broken down, it can build up and lead to illness. In some groups of East Asians, this enzyme is absent or reduced – a possible reason for the relatively lower rates of alcoholism in these groups (e.g. Higuchi et al., 1992). We know very little about other biological causes of substance abuse, but researchers continue to study the effects of neurotransmitter functioning, brain-wave functioning and biological sensitivities to substances in order to elucidate relevant mechanisms and relationships.
2 Psychosocial factors
Numerous psychosocial factors have been implicated in the onset and course of substance problems. Reinforcement certainly plays an important role. Consistent with the tension-reduction hypothesis, continued substance use is reinforced because substances often lead to positive feelings and help people escape negative feelings through use of these substances (Conger,1956). Substance users are said to engage in ‘self-medication’,using substances to help relieve tension or temporarily eliminate feelings of anxiety or depression.People also learn to use substances through observation. Those whose families or peers use substances are at high risk for substance use disorders (e.g. Jessor & Jessor, 1975). Learned associations also affect the course of substance use. If someone comes to associate particular people, places or circumstances with substance use, they are more likely to use the substance in similar circumstances (Collins & Marlatt, 1981). That is why people whoget treatment for substance problems often relapse when they return to their former environment and social group. Cognitive factors also play a role in the development and course of substance problems, at least in the case of alcoholism. People who expect positive results from using alcohol (e.g. they think it will make them feel good or improve their social standing) are more likely to use it and to develop alcohol problems (Marlatt, 1987; Smith, 1980).In addition, people who fall prey to the abstinence violation effect are more likely to relapse than are others (Marlatt, 1978). This effect occurs when a minor relapse (a violation of abstinence) leads to guilt, which then leads to a more severe relapse. So if an abstinent alcoholic has one drink, she may feel guilty and decide that, having already failed at abstinence, she may as well drink more. She ends up having a fullblown relapse instead of a momentary one. The notion of an ‘addictive’ personality has been suggested. This is a controversial topic. So far, there is no evidence for its existence, but research does indicate that some aspects of personality may contribute to substance problems. A disinhibited personality style that includes impulsivity and antisocial traits may be the best personality predictor of substance problems (e.g. Shedler & Block, 1990). Consistent with the tension-reduction hypothesis discussed earlier, it is also possible that substance problems are masking some other form of psychopathology. But the research on this topic is mixed and suggests that problems such as depression are as likely to follow from substance problems as they are to precede them (e.g. Schuckit, 1994). There are also broader environmental factors that may contribute to substance abuse, such as the extent to which substance use is condoned by a particular culture (e.g. Westermeyer,1999; Yeung & Greenwald, 1992). For example, groups whose religious values prohibit or limit the use of alcohol (e.g.Muslims, Mormons, Orthodox Jews) show relatively low rates ofalcoholism. Perhaps the best way to approach substance use disorders is from a multiple risk factor perspective, which suggests that the more risk factors someone experiences, the more likely he is to develop a problem (e.g. Bry, McKeon & Pandina, 1982). In addition to the risk factors already discussed, many others for substance abuse have been identified, including low socio-economic status, family dysfunction, peer rejection, behaviour problems, academic failure and availability of substances. Of course, because of the nature of the research in this field, some of these factors may be consequences of substance abuse instead of (or as well as) being risk factors.
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