II.   Alcohol & Other Drugs: The Basics

1. Basic Terms

How do we determine when the use of drugs or alcohol becomes a problem? Because of vastly different social attitudes about alcohol and drug use there have been few generally accepted and agreed-upon criteria for what level of use determines social use, abuse, or dependence.

However, with the notion of substance use being viewed as a continuum of behaviors that range from social use to abuse to dependence, much effort has been put forth to determine boundaries between different critical points on this continuum.

Over the last two decades, there has been a movement in the research community toward a global understanding of what defines addictive behavior. How we define addictive behavior is based in large part on the observation that there appears to be a number of common traits across extreme behaviors.

Individuals who have problems with eating, drinking alcohol, consuming drugs, gambling, smoking, sexuality, and so forth, present very similar descriptions of their disorders. To capture the essence of addiction that spans across these behaviors, a broad definition has evolved which can be generally applied to all addiction, including addiction to alcohol and drugs.

There are several different frameworks used to categorize various levels of addictive behavior that are widely referenced in the scientific and everyday press. The most widely used framework is the psychiatric diagnostic approach, exemplified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)1 and the International Classification of Diseases (ICD-10)2. Using the DSM-IV system as an example, the diagnosis of alcohol or substance use disorders includes two general subcategories: abuse and dependence.

Abuse and dependence are terms used to describe the pattern, level of severity, and life consequences connected to substance use. There are two terms that are often used to describe the behavioral pattern of alcohol and substance dependence: alcoholism and addiction.

For more information, please refer to the following sources:

1 American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th Edition). Washington D.C.: Author.

2 World Health Organization. (1992). International classification of diseases and related health problems (10th Rev.). Geneva: Author.

Figure 1 provides a visual aid that defines the unique characteristics of each term and the relationship between each behavior determined by behaviors and consequences.

Most drugs have their origins as medicines used to treat specific psychological, mental and physical disorders and to minimize pain (i.e., cocaine, morphine). There are many drugs prescribed today for the same reasons listed, however, there is still the potential for abuse or dependence if not taken appropriately, such as taking more doses than medically prescribed or after prolonged use (i.e., codeine, tranquilizers, loritabs). 

Non-problematic use can best be described as the use of any substance that is controlled, does not result in adverse consequences, use levels do not meet any criteria that would indicate abuse or dependence, or is used for therapeutic or medical reasons supervised by a doctor.
 
a. Abuse: The main feature of Substance Abuse is an unhealthy pattern of substance use leading to
significant negative consequences. This includes one or more of the items listed in Figure 1. Drinking and driving is an example of a situation that can result in harm to self or others. Also, not only may a person experience problems as a result of using alcohol or drugs, but these problems may be made worse by continued use of these substances.

Figure 1: Alcohol & Other Drugs: Signs of Problem Use

b. Dependence: Substance Dependence is marked by a group of mental, behavioral, and physical symptoms, indicating that the person continues to use a given drug despite significant substance- related problems. What is called dependence is a result of an individual displaying at least three of the seven symptoms listed in Figure 1.

√ Tolerance is needing to take more alcohol or drugs to feel drunk or “high,” or drinking the same amount with less effect.

√ Withdrawal defines physical symptoms (tremors, sweating) experienced by a person when he or she stops drinking or using a drug.

c. Alcoholism: The craving that an alcoholic feels for alcohol can be as strong as the need for food or water. An alcoholic will continue to drink despite serious family, health, or legal problems.
Alcoholism is chronic, meaning that it lasts a person's lifetime, it usually follows a predictable course, and it has the following symptoms:

√ Craving: A strong need, or urge to drink.

√ Loss of control: Not being able to stop drinking once drinking has begun.

√ Physical dependence: Withdrawal symptoms such as nausea, sweating, shakiness, and anxiety after stopping drinking.

√ Tolerance: The need to drink greater amounts of alcohol to get "high," or drinking the same amount with less effect.

d. Addiction: Addiction is a broad term used to describe a behavior that someone may lack control over, feel a compulsive need to continue, or an overwhelming attachment to (e.g., gambling, sex, drugs, alcohol, food, shopping, etc.). Addiction is viewed as a complicated behavior pattern that gets worse over time having biological, psychological, sociological, and behavioral influences and implications.

What distinguishes this pattern of behavior from others is the individual’s overwhelming involvement in or attachment to, compulsion to continue, and reduced ability to gain control over the substance use. The behavior pattern continues despite its negative impact on the physical, psychological, and social functioning of the individual.

2. What We Know About Alcohol and Drug Problems in the U.S.

The purpose of this information is to highlight that alcohol and drug abuse are significant and common health problems in the U.S.

ALCOHOL:
 Roughly 50% of Americans report using alcohol in any given month.
 Approximately 15% of Americans report binge drinking (5 or more drinks on a single occasion).
 There are roughly 15% of Americans with lifetime rates of alcohol abuse and dependence.
 Between 5-10% of American men will demonstrate alcoholism in their lifetime.

DRUGS:
 35% of Americans (12 and older) have used an illegal drug at least once.
 11% of Americans use an illegal drug at least once in any given year.
 Approximately 6% of Americans have suffered from drug abuse or dependence in their lifetime.

For additional information please refer to The National Institute on Drug Abuse: National Household Survey on Drug Abuse: http://www.drugabuse.gov

3. Alcohol and Drug Abuse in Couples and Families

Numerous research studies and clinical trials have successfully showed the relationships between alcohol/substance use, couple and family interactions, relationship satisfaction, and potential problem areas.

 25-30% of adults entering treatment for alcohol/drugs are married or in stable relationships.
 Alcoholics and substance abusers are just as likely to marry, but more likely to divorce/separate.
 Display high levels of relationship distress and dissatisfaction:
 Poor communication skills.
 Decreased expressions of caring behaviors.
 Distress and health concerns in spouses and children.
 Increased risk of interpersonal violence.

Techniques and skills that have been shown to have positive benefits on both abstinence maintenance and relationship improvement are located in the following sections titled:
Building Support for Abstinence, He Said – She Said: A Discussion on Communication
Barriers & Skills for Successful Communication, Increasing Positive Interactions: Couple &
Family Activities, Continuing Recovery: Helpful Guidelines, and Let’s Talk About…

4. Alcohol & Drug Classifications

With so many different types of drugs it can be confusing to know which drug has what effects and difficult to know the symptoms of intoxication and withdrawal. This section concludes with a general description of each drug category, including the drugs in that classification, rates of use in the U.S., and potential physical, emotional and psychological consequences of use.

An individual can meet diagnostic criteria, as outlined in the DSM-IV (described earlier), for abuse or dependence for any of the drugs described in each classification.

a. Alcohol:
 Affects all body systems: liver, digestive system, nervous system, sexual functioning, etc.
 Impairs coordination, leads to poor judgment, slurred speech, increases negative feelings, and memory lapses.
 Withdrawal symptoms range from the typical hangover to severe physical withdrawal
(including seizures) requiring medical attention.

b. Stimulants:  Cocaine, crack, amphetamines
 Regular use by 12% of Americans 12 years and older.
 2% of Americans report use of cocaine (powder).
 Approximately 1% of Americans report use of crack cocaine.
 Results in decreased appetite, increased energy, increased sexual feelings, increased heart rate, tremors, and restlessness.

c. Depressants: Alcohol, tranquilizers, sleeping medications, anti-anxiety drugs, barbiturates
 Decrease in brain activities.
 Disturbances in natural sleep patterns.
 Anesthetic (i.e., numbing, drowsiness) properties.
 Decrease negative feelings.
 Dangerous when taken in large amounts.
 
d. Marijuana: pot, hashish
■  It is estimated that more than 40% of Americans 12 years and older have used marijuana in their lifetime.
■  The most widely used illegal drug in the U.S.
■  Effects can include lack of concentration, short- and long-term memory problems, poor coordination, increased heart rate, and increased risk-taking behaviors.

e. Opiates and Analgesics: Heroine, morphine, methadone, percodan, darvon, codeine, loritabs
 Between 1 - 2% of Americans 12 years and older use heroine and analgesics, respectively.
 Used as a pain killer.
 Intoxication with extreme happiness.
 Highly addictive; physical dependence can develop even with short term use.

f. Hallucinogens: LSD, PCP, nitrous oxide, mescaline, mushrooms
 1% of Americans 12 years and older report use.
 Results in increased awareness of senses, altered images, visual/audio hallucinations, and extreme happiness.
 Can increase panic/anxiety, paranoia, and confusion.

g. Prescription Drugs: Any medically prescribed or over the counter drugs (taking more than the prescribed dose and/or when not needed)
 Most frequently abused of all drugs.
 High rates of prescription abuse for women.
 Highly addictive: painkillers, anti-depressants.
 25 - 33% of substance abusers illegally obtain.
 Often used in combination with other drugs.

h. Club Drugs: Ecstasy, GHB, Ketamine
 Synthetic, tablet form, and may contain other drugs increasing risk of serious consequences for user.
 Commonly used at ‘rave’ events, however, using club drugs is becoming more popular in other places such as bars and parties.
 Stimulant and hallucinogenic properties.
 Increases body temperature, causes dehydration, hyperactivity, and weight loss.
 Evidence is showing that use may result in memory impairment, depression, increased levels of anxiety, and sleep problems.

i. Multi-Drug Use: Frequent use of more than one substance (including alcohol)
 Increases risk of overdose; trips to the emergency room.
 People who attend treatment will often report use of more than one substance.

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See more of this publication at Sobriety: A Couple’s Workbook

Learning Sobriety Together: A Couple’s Workbook is also available as a pdf download – see list of manuals on the Addiction and Family Research Group site
http://addictionandfamily.org/