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In the early 1950s, the first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders refered to both alcohol and drug abuse as part of Sociopathic Personality Disturbances, which were through to be symptoms of deeper psychological disorders or moral weakness 14. By the third edition, in the 1980s, drug abuse was grouped into 'substance abuse'.
In its early reports, the World Health Organization (WHO) Expert Committee on Addiction-Producing Drugs used the terms 'abuse' and 'addiction' interchangeably. Beginning in 1950s, attempts were made to distinguish between scientific and emotionally-charged terminology. However, the term 'abuse' was still inserted into definitions of addiction and dependency.
In 1957, while not explicitly saying that 'drug abuse' was synonymous with 'addiction', the committee first attempted to clarify existing definitions of addiction and habituation as had been in common parlance since at least 1931:
Drug addiction is a state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: (i) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (ii) a tendency to increase the dose; (iii) a psychic (psychological) and generally a physical dependence on the effects of the drug; and (iv) detrimental effects on the individual and on society.
Drug habituation (habit) is a condition resulting from the repeated consumption of a drug. Its characteristics include (i) a desire (but not a compulsion) to continue taking the drug for the sense of improved well-being which it engenders; (ii) little or no tendency to increase the dose; (iii) some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome [withdrawal], and (iv) detrimental effects, if any, primarily on the individual.
In 1964, a new WHO committee found these definitions to be inadequate, and suggested using the blanket term 'drug dependence':
The definition of addiction gained some acceptance, but confusion in the use of the terms addiction and habituation and misuse of the former continued. Further, the list of drugs abused increased in number and diversity. These difficulties have become increasingly apparent and various attempts have been made to find a term that could be applied to drug abuse generally. The component in common appears to be dependence, whether psychic or physical or both. Hence, use of the term 'drug dependence', with a modifying phase linking it to a particular drug type in order to differentiate one class of drugs from another, had been given most careful consideration. The Expert Committee recommends substitution of the term 'drug dependence' for the terms 'drug addiction' and 'drug habituation'. 17 (emphasis added)
The committee did not clearly define dependence, but did go on to clarify that there was a distinction between physical and psychological ('psychic') dependence. It said that drug abuse was "a state of psychic dependence or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or continued basis." Psychic dependence was defined as a state in which "there is a feeling of satisfaction and psychic drive that requires periodic or continuous administration of the drug to produce pleasure or to avoid discomfort" and all drugs were said to be capable of producing this state:
There is scarcely any agent which can be taken into the body to which some individuals will not get a reaction satisfactory or pleasurable to them, persuading them to continue its use even to the point of abuse — that is, to excessive or persistent use beyond medical need. 17 (emphasis added)
This is believed to be the first reference to "medical need" as a factor in the distinction between use and abuse. 18
In 1965, the same WHO committee commented further , now providing a specific definition of abuse:
Drug abuse is the consumption of a drug apart from medical need or in unnecessary quantities. Its nature and significance may be considered from two points of view: one relates to the interaction between the drug and the individual, the other to the interaction between drug abuse and society. The first viewpoint is concerned with drug dependence and the interplay between the pharmacodynamic actions of the drug and the physiological and psychological status of the individual. The second — the interaction between drug abuse and society — is concerned with the interplay of a wide range of conditions, environmental, sociological, and economic.
Individuals may become dependent upon a wide variety of chemical substances that produce central nervous system effects ranging from stimulation to depression. All of these drugs have one effect in common: they are capable of creating, in certain individuals, a particular state of mind that is termed "psychic dependence ".
Some drugs… induce physical dependence, which is an adaptive state that manifests itself by intense physical disturbances when the administration of the drug is suspended or when its action is affected by the administration of a specific antagonist.
The committee offered several disclaimers of its definitions:
It must be emphasized that drug dependence and drug abuse, as used by the Committee, are general terms and carry no connotation of the degree of risk to public health or of the need for drug control or for a particular type of drug control. The Committee would point out again that the recommendation for the use of the terms drug abuse and drug dependence of this or that type must not be regarded as a re-definition; rather, these terms are intended as descriptive expressions for clarification in scientific reference, interdisciplinary discussions, and national and international procedures.
In 1973, these statements and recent legislation based upon the term "dependence" rather than "addiction" or "abuse" were praised by President Richard M. Nixon's National Commission on Marihuana and Drug Abuse in its final report:
The Commission applauds the much-belated attempt by the scientific community to sever its conceptual apparatus from the vocabulary of politics and emotion. "Addiction," like "narcotics" and "drug abuse," has a general connotation of evil, suggesting illicit ecstasy, guilt and sin. Because the public image is conditioned more by cultural perceptions than by medical ones, medically-precise meanings simply cannot be harmonized with common parlance. 19
And in 1975, the WHO further distanced itself from the term 'drug abuse':
"Drug abuse" is a term in need of some clarification. …The term is really a convenient, but not very precise, way of indicating that (1) an unspecified drug is being used in an uspecified manner and amount … and (2) such use has been judged by some person or group to be wrong (illegal or immoral) and/or harmful to the user or society, or both. What might be called "drug abuse" by some would not necessarily be considered so by others. … For these reasons, the term "drug abuse" is avoided here 20
However, the 1957 and 1964–1965 WHO definitions of addiction, dependence and drug abuse persist to the present day in medical literature and have become entrenched in global legislation, despite the disclaimers and reliance on contentious assumptions. The WHO itself continues to use 'drug abuse' in its publications, and uses the term 'abuse' consistently and exclusively when discussing the control and consumption of illegal substances. This is in keeping with guidelines issued by the WHO's parent organization, the United Nations, which discourages any recognition of "recreational" or "responsible" use of drugs. 22
Researchers may take note that somewhat less contentious definitions of addiction, dependence, and tolerance (with no speculation as to their roles in the definition of drug abuse) were jointly issued in 2001 by the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine in the publication "Definitions Related to the Use of Opioids for the Treatment of Pain".
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 initating 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.
The 1969 edition of the WHO's International Statistical Classification of Diseases and Related Health Problems (ICD) manual defined drug abuse as "persistent or sporadic excessive drug use inconsistent with or unrelated to acceptable medical practice", modern editions have not used the term because of it's ambiguity 2), prefering instead to refer to the cluster of symptoms previously called 'drug abuse' as 'substance abuse'.
In 1972, the American Psychiatric Association defined abuse in similar terms, adding legality and social acceptability and even cultural familiarity as factors:
…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, undersirable, harmful, threatening, or, at minimum, culture-alien. 5
Although the two most used diagnostic tools in the world (the DSM and the ICD) no longer recognise 'drug abuse' as a current medical diagnosis, the Handbook on Drug and Alcohol Abuse, defines drug abuse as "nonmedical use of drugs, both drugs that have and those that do not have generally accepted medical value".
Because of ambiguity in the meanings, the World Health Organization presently prefers to use the terms harmful use and hazardous use in place of drug abuse to distinguish between the health effects of drug abuse rather than the social consequences.
- Main article: Substance abuse
In medical terms, both the DSM and the ICD have adopted substance abuse as a blanket term to include drug abuse and other things, however other definitions differ, and may entail psychological or physical dependence, and focuses on treatment and prevention in terms of the social consequences of substance use.
Public health definitions
In the past two decades, public health practicitioners have attempted to look at drug abuse from a broader perspective than the individual, emphasising the role of society, culture and availability. Rather than alcohol or drug "abuse" many public health professionals have adopted the terms "alcohol and drug problems" or "harmful/hazardous use" of drugs.
Political and criminal justice definitions
Most countries have legislation designed to criminalise drug abuse. Usually however the legislative process is self-referential, defining abuse in terms of what is made illegal. The legislation concerns lists of drugs specified by the legislation. These drugs are often called illegal drugs but, generally, what is illegal is their unlicensed production, supply and possession. The drugs are also called controlled drugs or controlled substances.
The US National Institute on Drug Abuse defines drug abuse as "The use of illegal drugs or the inappropriate use of legal drugs. The repeated use of drugs to produce pleasure, to alleviate stress, or to alter or avoid reality (or all three)." In place of this definition, WHO uses the term drug misuse, defined as the "use of a substance for a purpose not consistent with legal or medical guidelines, as in the non-medical use of prescription medications." According to WHO, the term misuse is preferred by some in the belief that it is less judgmental. . Further, drug abuse may sometimes be used to refer to any use of illegal drugs, even when such use does not meet clinical definitions of abuse or addiction.
In 1975, psychiatrist Jerome H. Jaffe (in his role as Drug Policy Director in the Nixon Administration) defined drug abuse as "the use, usually by self-administration, of any drug in a manner that deviates from the approved medical or social patterns within a given culture". According to Jaffe, the term "conveys the notion of social disapproval, and it is not necessarily descriptive of any particular pattern of drug use or its potential adverse consequences".2.
Some of the most commonly abused drugs are alcohol, anabolic steroids, amphetamines,analgesics, barbiturates, benzodiazepines, cannabis, cocaine, laxatives, methaqualone, opiates, and tobacco. Depending on the actual compound, drug abuse may lead to health problems, social problems, physical dependence, or psychological addiction.
Some drugs that are subject to abuse have 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. But, not all centrally acting drugs are subject to abuse, which suggests that altering consciousness is not sufficient for a drug to have abuse potential. Among drugs that are abused, some appear to be more likely to lead to uncontrolled use than others, suggesting a possible hierarchy of drug-induced effects relative to abuse potential.4
Approaches to managing drug abuse
Attempts by government-sponsored drug control policy to interdict drug supply and eliminate drug abuse have been largely unsuccessful. 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. In spite of the best 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.6
In addition to being a major public health problem, some consider drug abuse to be a social problem with far-reaching implications. Stress, poverty, domestic and societal violence, and various diseases (i.e., injecting drug users as a source for HIV/AIDS) are sometimes thought to be spread by drug use. Studies have also shown that individuals dependent on illicit drugs experience higher rates of comorbid psychiatric syndromes. 7
- Main article: Harm reduction
One alternative involves replacing failed law enforcement policies with harm-reduction strategies, which focus on reducing the societal costs of drug abuse and other drug use. Techniques include education to avoid overdose, needle exchange programs to reduce the spread of blood-borne diseases, and opioid substitution therapy to reduce crime related to the procurement of drugs. This pragmatic approach is known as the harm reduction paradigm. Harm reduction also addresses special populations, such as drug-using parents, pregnant drug users and users with psychiatric comorbidity. The philosophy of harm reduction accepts that drug use is part of the community, but that it must be addressed as a public health issue rather than a criminal one.8
Harm-reduction measures are at odds with the prevailing framework of international drug control, which rests on law enforcement and the criminalization of behaviors related to illicit drug use. However, harm-reduction has had a notable impact and is slowly gaining popularity. In Brazil alone, a comprehensive harm-reduction and drug-access program successfully reduced AIDS mortality among injection drug users by 50%.9
Medical treatment therefore centers on two aspects: 1) breaking the addiction, 2) treating the health problems.
Most countries have health facilities that specialize in the treatment of drug abuse, although access may be limited to larger population centers and the social taboos regarding drug use may make those who need the medical treatment reluctant to take advantage of it. For example, it is estimated that only fifteen percent of injection drug abusers thought to be in need are receiving treatment.10 Patients may require acute and long-term maintenance treatment and relapse prevention, complemented by suitable rehabilitation. 11
The development of pharmacotherapies for drug dependency treatment are currently in progress. New immunotherapies that prevent drugs like cocaine, methamphetamine, phencyclidine, nicotine, and opioids from reaching the brain are in the early stages of testing. Medications such as Buprenorphine, which block the drugs active site in the brain are another new option for the treatment of opioid addiction. Depot forms of medications, which require only weekly or monthly dosing, are also under investigation.
Traditionally, new pharmacotherapies are quickly adopted in primary care settings, however, drugs for substance abuse treatment have faced many barriers . Naltrexone, a drug marketed under the name "ReVia," is a medication approved for the treatment of alcohol dependence. Unfortunately, this drug has reached very few patients. This may be due to a number of factors, including resistance by addiction treatment providers and lack of resources. 12
Most countries have legislation designed to criminalise drug abuse. Usually however this is limited to drugs specified by the legislation. These drugs are often called illegal drugs but, generally, what is illegal is their unlicensed production, supply and possession. The drugs are also called controlled substances. Legal punishments, even for simple possession, can be quite severe (including the death penalty in some countries). Legal regimes vary across countries, and even within them, and have fluctuated widely throughout history.
Despite (and perhaps because of) the legislation many large, organized criminal drug cartels operate world-wide. Advocates of decriminalization argue that it is the legislation which makes drug dealing such a lucrative business, and leads to much of the associated criminal activity.
- Note 1: (2002). Mosby's Medical, Nursing, & Allied Health Dictionary. Sixth Edition. Drug abuse defintion, p. 552. Nursing diagnoses, p. 2109. ISBN 0323014305.
- Note 2: World Health Organization Lexicon
- Note 3: Jaffe, J.H. (1975). Drug addiction and drug abuse. In L.S. Goodman & A. Gilman (Eds.) The pharmacological basis of therapeutics(5th ed.). New York: MacMillan. pp. 284–324.
- Note 4: Winger, Gail. (1992). A Handbook on Drug and Alcohol Abuse: The Biomedical Aspects. Oxford University Press. ISBN 019506397X
- Note 5: Glasscote, R.M., Sussex, J.N., Jaffe, J.H., Ball, J., Brill, L. (1972). The Treatment of Drug Abuse: Programs, Problems, Prospects. Washington, D.C.: Joint Information Service of the American Psychiatric Association and the National Association for Mental Health.
- Note 6: Wood, Evan, et al. (Apr 29, 2003). "Drug supply and drug abuse". Letters. Canadian Medical Association Journal 168:(9). See also: CMAJ, 2003;168(2):165-9.
- Note 7: Diala, C. Muntaner, C. Walrath, C. (May 2004). "Gender, occupational, and socioeconomic correlates of alcohol and drug abuse among U.S. rural, metropolitan, and urban residents". American Journal of Drug and Alcohol Abuse.
- Note 8: Phillips, Prashant. (Oct, 2004). "Care of Drug Users in General Practice: a harm reduction approach." Book review. Mental Health Practice 8:i2. p. 29.
- Note 9: Editorial. (Mar 1, 2005) "HIV, harm reduction and human rights/VIH, reduction des prejudices et droits de la personne." Canadian Medical Association Journal. 172:(5). p.605.
- Note 10: Appel, P.W., Ellison, A.A., Jansky, H.K., Oldak, R. (Feb 2004). "Barriers to enrollment in drug abuse treatment and suggestions for reducing them: opinions of drug injecting street outreach clients and other system stakeholders". American Journal of Drug and Alcohol Abuse.
- Note 11: Qureshi N.A., al-Ghamdy Y.S., al-Habeeb T.A. (2000). "Drug addiction: a general review of new concepts and future challenges". East Mediterr Health J. Jul;6(4):723-33. PMID 11794078
- Note 12: Board on Behavioral, Cognitive, and Sensory Sciences and Education (BCSSE). (2004) New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions. The National Acadamies Press. pp. 7–8, 140–141
- Note 13: WHO Expert Committee on Drug Dependence. Sixteenth report. Geneva, World Health Organization, 1969 (WHO Technical Report Series, No.407.
- Note 14: Schaffer Library on Drug Policy - Perspectives on Defining Substance Abuse
- Note 15: Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision) (Diagnostic and Statistical Manual of Mental Disorders) ISBN: 0890420254
- Note 16: Wurmser, L. (1974) Psychoanalytic Considerations of the Etiology of Compulsive Drug Use. Journal of the American Psychoanalytical Assocation, 22:820 (APA)
- Note 17: Eddy, N.B., Halbach, H., Isbell, H., Seevers, M.H. (1965) Drug dependence: its significance and characteristics. Bulletin of the World Health Org., 23:721–722
- Note 18: Zinberg, Norman E. (1984). Drug, Set and Setting: The Basis for Controlled Intoxicant Use. Oxford University Press. ISBN 0-300-03110-6. p. 38
- Note 19: National Commission on Marihuana and Drug Abuse. (1973) Report: Drug Use In America: Problem in Perspective. Washington, D.C.: Government Printing Office.
- Note 20: Kramer, J.F., Cameron, D.C., (eds.). (1975). A Manual on Drug Dependence. Geneva: WHO. p. 16.
- Note 21: Expert Committee on Addiction-producing Drugs: Seventh Report. Geneva: WHO. pp. 45–47.
- Note 22: (1987) The United Nations and Drug Abuse Control. New York: United Nations. p.49.
- National Institute on Drug Abuse, Part of US National Institute of Health. Focused on research of drug abuse and addiction.
- American Journal of Drug and Alcohol Abuse, Focusing on the pre-clinical, clinical, pharmacological, administrative, and social aspects of substance misuse, this journal provides an exchange of ideas between the various modalities involved in the study and treatment of drug abuse and alcoholism.