Features of Drug Abuse and Dependence

Drug addiction is a chronic, relapsing behavioral disorder

Before proceeding further, try writing down your definition of drug addiction in one or two sentences. Were you easily able to come up with a satisfactory definition? If not, don’t be concerned, because addiction is not a simple concept. This problem was highlighted by Burglass and Shaffer (1984) in the following (not entirely frivolous) description of addiction: “Certain individuals use certain substances in certain ways thought at certain times to be unacceptable by certain other individuals for reasons both certain and uncertain.” The medical establishment has attempted to develop a broadly acceptable definition, yet experts continue to disagree about what it means to be addicted to a drug (Walters and Gilbert, 2000).

Early views of drug addiction emphasized the importance of physical dependence. As you learned ealier, this means that abstinence from the drug leads to highly unpleasant withdrawal symptoms that motivate the individual to reinstate his or her drug use. It is true that some drugs of abuse, such as alcohol and opiates, can create strong physical dependence and severe withdrawal symptoms in dependent individuals. Certain other substances, however, produce relatively minor physical dependence. It may surprise you to learn that cocaine is one such substance, and that there was a time when cocaine was not considered to be addictive because of this lack of an opiate-like withdrawal syndrome.

Recent conceptions of addiction have focused more on other features of this phenomenon. First, there is an emphasis on behavior, specifically the compulsive nature of drug seeking and drug use in the addict. The addict is often driven by a strong urge to take the drug, which is called drug craving. Second, addiction is thought of as a chronic, relapsing disorder. This means that individuals remain addicted for long periods of time, and that drug-free periods (remissions) are often followed by relapses in which drug use recurs. In recent years, the medical profession has classified obesity in much the same way, since obese people typically struggle to lose weight for many years (sometimes their whole lives), go on frequent diets during which they lose some weight (remissions), and almost always regain the weight after each diet (relapse). A third important feature is that drug use persists despite serious harmful consequences to the addict. This is the paradox of addiction mentioned earlier in the post. One widely cited definition of addiction that encompasses the first two of the three features just described is as follows: “a behavioral pattern of drug use, characterized by overwhelming involvement with the use of a drug (compulsive use), the securing of its supply, and a high tendency to relapse after withdrawal” (Goldstein, 1989).

The term addiction has strong negative emotional associations for most of us. Despite the fact that drug addicts live in all parts of the country and come from all walks of life, we usually think of them as urban and poor. Our mental images are those of an unwashed heroin user huddled in an alley “shooting up” with a dirty syringe, or an emaciated “crack- head” engulfed in a cloud of cocaine vapor in an inner-city crack house, or a wino staggering down the street begging for a little change to buy his next bottle. Although some drug addicts fit these images, many others do not. For this reason as well as the conflicting definitions of addiction, the American Psychiatric Association stopped using the terms addiction and addict in its professional writings. This can be seen in the association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 2000).

The DSM represents an attempt to classify the entire range of psychiatric disorders, with objective criteria provided for the diagnosis of each disorder. Instead of using the term drug addiction, the DSM specifies a group of substance-related disorders, where substance refers to typical drugs of abuse as well as some psychoactive medications that have abuse potential. Within the category of substance-related disorders are two general disorders called substance dependence and substance abuse. Substance dependence, which is the more severe disorder, corresponds roughly to the notion of addiction. Substance abuse is a less severe disorder that may or may not lead subsequently to substance dependence. The diagnostic criteria for these disorders are shown in Table 1. You can see that there is no single criterion for either substance abuse or substance dependence. This reflects the fact that maladaptive drug use may result in many different adverse consequences, depending on which drug is being taken as well- as the amount and pattern of drug taking. Of course, someone with a long-standing, severe case of substance dependence may meet virtually all of the listed criteria, not just three or four.

Table 1 DSM-IVCriteria for Substance Dependence and Substance Abuse

The following are DSM-IV criteria for substance dependence:

A maladaptive pattern of substance use leading to clinically significant impairment of distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  1. Tolerance, as defined by either of the following:
    1. A need for markedly increased amounts of the substance to achieve intoxication or designed effect
    2. Markedly diminished effect with continued use of the same amount of the substance
  2. Withdrawal, as manifested by either of the following:
    1. The characteristic withdrawal syndrome for the substance
    2. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  3. The substance is’often taken in larger amounts or over a longer period than was intended
  4. There is a persistent desire or unsuccessful efforts to cut down or control substance use
  5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
  6. Important social, occupational, or recreational activities are given up or reduced because of substance use
  7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

The following are DSM-IV criteria for substance abuse:

  1. 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:
    1. 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)
    2. 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)
    3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
    4. 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)
  2. The symptoms have never met the criteria for Substance Dependence for this class of substance.

Source: From American Psychiatric Association, 2000.

In addition to the general categories of substance dependence and substance abuse, the DSM also includes specific diagnostic criteria for the abuse of or dependence ont alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioid drugs such as heroin, phencyclidine (PCP), and sedative-hypnotic and anxiolytic (antianxiety) drugs. All of these compounds are covered in detail in subsequent posts of the website. Finally, the DSM identifies a number of substance-induced disorders involving the acute intoxicating effects of particular substances as well as withdrawal symptoms in cases where such symptoms have been well characterized.

It is important to note that mere use of any drug, whether alcohol, tobacco, marijuana, cocaine, or heroin, does not constitute substance abuse or dependence. As indicated in the DSM, the use must be maladaptive, which means that harm is occurring to the user. Someone who snorts cocaine occasionally may be doing something illegal and dangerous, in that there is a potential for harm and for the subsequent development of a pattern of abuse or dependence. But if the DSM criteria for substance abuse or dependence are not met, then we cannot claim that the person is an addict or even that she is abusing the drug.

There are two types of progressions in drug use

Drug use can involve two different kinds of progressions. In one type of progression characteristic of many young people, the individual starts out taking a legal substance such as alcohol or tobacco, later progresses to marijuana, and in a small percentage of cases moves on to cocaine, heroin, other illicit substances, or illegally obtained prescription drugs. One theory that attempts to account for this type of progression is discussed later.

The second kind of progression pertains to changes in the amount, pattern, and consequences of drug use as they affect the user’s health and functioning. This progression can be portrayed as a continuum of drug use. Once an individual first experiments with an abused drug, he may or may not progress to regular, nonproblem use or beyond. Despite the popular view that drugs like cocaine and heroin are instantly and automatically addictive, that is not the case. Why, then, do some people who experiment with these (or other) substances become dependent, while others do not? This is one of the central questions that must be addressed by any good theory or model of drug addiction.

Another important feature of drug use is that people can move in both directions along the continuum. Regardless of whether they’re using heroin, cocaine, or alcohol, long-term drug addicts often have a history of numerous shifts along the continuum involving changes in the frequency and amount of drug use as well as periodic intervals of abstinence that are often associated with participation in a treatment program or incarceration in prison. Figure 8.5 illustrates one example of this phenomenon taken from a longitudinal study of male opioid (heroin) addicts in San Antonio, Texas (Maddux and Desmond, 1981). The figure presents drug status data over periods ranging from 7 to 20 years for 10 representative subjects out of a total of nearly 250. Particularly striking is the diversity of patterns among the subjects. For example, subject 111 exhibited periods of either occasional or daily use interspersed with long intervals of abstinence. In contrast, subject 162 used daily for most of the 20-year period except when he was institutionalized in a hospital or prison. When considered across all 10 subjects, the numerous instances of abstinence followed by renewed drug use supports the view mentioned earlier that addiction is a chronic, relapsing disorder.

For many people, the use of both alcohol and illicit drugs such as marijuana naturally declines once they reach adulthood and begin to take on the responsibilities associated with earning a living and having a family. This pattern is consistent with the data shown in Figure 8.1 as well as longitudinal studies documenting a reduction in drug use beyond the period of adolescence (Chen and Kandel, 1995). Some writers have called this process “maturing out” of a drug- using lifestyle. There are scattered reports that maturing out may even occur in some cases of substance dependence and not merely heavy use; however, recovery from substance dependence is a complex process that cannot be accounted for by any single factor.

Which drugs are the most addictive?

Just as we all have mental images of drug addicts, we also have ideas about which drugs are the most addictive. Drugs thought to have a high addictive potential-are sometimes called “hard drugs.” There are two sets of standards by which we might classify drugs according to their addictive potential. The first are legal standards. As discussed earlier, the Controlled Substances Act of 1970 established a system by which most substances with abuse potential are classified into one of five different schedules. These schedules, along with representative drugs. Schedule I substances are considered to have no medicinal value and thus can be obtained only for research use by registered investigators/ Items listed under Schedules II to V are available for medicinal purposes with a prescription from a medical professional such as a physician, dentist, or veterinarian. They can also be obtained for research use. Note that the Schedule of Controlled Substances specifically excludes alcohol and tobacco, thus permitting these substances to be purchased and used legally without registration or prescription.

The Schedule of Controlled Substances was formulated more than 30 years ago and was based not only on the scientific knowledge of that time but also partly on political considerations. Although it has been updated periodically since its inception, we may still ask whether this classification system accurately reflects our current understanding of various abused substances. For example, marijuana and its major active ingredient, A9-tetrahydrocannabinol (THC), are in Schedule I, which means that they are considered to have no medicinal value as well as a high level of abuse potential. We discuss the possibility that marijuana or THC may be useful in some therapeutic situations. For now, let’s consider the second point regarding marijuana’s potential for producing abuse or dependence.

TABLE 2 Schedule of Controlled Substances

Schedule

Description Representative substances

I

Substances that have no accepted medical use in the U.S. and have a high abuse potential Heroin, LSD, mescaline, marijuana, THC, MDMA

II

Substances that have a high abuse potential with severe psychic or physical dependence liability Opium, morphine, codeine, meperidine (Demerol), cocaine, amphetamine, methylphenidate (Ritalin), pentobarbital, phencyclidine (PCP)

III

Substances that have an abuse potential less than those in Schedules I and II, including compounds containing limited quantities of certain narcotics and nonnarcotic drugs Paregoric, barbiturates other than those listed in another schedule

IV

Substances that have an abuse potential less than those in Schedule III Phenobarbital, chloral hydrate, diazepam (Valium), alprazolam (Xanax)

V

Substances that have an abuse potential less than those in Schedule IV, consisting of preparations containing limited amounts of certain narcotic drugs generally for antitussive (cough suppressant) and antidiarrheal purposes  

Several years ago, two leading addiction experts rated various substances for their abuse potential in five different categories: (1) presence and severity of withdrawal symptoms; (1) strength of the drug’s reinforcing effects based on human and animal studies; (3) degree of tolerance produced by the drug; (4) degree of dependence produced by the drug based on difficulty quitting, relapse rates, and the percentage of users who become dependent; and (5) degree of intoxication produced by the drug. The ratings were made by Dr. Jack Henningfield, formerly Chief of Clinical Pharmacology at the Addiction Research Center of the National Institute on Drug Abuse, and Dr. Neil Benowitz, a prominent addiction researcher at the University of California at San Francisco. Their ratings are shown in Table 3, with 1 representing the most serious and 6 being the least serious. We can see that the two sets of ratings are fairly consistent with each long-term health consequences of using these substances, only their abuse potential based on the listed criteria. Not only is this obviously important for tobacco smoking and lung disease, but there is also evidence for potentially serious consequences of heavy marijuana use over long periods of time. Nevertheless, the disparity between current scientific opinion (at least as represented by these two experts) and the Schedule of Controlled Substances is striking. Two of the top four substances in terms of their abuse liability (alcohol and nicotine) are legal, whereas one of the two least problematic substances (marijuana) is classified in Schedule I. At some point in the future, the political climate in this country might be more receptive than it is now to bringing federal regulations in line with the weight o f scientific evidence.

Post Summary

High levels of drug use continue in our society despite significant governmental attempts to control such use. Although early ideas about addiction emphasized the role of physical dependence, recent conceptions have focused on the compulsive features of drug seeking and use (despite the potentially harmful consequences) and the concept of drug addiction as a chronic, relapsing disorder characterized by repeated periods of remission followed by relapses. The DSM specifies a disorder called substance dependence, the characteristics of which correspond closely to those usually associated with addiction. Maladaptive drug use that does not meet the criteria for substance dependence is called substance abuse.

TABLE 3 Abuse Potential of Different Substances as Rated by Two Addiction Experts

     

Category

   
Substance

Withdrawal

Reinforcement

Tolerance

Dependence

Intoxication

Henningfield ratings
Nicotine

3

4

2

l

5

Heroin

2

2

1 ‘

2

2

Cocaine

4

1

4

3

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3

Alcohol

1

3

3

4

1

Caffeine

5

6

5

5

6

Marijuana

6

5

6

6

4

Benowitz ratings
Nicotine

3.5

4

4

1

6

Heroin

2

2

2

2

2

Cocaine

3.5

1

1

3

3

Alcohol

1

3

4

4

1

Caffeine

5

5

3

5

5

Marijuana

6

6

5

6

4

Source: From Hilts, 1994.

a In this rating system, 1 = most serious, 6 = least serious. Note that for the category of withdrawal, Benowitz gave equal ratings of 3 to nicotine and cocaine, and ratings of 4 and 5 to caffeine and marijuana, respectively. These ratings were altered as shown so that every category would add up to the same value.

Young people often progress from legal substances like alcohol or tobacco to marijuana, and some even go on to try cocaine, heroin, or illegally obtained prescription drugs. The gateway theory attempts to account for this progression, although other explanations have also been offered to explain the same findings. A second kind of progression consists of movement along a continuum of drug use. Movement may occur in both directions along this continuum, and even in heavy users, there are often periods of abstinence interspersed among the intervals of regular drug consumption.

The Schedule of Controlled Substances classifies drugs with abuse potential into five categories, or schedules, based on their abuse potential and medicinal value. Alcohol and tobacco are not listed on the schedule, so they can be purchased for recreational use and without a prescription. Although the Schedule of Controlled Substances is a reasonable classification system in most cases, it is not entirely consistent with current scientific knowledge concerning the abuse liability and potential medicinal use of certain substances, particularly marijuana.

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