Substance use disorders are a type of substance-related disorder that involves a pathological pattern of behavior in which patients continue to use a substance despite experiencing significant problems related to its use. There may also be physiological manifestations, including changes in brain circuits.
The substances involved are typically members of the 10 drug classes that typically cause substance-related disorders. These substances all directly activate the brain's reward system and produce feelings of pleasure. The activation can be so intense that patients crave the substance intensely and neglect normal activities to obtain and use it.
The common terms "drug addiction", "abuse" and "addiction" are often used to refer to substance use, but these terms are defined too loosely and variably to be useful in systematic diagnosis. Substance use disorder is more complete and has fewer negative connotations.
Use of Recreational and Illicit Substances
Illegal drug use, while problematic because it is illegal, does not always lead to a substance use disorder. Conversely, legal substances, such as alcohol and prescription drugs (and cannabis in a growing number of US states), can be involved in a substance use disorder. The problem caused by the abuse of prescription drugs and illegal substances is transversal to all socio-economic groups.
Recreational drug use, while not generally sanctioned by society, is not a new phenomenon, and has existed in one form or another for centuries. People have used substances for a variety of reasons:
- To change or improve the mood
- As part of religious ceremonies
- To get spiritual enlightenment
- To improve performance
Some consumers are apparently free; they tend to use drugs episodically in relatively small doses, avoiding the onset of clinical toxicity and the development of tolerance and physical dependence. Various recreational drugs (e.g. raw opium, alcohol, marijuana, caffeine, hallucinogenic mushrooms, coca leaves) are "natural" (i.e. plant-based extracts); they contain a mixture of psychoactive compounds in relatively low concentrations and are not synthetic psychoactive substances.
Etiology
People with a substance use disorder usually move from experimentation to casual use to eventually intense use and sometimes substance use disorder. This progression is complex and only partially understood. The process depends on the interaction between the substance, the consumer and the context.
Drug
Drugs in the 10 classes vary in how likely they are to cause a substance use disorder. The likelihood is termed drug addiction liability. The liability for drug addiction depends on a combination of factors, including-
- Route of administration
- The rate at which the drug crosses the blood-brain barrier and stimulates the reward circuit
- Time of onset of effect
- Ability to induce tolerance and/or withdrawal symptoms
Additionally, substances that are legally and/or readily available (e.g. alcohol, tobacco) are more likely to be used initially and thereby increase the risk of progression to problematic use. Furthermore, if the perception of risk in using a particular substance decreases, there may be subsequent experimentation and/or recreational uses of the substance, increasing exposure to substances of abuse. Fluctuations in risk perception are influenced by multiple factors, including outcomes regarding medical and psychiatric sequelae of use and social outcomes.
During the treatment of medical illness or following surgery or dental procedures, patients have regularly prescribed opioids. A substantial portion of these drugs is neglected, as they represent an important source for children, adolescents and adults who wish to use them for non-medical purposes. In response, more emphasis was placed on the need for
- Prescribe opioid medications in lower amounts more appropriate to the duration and severity of pain
- Promote the safe storage of unused drugs
- Expand prescription withdrawal programs
- Consumer
Consumer predisposing factors include:
- Physical characteristics
- Personal characteristics
- Circumstances and disturbances
The physical characteristics are likely to include genetic factors. However, although researchers have long sought to identify specific factors, they have found few biochemical or metabolic differences between people who take drugs and those who do not develop a substance use disorder.
The personal characteristics are clearly not a strong factor, although people with low levels of self-control (impulsivity) or high levels of risk-taking and novelty-seeking may be at increased risk of developing substance use disorder. However, the hypothesis of an addictive personality that has been variously described by some behavioral scholars has little scientific evidence to support it.
A number of coexisting circumstances and disorders appear to increase the risk. For example, people who are sad, emotionally upset, or socially alienated may find these feelings temporarily relieved by a drug; this can lead to increased use and sometimes a substance use disorder. Patients with other, unrelated psychiatric disorders are at increased risk of developing a substance use disorder. Patients with chronic pain (e.g. back pain, pain due to sickle cell disease, neuropathic pain, fibromyalgia) often take opioid drugs for relief; many subsequently develop a substance use disorder. However, in many of these patients, non-opioid drugs and other substance abuse treatments can adequately relieve pain and suffering.
Tips and Mistakes to Avoid
The hypothesis of an addictive personality, which has been variously described by some behavioral scholars, has little scientific evidence to support it.
Context
Cultural and social factors are very important for initiation and maintenance (or relapsing a) of substance use. Observing family members (e.g. parents, older siblings) and peers who use drugs increases the risk of people starting to use drugs. Peers represent a particularly strong influence among adolescents (see Drug and Narcotic Abuse in Adolescents). People who are trying to stop using a substance find it much more difficult if they are surrounded by other users who also use that substance.
Doctors may inadvertently contribute to the harmful use of psychoactive drugs by over-zealously prescribing them to relieve stress. Many social factors including mass media contribute to the patient's expectation that drugs should be used to relieve any discomfort.
Diagnosis
Specific Criteria
The diagnosis of substance use disorder is based on the identification of a pathological pattern of behavior in which patients continue to use a substance despite experiencing significant problems related to its use. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) provides 11 criteria divided into 4 categories.
Reduced Usage Control
- A person who takes the substance in larger quantities or for a longer time than originally intended
- A person who wants to stop or reduce the use of the substance
- A person who spends significant time obtaining, using, or recovering from the effects of the substance
- A person who has an intense desire (craving) to use the substance
- Social impairment
- A person who does not comply with the main duties of the role in the workplace, at school, or at home
- A person who continues to use the substance, even if it causes (or worsens) social or interpersonal problems
- A person who reduces or gives up significant social, work or leisure activity due to substance use
Risky Use
- A person using the substance in physically hazardous situations (e.g. while driving or in hazardous social circumstances)
- A person who continues to use the substance even knowing that a medical or psychological problem is worsening
Pharmacological Symptoms*
Tolerance: the subject needs to progressively increase the dose of the substance to produce the intoxication or the desired effect, or the effect of an administered dose decreases over time
Withdrawal: unpleasant physical effects that occur when the substance is withdrawn or when it is blocked by a specific antagonist
*Note that some medications, particularly opioids, sedatives/hypnotics and stimulants, can cause tolerance and/or withdrawal symptoms, even when taken as prescribed for legitimate medical reasons and for relatively short periods (<1 week for opioids). Withdrawal symptoms that develop following appropriate medical uses do not count as criteria for diagnosing a substance use disorder.
People who have ≥ 2 of these criteria within a 12-month period are considered to have a substance use disorder. The severity of the substance use disorder is determined by the number of symptoms:
- Mild: 2 to 3 criteria
- Moderate: 4 to 5 criteria
- Severe: ≥ 6 criteria
Early intervention programs aim to identify the issues and trigger points, which allow addiction to flourish and takes measures to prevent its growth.
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