Substance abuse, also known as drug abuse, refers to a
maladaptive pattern of use of a substance that is not considered
dependent. The term "drug abuse" does not exclude dependency, but is
otherwise used in a similar manner in nonmedical contexts. The terms
have a huge range of definitions related to taking a psychoactive drug or performance enhancing drug
for a non-therapeutic or non-medical effect. All of these definitions
imply a negative judgment of the drug use in question (compare with the
term responsible drug use for alternative views). Some of the drugs most often associated with this term include alcohol, amphetamines, barbiturates, benzodiazepines (particularly temazepam, nimetazepam, and flunitrazepam), cocaine, methaqualone, and opioids.
Use of these drugs may lead to criminal penalty in addition to possible
physical, social, and psychological harm, both strongly depending on
Other definitions of drug abuse fall into four main categories: public
health definitions, mass communication and vernacular usage, medical
definitions, and political and criminal justice definitions.
Substance abuse is a form of substance-related disorder.
Public health definitions
practitioners have attempted to look at drug abuse from a broader
perspective than the individual, emphasizing the role of society,
culture and availability. Rather than accepting the loaded terms alcohol
or drug "abuse," many public health professionals have adopted phrases
such as "substance and alcohol type problems" or "harmful/problematic
use" of drugs.
The Health Officers Council of British Columbia in their 2005 policy discussion paper, A Public Health Approach to Drug Control in Canada
has adopted a public health model of psychoactive substance use that
challenges the simplistic black-and-white construction of the binary (or
complementary) antonyms "use" vs. "abuse". This model explicitly recognizes a spectrum of use, ranging from beneficial use to chronic dependence (see diagram to the right).
In the modern medical profession, the two most used diagnostic tools in the world, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD), no longer recognize 'drug abuse' as a current medical diagnosis. Instead, DSM has adopted substance abuse
as a blanket term to include drug abuse and other things. ICD refrains
from using either "substance abuse" or "drug abuse", instead using the
term "harmful use" to cover physical or psychological harm to the user
from use. Physical dependence, abuse of, and withdrawal from drugs and
other miscellaneous substances is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) ). Its section Substance dependence begins with:
- "Substance dependence When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence
may be diagnosed. Compulsive and repetitive use may result in tolerance
to the effect of the drug and withdrawal symptoms when use is reduced
or stopped. These, along with Substance Abuse are considered Substance Use Disorders...." 
However, other definitions differ; they may entail psychological or physical dependence, and may focus on treatment and prevention in terms of the social consequences of substance uses.
Drug misuse is a term used commonly for prescription medications
with clinical efficacy but abuse potential and known adverse effects
linked to improper use, such as psychiatric medications with sedative, anxiolytic, analgesic, or stimulant
properties. Prescription misuse has been variably and inconsistently
defined based on drug prescription status, the uses that occur without a
prescription, intentional use to achieve intoxicating effects, route of
administration, co-ingestion with alcohol, and the presence or absence of abuse or dependence symptoms.
Tolerance relates to the pharmacological property of substances in
which chronic use leads to a change in the central nervous system,
meaning that more of the substance is needed in order to produce desired
effects. Stopping or reducing the use of this substance would cause
withdrawal symptoms to occur.
As a value judgment
Philip Jenkins points out that there are two issues with the term "drug abuse". First, what constitutes a "drug" is debatable. For instance, GHB, a naturally occurring substance in the central nervous system is considered a drug, and is illegal in many countries, while nicotine
is not officially considered a drug in most countries. Second, the word
"abuse" implies a recognized standard of use for any substance.
Drinking an occasional glass of wine is considered acceptable in many
Western countries, while drinking several bottles is seen as an abuse.
Strict temperance advocates, which may or may not be religiously
motivated, would see drinking even one glass as an abuse, and some
groups even condemn caffeine use in any quantity. Similarly, adopting the view that any (recreational) use of marijuana or amphetamines constitutes drug abuse implies that we have already decided that substance is harmful even in minute quantities.
Signs and symptoms
Depending on the actual compound, drug abuse including alcohol may lead to health problems, social problems, morbidity, injuries, unprotected sex, violence, deaths, motor vehicle accidents, homicides, suicides, physical dependence or psychological addiction.
There is a high rate of suicide in alcoholics and drug abusers. The reasons believed to cause the increased risk of suicide include the long-term abuse of alcohol
and drugs causing physiological distortion of brain chemistry as well
as the social isolation. Another factor is the acute intoxicating
effects of the drugs may make suicide more likely to occur. Suicide is
also very common in adolescent alcohol abusers, with 1 in 4 suicides in adolescents being related to alcohol abuse.
In the USA approximately 30 percent of suicides are related to alcohol
abuse. Alcohol abuse is also associated with increased risks of
committing criminal offences including child abuse, domestic violence, rapes, burglaries and assaults.
Drug abuse, including alcohol and prescription drugs can induce
symptomatology which resembles mental illness. This can occur both in
the intoxicated state and also during the withdrawal
state. In some cases these substance induced psychiatric disorders can
persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. A protracted withdrawal syndrome can also occur with symptoms persisting for months after cessation of use. Benzodiazepines
are the most notable drug for inducing prolonged withdrawal effects
with symptoms sometimes persisting for years after cessation of use.
Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use and cannabis may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia.
Severe anxiety and depression are commonly induced by sustained alcohol
abuse which in most cases abates with prolonged abstinence. Even
moderate alcohol sustained use may increase anxiety and depression
levels in some individuals. In most cases these drug induced psychiatric
disorders fade away with prolonged abstinence.
Drug abuse makes central nervous system
(CNS) effects, which produce changes in mood, levels of awareness or
perceptions and sensations. Most of these drugs also alter systems other
than the CNS. Some of these are often thought of as being abused. Some
drugs appear to be more likely to lead to uncontrolled use than others.
Traditionally, new pharmacotherapy's are quickly adopted in primary
care settings, however; drugs for substance abuse treatment have faced
many barriers. Naltrexone,
a drug originally marketed under the name "ReVia," and now marketed in
intramuscular formulation as "Vivitrol" or in oral formulation as a
generic, is a medication approved for the treatment of alcohol
dependence. This drug has reached very few patients. This may be due to a
number of factors, including resistance by Addiction Medicine specialists and lack of resources.
The ability to recognize the signs of drug use or the symptoms of
drug use in family members by parents and spouses has been affected
significantly by the emergence of home drug test technology which helps identify recent use of common street and prescription drugs with near lab quality accuracy.
1 in 5 teenagers report having abused a prescription medication and
over 2500 teenagers a day experiment with prescription medications taken
from the home. The Massachusetts legislature just enacted a law that
requires all pharmacies located within the Commonwealth to display, and
offer for sale, medical lock boxes for home use and to place those
products within 50 feet of the pharmacy counter. Products such as the
RxDrugSAFE, a fingerprint recognition home medical safe, combat
unauthorized access to prescription medications at home, thereby
preventing abuse. This new law is the first such law enacted within the
Disability-adjusted life year
for drug use disorders per 100,000 inhabitants in 2002.
less than 40
more than 440
The initiation of drug and alcohol use is most likely to occur during
adolescence, and some experimentation with substances by older
adolescents is common. For example, results from Monitoring the Future
(2008), a nationwide study on rates of substance use, show that 47% of
12th graders report having used an illicit drug at some point in their
lives . In 2009 in the United States about 21% of high school students have taken prescription drugs without a prescription.
And earlier in 2002, the World health Organization estimated that
around 140 million people were alcohol dependent and another 400 million
sufferd alcohol-related problems.
Thankfully, the large majority of adolescents will phase out of drug
use before it becomes problematic. Thus, although rates of overall use
are high, the percentage of adolescents who meet criteria for substance
abuse is significantly lower (close to 5%) .
According to BBC, "Worldwide, the UN estimates there are more than 50
million regular users of morphine diacetate (heroin), cocaine and
Total recorded alcohol per capita consumption (15+), in liters of pure alcohol
APA, AMA, and NCDA
In 1932, the American Psychiatric Association created a definition
that used legality, social acceptability, and cultural familiarity as
as a general rule, we reserve the term drug abuse to apply to the
illegal, nonmedical use of a limited number of substances, most of them
drugs, which have properties of altering the mental state in ways that
are considered by social norms and defined by statute to be
inappropriate, undesirable, harmful, threatening, or, at minimum,
In 1966, the American Medical Association's
Committee on Alcoholism and Addiction defined abuse of stimulants
(amphetamines, primarily) in terms of 'medical supervision':
'use' refers to the proper place of stimulants in medical
practice; 'misuse' applies to the physician's role in initiating a
potentially dangerous course of therapy; and 'abuse' refers to
self-administration of these drugs without medical supervision and
particularly in large doses that may lead to psychological dependency,
tolerance and abnormal behavior.
In 1973 the National Commission on Marihuana and Drug Abuse stated:
...drug abuse may refer to any type of drug or chemical without
regard to its pharmacologic actions. It is an eclectic concept having
only one uniform connotation: societal disapproval. ... The Commission
believes that the term drug abuse must be deleted from official
pronouncements and public policy dialogue. The term has no functional
utility and has become no more than an arbitrary codeword for that drug
use which is presently considered wrong.
In the first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders
(published in 1952) grouped alcohol and drug abuse under Sociopathic
Personality Disturbances, which were thought to be symptoms of deeper
psychological disorders or moral weakness.
The third edition, published in 1980, was the first to recognize
substance abuse (including drug abuse) and substance dependence as
conditions separate from substance abuse alone, bringing in social and
cultural factors. The definition of dependence emphasised tolerance to
drugs, and withdrawal from them as key components to diagnosis, whereas
abuse was defined as "problematic use with social or occupational
impairment" but without withdrawal or tolerance.
In 1987 the DSM-IIIR
category "psychoactive substance abuse," which includes former concepts
of drug abuse is defined as "a maladaptive pattern of use indicated
by...continued use despite knowledge of having a persistent or recurrent
social, occupational, psychological or physical problem that is caused
or exacerbated by the use (or by) recurrent use in situations in which
it is physically hazardous." It is a residual category, with dependence
taking precedence when applicable. It was the first definition to give
equal weight to behavioural and physiological factors in diagnosis.
By 1988, the DSM-IV defines substance dependence as "a syndrome
involving compulsive use, with or without tolerance and withdrawal";
whereas substance abuse is "problematic use without compulsive use,
significant tolerance, or withdrawal." Substance abuse can be harmful to
your health and may even be deadly in certain scenarios
By 1994, The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association,
the DSM-IV-TR, defines substance dependence as "when an individual
persists in use of alcohol or other drugs despite problems related to
use of the substance, substance dependence may be diagnosed." followed by criteria for the diagnose
DSM-IV-TR defines substance abuse as:
- A. A maladaptive pattern of substance use leading to clinically
significant impairment or distress, as manifested by one (or more) of
the following, occurring within a 12-month period:
- Recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home (e.g., repeated absences or poor
work performance related to substance use; substance-related absences,
suspensions or expulsions from school; neglect of children or household)
- Recurrent substance use in situations in which it is physically
hazardous (e.g., driving an automobile or operating a machine when
impaired by substance use)
- Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
- Continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the effects of
the substance (e.g., arguments with spouse about consequences of
intoxication, physical fights)
- B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
The fifth edition of the DSM (DSM-5),
planned for release in 2013, is likely to have this terminology
revisited yet again. Under consideration is a transition from the
abuse/dependence terminology. At the moment, abuse is seen as an early
form or less hazardous form of the disease characterized with the
dependence criteria. However, the APA's 'dependence' term, as noted
above, does not mean that physiologic dependence is present but rather
means that a disease state is present, one that most would likely refer
to as an addicted state. Many involved recognize that the terminology
has often led to confusion, both within the medical community and with
the general public. The American Psychiatric Association requests input
as to how the terminology of this illness should be altered as it moves
forward with DSM-5 discussion.
Society and culture
- Related articles: Drug control law, Prohibition (drugs), Arguments for and against drug prohibition
Most governments have designed legislation to criminalize certain types of drug use. These drugs are often called "illegal drugs" but generally what is illegal is their unlicensed
production, distribution, and possession. These drugs are also called
"controlled substances". Even for simple possession, legal punishment
can be quite severe (including the death penalty in some countries). Laws vary across countries, and even within them, and have fluctuated widely throughout history.
Attempts by government-sponsored drug control policy to interdict
drug supply and eliminate drug abuse have been largely unsuccessful. In
spite of the huge efforts by the U.S., drug supply and purity has
reached an all time high, with the vast majority of resources spent on
interdiction and law enforcement instead of public health. In the United States, the number of nonviolent drug offenders in prison exceeds by 100,000 the total incarcerated population in the EU, despite the fact that the EU has 100 million more citizens.
Despite drug legislation (or perhaps because of it), large, organized criminal drug cartels
operate worldwide. Advocates of decriminalization argue that drug
prohibition makes drug dealing a lucrative business, leading to much of
the associated criminal activity.
The UK Home Office estimated that the social and economic cost of drug abuse to the UK economy in terms of crime, absenteeism and sickness is in excess of £20 billion a year.
However, it does not estimate what portion of those crimes are
unintended consequences of drug prohibition (crimes to sustain expensive
drug consumption, risky production and dangerous distribution), nor
what is the cost of enforcement. Those aspects are necessary for a full
analysis of the economics of prohibition.
The Home Office has a recent history of taking a hard line on
controlled drugs, including those with no known fatalities and even
medical benefits, in direct opposition to the scientific community.
Treatment for binge drinking and other forms of substance abuse is
critical for many around the world. Behavioral interventions and
medications exist that have helped many people reduce, or discontinue,
their substance abuse. From the applied behavior analysis literature, the behavioral psychology literature, and from randomized clinical trials, several evidenced based interventions have emerged:
In children and adolescents, cognitive behavioral therapy (CBT)  and family therapy 
currently have the most research evidence for the treatment of
substance abuse problems. These treatments can be administered in a
variety of different formats, each of which has varying levels of
research support 
It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious.
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|Psychoactive substance-related disorder (F10F19, 291292; 303305)