Physical dependence is a physical condition caused by chronic use of a tolerance-forming drug, in which abrupt or gradual drug withdrawal causes unpleasant physical symptoms.
Physical dependence can develop from low-dose therapeutic use of certain medications such as benzodiazepines, opioids, antiepileptics and antidepressants, as well as the recreational misuse of drugs such as alcohol, opioids and benzodiazepines. The higher the dose used, the greater the duration of use, and the earlier age use began are predictive of worsened physical dependence and thus more severe withdrawal syndromes.
Acute withdrawal syndromes can last days, weeks or months. Protracted withdrawal syndrome, also known as post-acute-withdrawal syndrome or “PAWS”, is a low-grade continuation of some of the symptoms of acute withdrawal, typically in a remitting-relapsing pattern, often resulting in relapse and prolonged disability of a degree to preclude the possibility of lawful employment. Protracted withdrawal syndrome can last for months, years, or depending on individual factors, indefinitely. Protracted withdrawal syndrome is noted to be most often caused by benzodiazepines. To dispel the popular mis-association with addiction, physical dependence to medications is sometimes compared to dependence on insulin by persons with diabetes.
Physical dependence can manifest itself in the appearance of both physical and psychological symptoms which are caused by physiological adaptions in the central nervous system and the brain due to chronic exposure to a substance. Symptoms which may be experienced during withdrawal or reduction in dosage include increased heart rate and/or blood pressure, sweating, and tremors. More serious withdrawal symptoms such as confusion, seizures, and visual hallucinations indicate a serious emergency and the need for immediate medical care.
Sedative hypnotic drugs such as alcohol, benzodiazepines, and barbiturates are the only commonly available substances that can be fatal in withdrawal due to their propensity to induce withdrawal convulsions. Abrupt withdrawal from other drugs, such as opioids can cause an extremely painful withdrawal that is very rarely fatal in patients of general good health and with medical treatment, but is more often fatal in patients with weakened cardiovascular systems; toxicity is generally caused by the often-extreme increases in heart rate and blood pressure (which can be treated with clonidine), or due to arrhythmia due to electrolyte imbalance caused by the inability to eat, and constant diarrhoea and vomiting (which can be treated with loperamide and ondansetron respectively) associated with acute opioid withdrawal, especially in longer-acting substances where the diarrhoea and emesis can continue unabated for weeks, although life-threatening complications are extremely rare, and nearly non-existent with proper medical management.
Treatment for physical dependence depends upon the drug being withdrawn and often includes administration of another drug, especially for substances that can be dangerous when abruptly discontinued or when previous attempts have failed. Physical dependence is usually managed by a slow dose reduction over a period of weeks, months or sometimes longer depending on the drug, dose and the individual. A physical dependence on alcohol is often managed with a cross tolerant drug, such as long acting benzodiazepines to manage the alcohol withdrawal symptoms.
Drugs That Cause Physical Dependence
All µ-opioids with any (even slight) agonist effect, such as (partial list) morphine, heroin, codeine, oxycodone, buprenorphine, nalbuphine, methadone, and fentanyl, but not agonists specific to non-µ opioid receptors, such as salvinorin A (a k-opioid agonist), nor opioid antagonists or inverse agonists, such as naltrexone (a universal opioid inverse agonist).
All GABA agonists and positive allosteric modulators of both the GABA-A ionotropic receptor and GABA-B metabotropic receptor subunits, including (partial list):
A wide range of drugs whilst not causing a true physical dependence can still cause withdrawal symptoms or rebound effects during dosage reduction or especially abrupt or rapid withdrawal. These can include caffeine, stimulants, steroidal drugs and antiparkinsonian drugs. It is debated whether the entire antipsychotic drug class causes true physical dependency, a subset, or if none do. But, if discontinued too rapidly, it could cause an acute withdrawal syndrome. When talking about illicit drugs rebound withdrawal, especially with stimulants, it is sometimes referred to as “coming down” or “crashing”.
Some drugs, like anticonvulsants and antidepressants, describe the drug category and not the mechanism. The individual agents and drug classes in the anticonvulsant drug category act at many different receptors and it is not possible to generalise their potential for physical dependence or incidence or severity of rebound syndrome as a group so they must be looked at individually. Anticonvulsants as a group however are known to cause tolerance to the anti-seizure effect. SSRI drugs, which have an important use as antidepressants, engender a discontinuation syndrome that manifests with physical side effects; e.g. there have been case reports of a discontinuation syndrome with venlafaxine (Effexor).
Low-threshold treatment programmes are harm reduction-based health care centres targeted towards people who use substances.
“Low-threshold” programmes are programmes that make minimal demands on the patient, offering services without attempting to control their intake of drugs, and providing counselling only if requested. Low-threshold programmes may be contrasted with “high-threshold” programmes, which require the user to accept a certain level of control and which demand that the patient accept counselling and cease all drug use as a precondition of support.
Low-threshold treatment programmes are distinct from simple needle exchange programmes, and may include comprehensive healthcare and counselling services. The International Journal of Drug Policy in its volume 24 published an Editorial which endeavoured to define a service known to be “low-threshold”, based on some popular and known criteria. According to that Editorial, low-threshold services for drug users can be defined as those which offer services to drug users; do not impose abstinence from drug use as a condition of service access; and endeavour to reduce other documented barriers to service access. Beyond comprehensive needle exchange services, other examples of low-threshold, community-based programmes include those that support people who use alcohol or drugs to consider positive or health protective changes without a demand for “recovery,” such as those piloted in New York City in the 1990s as “recovery readiness” efforts to bolster HIV prevention.
Injection drug users (IDUs) are at risk of a wide range of health problems arising from non-sterile injecting practices, complications of the drug itself or of the lifestyle associated with drug use and dependence. Furthermore, unrelated health problems, such as diabetes, may be neglected because of drug dependence. Sharing of health information with police, or requirements that patients abstain from all illegal drug use prior to receiving support are further impediments to health seeking, or require patients to lie about drug use in order to receive other lifesaving services. For all these reasons, despite their increased health care needs, IDUs do not have the required access to care or may be reluctant to use conventional services. Consequently, their health may deteriorate to a point at which emergency treatment is required, with considerable costs to both the IDUs and the health system. Accordingly, harm reduction based health care centres, also known as targeted health care outlet or low-threshold health care outlet for IDUs have been established across a range of settings utilising a variety of models. These targeted outlets provide integrated, low-threshold services within a harm-reduction framework targeting IDUs, and sometimes include social and/or other services. Where a particular service is not provided, referral and assistance with access is available. In 2007, for example, 33% of all US needle-syringe programmes (NSPs) provided on-site medical care, and 7% provided buprenorphine treatment. Similarly, in many European countries NSP outlets serve as low-threshold primary health care centres targeting primarily IDUs.
Health Care Models
These targeted outlets vary widely and may be either “distributive”, providing basic harm reduction services and simple healthcare with facilitated referrals to specialist services, or “one-stop-shops” where a range of services including specialist services are provided onsite. The services being offered by these outlets range from simple needle and syringe provision, to expanded services including basic and preventive primary healthcare, hepatitis B and A vaccinations, hepatitis C testing, counselling, tuberculosis screening and sometimes opioid maintenance therapy. Some centres offer hepatitis, HIV treatment and dental care. The goal of these outlets is to provide:
Opportunistic health care;
Increased temporal and spatial availability of health care;
Trustworthy services of health care;
Cost-effective mode of health care; and
Targeted and tailored services.
In the United States as of 2011, 211 NSPs were known to be operating in 32 states, the District of Columbia, Puerto Rico and the Indian Nations. The bulk of funding has come from state and local governments, since for most of the last several decades, federal funding for needle exchange programs has been specifically banned.
Globally, as of 2008, at least 77 countries and territories offer NSPs with varying structures, aims, and goals. Some countries use needle exchange services as part of integrated programmes to contain drug use, while others aim simply to contain HIV infection as their top priority, considering a reduction in the incidence of drug use as a much lower priority. Acceptance of NSPs vary widely from country to country. On the one hand, in Australia and New Zealand, electronic dispensing machines are available at selected locations such as the Auckland needle exchange and the Christchurch needle exchange, allowing needle exchange service 24 hours to registered users. On the other hand, over half of the countries in Asia, the Middle East, and North Africa retain the death penalty for drug offenses, although some have not carried out executions in recent years.
Low-threshold programmes offering needle exchange have faced much opposition on political and moral grounds. Concerns are often expressed that NSPs may encourage drug use, or may actually increase the number of dirty needles in the community. Another fear is that NSPs may draw drug activity into the communities in which they operate. It has also been argued that in fighting disease, needle exchanges take attention away from bigger drug problems, and that, contrary to saving lives, they actually contribute to drug-related deaths. Even in Australia, which is considered a leading country in harm reduction, a survey showed that a third of the public believed that NSPs encouraged drug use, and 20% believed that NSPs dispensed drugs. In the United States, the ambivalent public attitude towards NSPs is often reflected in police interference, with 43% of NSP programme managers reporting frequent (at least monthly) client harassment, 31% reporting frequent confiscation of clients’ syringes, 12% reporting frequent client arrest, and 26% reporting uninvited police appearances at programme sites. A single 1997 study which showed a correlation between frequent programme use and elevated rates of HIV infection among IDUs in Vancouver, Canada, has become widely cited by opponents of NSPs as demonstrating their counter-productiveness.
Authors from the 1997 Vancouver study have, in multiple publications, issued disclaimers against the misuse of their work by opponents of NSPs. They point out that frequent attendees of the program tended to be young and often indulged in extreme high-risk behaviours. The 1997 results were hence of statistically biased sampling. They have emphasized that the correct message to be derived from their 1997 study can be read in the title of their work: “Needle exchange is not enough”. This is the same message presented by many other articles since.
Comprehensive, systematic surveys of the costs and effectiveness of low-threshold primary healthcare programmes are not available due to the heterogeneity of these programmes and the study designs. Narrower focus studies dealing solely with the needle exchange issue are abundant, however, and generally support the thesis that NSPs reduce the risk of prevalence of HIV, hepatitis and other blood-borne diseases. These studies suggest that such outlets improve the overall health status of IDUs and save on the health budget by reducing episodes in emergency departments and tertiary hospitals. In Australia, monitoring of drug users participating in NSPs showed the incidence of HIV among NSP clients to be essentially identical to that of the general population. Fears that NSPs may draw drug activity into the communities in which they operate are contradicted by a study that showed that by far the greatest number of clients of an NSP in Chicago came to the area to exchange needles (60%) rather than to buy drugs (3.8%).
Internationally, support for the effectiveness of low-threshold programmes including needle exchange have come from studies conducted in Afghanistan, China, Spain, Taiwan, Estonia, Canada, Iran, and many other countries. However, in many countries, there is strong opposition to such programmes.
Despite the lack of randomised clinical trials demonstrating the impact of low-threshold services, the available evidence, barriers to service access and the late presentation of seriously ill IDUs to hospital, suggests the ongoing need for targeted and low-threshold services. In addition, prevention of HIV and hepatitis C transmission is clearly possible for those unable or unwilling to stop injecting drug use, and a range of countries using low-threshold approach have achieved control or virtual elimination of HIV transmission among people who inject drugs. For these reasons, organisations ranging from the US National Institutes of Health, the Centres for Disease Control, the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organisation, the European Monitoring Centre for Drugs and Drug Addiction and many others have endorsed low-threshold programmes including needle exchange.
Substance dependence, also known as drug dependence, is a biopsychological situation where-by an individual’s functionality is dependent on the necessitated re-consumption of a psychoactive substance, because of an adaptive state that has developed with the individual from psychoactive substance consumption, which results in the experience of withdrawal, which necessitates the re-consumption of the drug.
A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioural and drug addictions, but not dependence.
The International Classification of Diseases classifies substance dependence as a mental and behavioural disorder. Within the framework of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), substance dependence is redefined as a drug addiction, and can be diagnosed without the occurrence of a withdrawal syndrome. It was described accordingly: “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. This, along with Substance Abuse are considered Substance Use Disorders.” In the DSM-5 (released in 2013), substance abuse and substance dependence have been merged into the category of substance use disorders and they no longer exist as individual diagnoses.
The phenomenon of drug addiction has occurred to some degree throughout recorded history (see “Opium”). Modern agricultural practices, improvements in access to drugs, advancements in biochemistry, and dramatic increases in the recommendation of drug usage by clinical practitioners have exacerbated the problem significantly in the 20th century. Improved means of active biological agent manufacture and the introduction of synthetic compounds, such as fentanyl and methamphetamine, are also factors contributing to drug addiction.
For the entirety of US history, drugs have been used by some members of the population. In the country’s early years, most drug use by the settlers was of alcohol or tobacco.
The 19th century saw opium usage in the US become much more common and popular. Morphine was isolated in the early 19th century, and came to be prescribed commonly by doctors, both as a painkiller and as an intended cure for opium addiction. At the time, the prevailing medical opinion was that the addiction process occurred in the stomach, and thus it was hypothesized that patients would not become addicted to morphine if it was injected into them via a hypodermic needle, and it was further hypothesized that this might potentially be able to cure opium addiction. However, many people did become addicted to morphine. In particular, addiction to opium became widespread among soldiers fighting in the Civil War, who very often required painkillers and thus were very often prescribed morphine. Women were also very frequently prescribed opiates, and opiates were advertised as being able to relieve “female troubles”.
Many soldiers in the Vietnam War were introduced to heroin and developed a dependency on the substance which survived even when they returned to the US. Technological advances in travel meant that this increased demand for heroin in the US could now be met. Furthermore, as technology advanced, more drugs were synthesized and discovered, opening up new avenues to substance dependency.
Addiction: A biopsychosocial disorder characterised by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences.
Addictive drug: Psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug’s effect on brain reward systems.
Dependence: An adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g. drug intake).
Drug sensitisation or reverse tolerance: The escalating effect of a drug resulting from repeated administration at a given dose.
Drug withdrawal: Symptoms that occur upon cessation of repeated drug use.
Physical dependence: Dependence that involves persistent physical-somatic withdrawal symptoms (e.g. fatigue and delirium tremens).
Psychological dependence: Dependence that involves emotional-motivational withdrawal symptoms (e.g. dysphoria and anhedonia).
Reinforcing stimuli: Stimuli that increase the probability of repeating behaviours paired with them.
Rewarding stimuli: Stimuli that the brain interprets as intrinsically positive and desirable or as something to approach.
Sensitisation: An amplified response to a stimulus resulting from repeated exposure to it.
Substance use disorder: A condition in which the use of substances leads to clinically and functionally significant impairment or distress.
Tolerance: The diminishing effect of a drug resulting from repeated administration at a given dose.
Withdrawal is the body’s reaction to abstaining from a substance upon which a person has developed a dependence syndrome. When dependence has developed, cessation of substance-use produces an unpleasant state, which promotes continued drug use through negative reinforcement; i.e. the drug is used to escape or avoid re-entering the associated withdrawal state. The withdrawal state may include physical-somatic symptoms (physical dependence), emotional-motivational symptoms (psychological dependence), or both. Chemical and hormonal imbalances may arise if the substance is not re-introduced. Psychological stress may also result if the substance is not re-introduced.
Infants also suffer from substance withdrawal, known as neonatal abstinence syndrome (NAS), which can have severe and life-threatening effects. Addiction to drugs such as alcohol in expectant mothers not only causes NAS, but also an array of other issues which can continually affect the infant throughout their lifetime.
The dependence potential of a drug varies from substance to substance, and from individual to individual. Dose, frequency, pharmacokinetics of a particular substance, route of administration, and time are critical factors for developing a drug dependence.
An article in The Lancet compared the harm and dependence liability of 20 drugs, using a scale from zero to three for physical dependence, psychological dependence, and pleasure to create a mean score for dependence. Selected results can be seen in the chart below.
Capture rates enumerate the percentage of users who reported that they had become dependent to their respective drug at some point (Drug/% users):
Two factors have been identified as playing pivotal roles in psychological dependence: the neuropeptide “corticotropin-releasing factor” (CRF) and the gene transcription factor “cAMP response element binding protein” (CREB). The nucleus accumbens (NAcc) is one brain structure that has been implicated in the psychological component of drug dependence. In the NAcc, CREB is activated by cyclic adenosine monophosphate (cAMP) immediately after a high and triggers changes in gene expression that affect proteins such as dynorphin; dynorphin peptides reduce dopamine release into the NAcc by temporarily inhibiting the reward pathway. A sustained activation of CREB thus forces a larger dose to be taken to reach the same effect. In addition, it leaves the user feeling generally depressed and dissatisfied, and unable to find pleasure in previously enjoyable activities, often leading to a return to the drug for another dose.
In addition to CREB, it is hypothesized that stress mechanisms play a role in dependence. Koob and Kreek have hypothesized that during drug use, CRF activates the hypothalamic-pituitary-adrenal axis (HPA axis) and other stress systems in the extended amygdala. This activation influences the dysregulated emotional state associated with psychological dependence. They found that as drug use escalates, so does the presence of CRF in human cerebrospinal fluid. In rat models, the separate use of CRF inhibitors and CRF receptor antagonists both decreased self-administration of the drug of study. Other studies in this review showed dysregulation of other neuropeptides that affect the HPA axis, including enkephalin which is an endogenous opioid peptide that regulates pain. It also appears that µ-opioid receptors, which enkephalin acts upon, is influential in the reward system and can regulate the expression of stress hormones.
Increased expression of AMPA receptors in nucleus accumbens MSNs is a potential mechanism of aversion produced by drug withdrawal.
Upregulation of the cAMP signal transduction pathway in the locus coeruleus by CREB has been implicated as the mechanism responsible for certain aspects of opioid-induced physical dependence. The temporal course of withdrawal correlates with LC firing, and administration of α2 agonists into the locus coeruleus leads to a decrease in LC firing and norepinephrine release during withdrawal. A possible mechanism involves upregulation of NMDA receptors, which is supported by the attenuation of withdraw by NMDA receptor antagonists. Physical dependence on opioids has been observed to produce an elevation of extracellular glutamate, an increase in NMDA receptor subunits NR1 and NR2A, phosphorylated CaMKII, and c-fos. Expression of CaMKII and c-fos is attenuated by NMDA receptor antagonists, which is associated with blunted withdrawal in adult rats, but not neonatal rats While acute administration of opioids decreases AMPA receptor expression and depresses both NMDA and non-NMDA excitatory postsynaptic potentials in the NAC, withdrawal involves a lowered threshold for LTP and an increase in spontaneous firing in the NAc.
“Substance dependence”, as defined in the DSM-IV, can be diagnosed with physiological dependence, evidence of tolerance or withdrawal, or without physiological dependence. DSM-IV substance dependencies include:
303.90 Alcohol dependence.
304.00 Opioid dependence.
304.10 Sedative, hypnotic, or anxiolytic dependence (including benzodiazepine dependence and barbiturate dependence).
Addiction is a complex but treatable condition. It is characterized by compulsive drug craving, seeking, and use that persists even if the user is aware of severe adverse consequences. For some people, addiction becomes chronic, with periodic relapses even after long periods of abstinence. As a chronic, relapsing disease, addiction may require continued treatments to increase the intervals between relapses and diminish their intensity. While some with substance issues recover and lead fulfilling lives, others require ongoing additional support. The ultimate goal of addiction treatment is to enable an individual to manage their substance misuse; for some this may mean abstinence. Immediate goals are often to reduce substance abuse, improve the patient’s ability to function, and minimise the medical and social complications of substance abuse and their addiction; this is called “harm reduction”.
Treatments for addiction vary widely according to the types of drugs involved, amount of drugs used, duration of the drug addiction, medical complications and the social needs of the individual. Determining the best type of recovery programme for an addicted person depends on a number of factors, including: personality, drugs of choice, concept of spirituality or religion, mental or physical illness, and local availability and affordability of programmes.
Many different ideas circulate regarding what is considered a successful outcome in the recovery from addiction. Programs that emphasize controlled drinking exist for alcohol addiction. Opiate replacement therapy has been a medical standard of treatment for opioid addiction for many years.
Treatments and attitudes toward addiction vary widely among different countries. In the US and developing countries, the goal of commissioners of treatment for drug dependence is generally total abstinence from all drugs. Other countries, particularly in Europe, argue the aims of treatment for drug dependence are more complex, with treatment aims including reduction in use to the point that drug use no longer interferes with normal activities such as work and family commitments; shifting the addict away from more dangerous routes of drug administration such as injecting to safer routes such as oral administration; reduction in crime committed by drug addicts; and treatment of other comorbid conditions such as AIDS, hepatitis and mental health disorders. These kinds of outcomes can be achieved without eliminating drug use completely. Drug treatment programmes in Europe often report more favourable outcomes than those in the US because the criteria for measuring success are functional rather than abstinence-based. The supporters of programmes with total abstinence from drugs as a goal believe that enabling further drug use means prolonged drug use and risks an increase in addiction and complications from addiction.
Residential drug treatment can be broadly divided into two camps: 12-step programs and therapeutic communities. 12-step programs are a nonclinical support-group and spiritual-based approach to treating addiction. Therapy typically involves the use of cognitive-behavioural therapy, an approach that looks at the relationship between thoughts, feelings and behaviours, addressing the root cause of maladaptive behaviour. Cognitive-behavioural therapy treats addiction as a behaviour rather than a disease, and so is subsequently curable, or rather, unlearnable. Cognitive-behavioural therapy programmes recognise that, for some individuals, controlled use is a more realistic possibility.
One of many recovery methods are 12-step recovery programs, with prominent examples including Alcoholics Anonymous, Narcotics Anonymous, Drug Addicts Anonymous and Pills Anonymous. They are commonly known and used for a variety of addictions for the individual addicted and the family of the individual. Substance-abuse rehabilitation (rehab) centres offer a residential treatment programme for some of the more seriously addicted, in order to isolate the patient from drugs and interactions with other users and dealers. Outpatient clinics usually offer a combination of individual counselling and group counselling. Frequently, a physician or psychiatrist will prescribe medications in order to help patients cope with the side effects of their addiction. Medications can help immensely with anxiety and insomnia, can treat underlying mental disorders (cf. self-medication hypothesis, Khantzian 1997) such as depression, and can help reduce or eliminate withdrawal symptomology when withdrawing from physiologically addictive drugs. Some examples are using benzodiazepines for alcohol detoxification, which prevents delirium tremens and complications; using a slow taper of benzodiazepines or a taper of phenobarbital, sometimes including another antiepileptic agent such as gabapentin, pregabalin, or valproate, for withdrawal from barbiturates or benzodiazepines; using drugs such as baclofen to reduce cravings and propensity for relapse amongst addicts to any drug, especially effective in stimulant users, and alcoholics (in which it is nearly as effective as benzodiazepines in preventing complications); using clonidine, an alpha-agonist, and loperamide for opioid detoxification, for first-time users or those who wish to attempt an abstinence-based recovery (90% of opioid users relapse to active addiction within eight months or are multiple relapse patients); or replacing an opioid that is interfering with or destructive to a user’s life, such as illicitly-obtained heroin, dilaudid, or oxycodone, with an opioid that can be administered legally, reduces or eliminates drug cravings, and does not produce a high, such as methadone or buprenorphine – opioid replacement therapy – which is the gold standard for treatment of opioid dependence in developed countries, reducing the risk and cost to both user and society more effectively than any other treatment modality (for opioid dependence), and shows the best short-term and long-term gains for the user, with the greatest longevity, least risk of fatality, greatest quality of life, and lowest risk of relapse and legal issues including arrest and incarceration.
In a survey of treatment providers from three separate institutions, the National Association of Alcoholism and Drug Abuse Counsellors, Rational Recovery Systems and the Society of Psychologists in Addictive Behaviours, measuring the treatment provider’s responses on the “Spiritual Belief Scale” (a scale measuring belief in the four spiritual characteristics of AA identified by Ernest Kurtz); the scores were found to explain 41% of the variance in the treatment provider’s responses on the “Addiction Belief Scale” (a scale measuring adherence to the disease model or the free-will model of addiction).
Behavioural programming is considered critical in helping those with addictions achieve abstinence. From the applied behaviour analysis literature and the behavioural psychology literature, several evidence based intervention programmes have emerged:
Behavioural marital therapy;
Community reinforcement approach;
Cue exposure therapy; and
Contingency management strategies.
In addition, the same author suggests that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious. Community reinforcement has both efficacy and effectiveness data. In addition, behavioural treatment such as community reinforcement and family training (CRAFT) have helped family members to get their loved ones into treatment. Motivational intervention has also shown to be an effective treatment for substance dependence.
Alternative therapies, such as acupuncture, are used by some practitioners to alleviate the symptoms of drug addiction. In 1997, the American Medical Association (AMA) adopted, as policy, the following statement after a report on a number of alternative therapies including acupuncture:
There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.
Treatment and Issues
Medical professionals need to apply many techniques and approaches to help patients with substance related disorders. Using a psychodynamic approach is one of the techniques that psychologists use to solve addiction problems. In psychodynamic therapy, psychologists need to understand the conflicts and the needs of the addicted person, and also need to locate the defects of their ego and defence mechanisms. Using this approach alone has proven to be ineffective in solving addiction problems. Cognitive and behavioural techniques should be integrated with psychodynamic approaches to achieve effective treatment for substance related disorders. Cognitive treatment requires psychologists to think deeply about what is happening in the brain of an addicted person. Cognitive psychologists should zoom in to neural functions of the brain and understand that drugs have been manipulating the dopamine reward centre of the brain. From this particular state of thinking, cognitive psychologists need to find ways to change the thought process of the addicted person.
There are two routes typically applied to a cognitive approach to substance abuse: tracking the thoughts that pull patients to addiction and tracking the thoughts that prevent them from relapsing. Behavioural techniques have the widest application in treating substance related disorders. Behavioural psychologists can use the techniques of “aversion therapy”, based on the findings of Pavlov’s classical conditioning. It uses the principle of pairing abused substances with unpleasant stimuli or conditions; for example, pairing pain, electrical shock, or nausea with alcohol consumption. The use of medications may also be used in this approach, such as using disulfiram to pair unpleasant effects with the thought of alcohol use. Psychologists tend to use an integration of all these approaches to produce reliable and effective treatment. With the advanced clinical use of medications, biological treatment is now considered to be one of the most efficient interventions that psychologists may use as treatment for those with substance dependence.
Another approach is to use medicines that interfere with the functions of the drugs in the brain. Similarly, one can also substitute the misused substance with a weaker, safer version to slowly taper the patient off of their dependence. Such is the case with Suboxone in the context of opioid dependence. These approaches are aimed at the process of detoxification. Medical professionals weigh the consequences of withdrawal symptoms against the risk of staying dependent on these substances. These withdrawal symptoms can be very difficult and painful times for patients. Most will have steps in place to handle severe withdrawal symptoms, either through behavioural therapy or other medications. Biological intervention should be combined with behavioural therapy approaches and other non-pharmacological techniques. Group therapies including anonymity, teamwork and sharing concerns of daily life among people who also suffer from substance dependence issues can have a great impact on outcomes. However, these programs proved to be more effective and influential on persons who did not reach levels of serious dependence.
Society and Culture
Internationally, the US and Eastern Europe contain the countries with the highest substance abuse disorder occurrence (5-6%). Africa, Asia, and the Middle East contain countries with the lowest worldwide occurrence (1-2%). Across the globe, those that tended to have a higher prevalence of substance dependence were in their twenties, unemployed, and men. The National Survey on Drug Use and Health (NSDUH) reports on substance dependence/abuse rates in various population demographics across the US When surveying populations based on race and ethnicity in those ages 12 and older, it was observed that American Indian/Alaskan Natives were among the highest rates and Asians were among the lowest rates in comparison to other racial/ethnic groups.
When surveying populations based on gender in those ages 12 and older, it was observed that males had a higher substance dependence rate than females. However, the difference in the rates are not apparent until after age 17. Drug and Alcohol Dependence reports that older adults abuse drugs including alcohol at a rate of 15-20%. It’s estimated that 52 million Americans beyond 12 years old have abused a substance.
Alcohol dependence or abuse rates were shown to have no correspondence with any person’s education level when populations were surveyed in varying degrees of education from ages 26 and older. However, when it came to illicit drug use there was a correlation, in which those that graduated from college had the lowest rates. Furthermore, dependence rates were greater in unemployed populations ages 18 and older and in metropolitan-residing populations ages 12 and older.
The National Opinion Research Centre at the University of Chicago reported an analysis on disparities within admissions for substance abuse treatment in the Appalachian region, which comprises 13 states and 410 counties in the Eastern part of the US While their findings for most demographic categories were similar to the national findings by NSDUH, they had different results for racial/ethnic groups which varied by sub-regions. Overall, Whites were the demographic with the largest admission rate (83%), while Alaskan Native, American Indian, Pacific Islander, and Asian populations had the lowest admissions (1.8%).
Depending on the jurisdiction, addictive drugs may be legal, legal only as part of a government sponsored study, illegal to use for any purpose, illegal to sell, or even illegal to merely possess.
Most countries have legislation which brings various drugs and drug-like substances under the control of licensing systems. Typically this legislation covers any or all of the opiates, amphetamines, cannabinoids, cocaine, barbiturates, benzodiazepines, anaesthetics, hallucinogenics, derivatives and a variety of more modern synthetic drugs. Unlicensed production, supply or possession is a criminal offence.
Usually, however, drug classification under such legislation is not related simply to addictiveness. The substances covered often have very different addictive properties. Some are highly prone to cause physical dependency, while others rarely cause any form of compulsive need whatsoever. Also, under legislation specifically about drugs, alcohol and nicotine are not usually included.
Although the legislation may be justifiable on moral or public health grounds, it can make addiction or dependency a much more serious issue for the individual: reliable supplies of a drug become difficult to secure, and the individual becomes vulnerable to both criminal abuse and legal punishment.
It is unclear whether laws against illegal drug use do anything to stem usage and dependency. In jurisdictions where addictive drugs are illegal, they are generally supplied by drug dealers, who are often involved with organized crime. Even though the cost of producing most illegal addictive substances is very low, their illegality combined with the addict’s need permits the seller to command a premium price, often hundreds of times the production cost. As a result, addicts sometimes turn to crime to support their habit.
In the United States, drug policy is primarily controlled by the federal government. The Department of Justice’s Drug Enforcement Administration (DEA) enforces controlled substances laws and regulations. The Department of Health and Human Services’ Food and Drug Administration (FDA) serve to protect and promote public health by controlling the manufacturing, marketing, and distribution of products, like medications.
The United States’ approach to substance abuse has shifted over the last decade, and is continuing to change. The federal government was minimally involved in the 19th century. The federal government transitioned from using taxation of drugs in the early 20th century to criminalising drug abuse with legislations and agencies like the Federal Bureau of Narcotics (FBN) mid-20th century in response to the nation’s growing substance abuse issue. These strict punishments for drug offenses shined light on the fact that drug abuse was a multi-faceted problem. The President’s Advisory Commission on Narcotics and Drug Abuse of 1963 addressed the need for a medical solution to drug abuse. However, drug abuse continued to be enforced by the federal government through agencies such as the DEA and further legislations such as The Controlled Substances Act (CSA), the Comprehensive Crime Control Act of 1984, and Anti-Drug Abuse Acts.
In the past decade, there have been growing efforts through state and local legislations to shift from criminalizing drug abuse to treating it as a health condition requiring medical intervention. 28 states currently allow for the establishment of needle exchanges. Florida, Iowa, Missouri and Arizona all introduced bills to allow for the establishment of needle exchanges in 2019. These bills have grown in popularity across party lines since needle exchanges were first introduced in Amsterdam in 1983. In addition, AB-186 Controlled substances: overdose prevention program was introduced to operate safe injection sites in the City and County of San Francisco. The bill was vetoed on 30 September 2018 by California Governor Jerry Brown. The legality of these sites are still in discussion, so there are no such sites in the United States yet. However, there is growing international evidence for successful safe injection facilities.
1935 – Dr. Robert Smith takes his last drink, and Alcoholics Anonymous is founded in Akron, Ohio, United States, by him and Bill Wilson.
Dr. Robert Smith
Robert Holbrook Smith (08 August 1879 to 16 November 1950), also known as Dr. Bob, was an American physician and surgeon who founded Alcoholics Anonymous with Bill Wilson (more commonly known as Bill W.).
Family and Early Life
Smith was born in St. Johnsbury, Vermont, where he was raised, to Susan A. (Holbrook) and Walter Perrin Smith. His parents took him to religious services four times a week, and in response he determined he would never attend religious services when he grew up. He graduated from St Johnsbury Academy in 1898, having met his future wife Anne Robinson Ripley at a dance there.
Education, Marriage, Work, and Alcoholism
Smith began drinking at college attending Dartmouth College in Hanover, New Hampshire. Early on he noticed that he could recover from drinking bouts quicker and easier than his classmates and that he never had headaches, which caused him to believe he was an alcoholic from the time he began drinking. Smith was a member of Kappa Kappa Kappa fraternity at Dartmouth. After graduation in 1902, he worked for three years selling hardware in Boston, Chicago, and Montreal and continued drinking heavily. He then returned to school to study medicine at the University of Michigan. By this time drinking had begun to affect him to the point where he began missing classes. His drinking caused him to leave school, but he returned and passed his examinations for his sophomore year. He transferred to Rush Medical College, but his alcoholism worsened to the point that his father was summoned to try to halt his downward trajectory. But his drinking increased and after a dismal showing during final examinations, the university required that he remain for two extra quarters and remain sober during that time as a condition of graduating.
After graduation, Smith became a hospital intern, and for two years he was able to stay busy enough to refrain from heavy drinking. He married Anne Robinson Ripley on January 25, 1915, and opened up his own office in Akron, Ohio, specialising in colorectal surgery and returned to heavy drinking. Recognising his problem, he checked himself into more than a dozen hospitals and sanitariums in an effort to stop his drinking. He was encouraged by the passage of Prohibition in 1919, but soon discovered that the exemption for medicinal alcohol, and bootleggers, could supply more than enough to continue his excessive drinking. For the next 17 years his life revolved around how to subvert his wife’s efforts to stop his drinking and obtain the alcohol he craved while trying to hold together a medical practice in order to support his family and his drinking.
Meeting Bill Wilson
In January 1933, Anne Smith attended a lecture by Frank Buchman, the founder of the Oxford Group. For the next two years she and Smith attended local meetings of the group in an effort to solve his alcoholism, but recovery eluded him until he met Bill Wilson on 12 May 1935. Wilson was an alcoholic who had learned how to stay sober, thus far only for some limited amounts of time, through the Oxford Group in New York, and was close to discovering long-term sobriety by helping other alcoholics. Wilson was in Akron on business that had proven unsuccessful and he was in fear of relapsing. Recognising the danger, he made inquiries about any local alcoholics he could talk to and was referred to Smith by Henrietta Seiberling, one of the leaders of the Akron Oxford Group. After talking to Wilson, Smith stopped drinking and invited Wilson to stay at his home. He relapsed almost a month later while attending a professional convention in Atlantic City. Returning to Akron on 09 June, he was given a few drinks by Wilson to avoid delirium tremens. He drank one beer the next morning to settle his nerves so he could perform an operation, which proved to be the last alcoholic drink he would ever have. The date, 10 June 1935, is celebrated as the anniversary of the founding of Alcoholics Anonymous.
Smith was called the “Prince of Twelfth Steppers” by Wilson because he helped more than 5000 alcoholics before his death. He was able to stay sober from 10 June 1935, until his death in 1950 from colon cancer. He is buried at the Mount Peace Cemetery in Akron, Ohio.
Alcoholics Anonymous (AA) is an international mutual aid fellowship with the stated purpose of enabling its members to “stay sober and help other alcoholics achieve sobriety.” AA is nonprofessional, non-denominational, self-supporting, and apolitical. Its only membership requirement is a desire to stop drinking. The AA programme of recovery is set forth in the Twelve Steps.
AA was founded in 1935 in Akron, Ohio, when one alcoholic, Bill Wilson, talked to another alcoholic, Bob Smith, about the nature of alcoholism and a possible solution. With the help of other early members, the book Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered From Alcoholism was written in 1939. Its title became the name of the organisation and is today commonly referred to as “The Big Book”. AA’s initial Twelve Traditions were introduced in 1946 to help the fellowship be stable and unified while disengaged from “outside issues” and influences.
The Traditions recommend that members remain anonymous in public media, altruistically help other alcoholics, and that AA groups avoid official affiliations with other organisations. They also advise against dogma and coercive hierarchies. Subsequent fellowships such as Narcotics Anonymous have adapted the Twelve Steps and the Twelve Traditions to their respective primary purposes.
AA membership has since spread internationally “across diverse cultures holding different beliefs and values”, including geopolitical areas resistant to grassroots movements. As of 2016, close to two million people worldwide are estimated to be members of AA.
Substance-induced psychosis (commonly known as toxic psychosis or drug-induced psychosis) is a form of psychosis that is attributed to substance use.
It is a psychosis that results from the effects of chemicals or drugs, including those produced by the body itself. Various psychoactive substances have been implicated in causing or worsening psychosis in users.
Signs and Symptoms
Psychosis manifests as disorientation, visual hallucinations and/or haptic hallucinations. It is a state in which a person’s mental capacity to recognise reality, communicate, and relate to others is impaired, thus interfering with the capacity to deal with life demands. While there are many types of psychosis, substance-induced psychosis can be pinpointed to specific chemicals.
Transition to schizophrenia
A 2019 systematic review and meta-analysis by Murrie and colleagues found that the pooled proportion of transition from substance-induced psychosis to schizophrenia was 25% (95% CI 18%-35%), compared with 36% (95% CI 30%-43%) for brief, atypical and not otherwise specified psychoses.
Type of substance was the primary predictor of transition from drug-induced psychosis to schizophrenia, with highest rates associated with cannabis (6 studies, 34%, CI 25%-46%), hallucinogens (3 studies, 26%, CI 14%-43%) and amphetamines (5 studies, 22%, CI 14%-34%). Lower rates were reported for opioid (12%), alcohol (10%) and sedative (9%) induced psychoses.
Transition rates were slightly lower in older cohorts but were not affected by sex, country of the study, hospital or community location, urban or rural setting, diagnostic methods, or duration of follow-up.
Psychotic states may occur after using a variety of legal and illegal substances. Usually such states are temporary and reversible, with fluoroquinolone-induced psychosis being a notable exception. Substances whose use or withdrawal are implicated in psychosis include the following:
International Classification of Diseases
Psychoactive substance-induced psychotic disorders outlined within the ICD-10 codes F10.5-F19.5:
Alcohol is a common cause of psychotic disorders or episodes, which may occur through acute intoxication, chronic alcoholism, withdrawal, exacerbation of existing disorders, or acute idiosyncratic reactions.
Research has shown that excessive alcohol use causes an 8-fold increased risk of psychotic disorders in men and a 3 fold increased risk of psychotic disorders in women.
While the vast majority of cases are acute and resolve fairly quickly upon treatment and/or abstinence, they can occasionally become chronic and persistent.
Alcoholic psychosis is sometimes misdiagnosed as another mental illness such as schizophrenia.
Studies show stronger opioids such as Fentanyl are more likely to cause psychosis and hallucinations.
Some studies indicate that cannabis may trigger full-blown psychosis.
Recent studies have found an increase in risk for psychosis in cannabis users.
It is also important to this topic to understand the paradoxical effects of some sedative drugs.
Serious complications can occur in conjunction with the use of sedatives creating the opposite effect as to that intended.
Malcolm Lader at the Institute of Psychiatry in London estimates the incidence of these adverse reactions at about 5%, even in short-term use of the drugs.
The paradoxical reactions may consist of depression, with or without suicidal tendencies, phobias, aggressiveness, violent behaviour and symptoms sometimes misdiagnosed as psychosis.
However, psychosis is more commonly related to the benzodiazepine withdrawal syndrome.
F15.5 other stimulants:
Amphetamines; methamphetamine; and methylphenidate.
Refer to stimulant psychosis.
F16.5 hallucinogens (LSD and others).
F18.5 volatile solvents (volatile inhalants):
Toluene, found in glue, paint, thinner, etc. See also toluene toxicity.
F17.5 is reserved for tobacco-induced psychosis, but is traditionally not associated with the induction of psychosis.
The code F15.5 also includes caffeine-induced psychosis, despite not being specifically listed in the DSM-IV. However, there is evidence that caffeine, in extreme acute doses or when taken in excess for long periods of time, may induce psychosis.
Fluoroquinolone drugs, fluoroquinolone use has been linked to serious cases of toxic psychosis that have been reported to be irreversible and permanent, see adverse effects of fluoroquinolones. The related quinoline derivative mefloquine (Lariam) has also been associated with psychosis.
Carbon monoxide, carbon dioxide, and carbon disulfide.
Sarin and other nerve gases.
Acetone and other ketones.
Antifreeze – a mixture of ethylene glycol and other glycols.
Arsenic and its compounds.
Murrie, B., Lappin, J., Large, M. & Sara, G. (2019) Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis. Schizophrenia Bulletin. 46(3), pp.505-516. doi:10.1093/schbul/sbz102.
Stahl’s Illustrated Substance Use and Impulsive Disorders.
Author(s): Stephen M. Stahl and Meghan M. Grady.
Edition: First (1st), Illustrated Edition.
Publisher: Cambridge University Press.
Type(s): Paperback and Kindle.
All of the titles in the Stahl’s Illustrated series are designed to be fun. Concepts are illustrated by full-colour images that will be familiar to readers of Stahl’s Essential Psychopharmacology, 3rd edition, and The Prescriber’s Guide. The visual learner will find that these books make psychopharmacology concepts easy to master, while the non-visual learner will enjoy a shortened text version of complex psychopharmacology concepts. Each chapter builds on previous ones, synthesizing information from basic biology and diagnostics to building treatment plans and dealing with complications and comorbidities. Novices may want to begin by looking through all the graphics and gaining a feel for the visual vocabulary. Readers more familiar with these topics should find that going back and forth between images and text provides an interaction with which to vividly conceptualize complex pharmacologies. Each book ends with a Suggested Reading section to help guide more in-depth learning about particular concepts.
Physical Health and Schizophrenia (Oxford Psychiatry Library Series).
Author(s): David J. Castle, Peter F. Buckley, and Fiona P. Gaughran.
Edition: First (1st), Illustrated Edition.
Publisher: Oxford University Press.
Type(s): Paperback and Kindle.
In comparison to the general population, people with schizophrenia and related disorders have poorer physical health and increased mortality. Whilst it is recognized that serious mental illnesses such as schizophrenia carry a reduced life expectancy, it is often assumed that suicide is the main cause of this disparity. In actuality, suicide accounts for no more than a third of the early mortality associated with schizophrenia: the vast majority is due to cardiovascular factors
Physical Health and Schizophreniaoffers a user-friendly guide to the physical health problems associated with schizophrenia and a clear overview of strategies and interventions to tackle these issues. Spanning eight chapters this resource covers the essential topics in a practical and easy-to-read format to suit the needs of busy clinicians. It also includes an appendix designed specifically for patients and carers, with practical tips on how to be actively involved in monitoring and managing physical health problems.
Part of the Oxford Psychiatry Library series, Physical Health and Schizophrenia offers readers a fully up-to-date and valuable insight into this complex issue. With helpful key points at the start of each chapter and a clear layout, this is an essential resource for busy clinicians and researchers in any mental health field as well as those working in primary care.
Author(s): David J. Castle, Peter F. Buckley, and Rachel Upthegrove.
Edition: First (1st).
Publisher: Oxford University Press.
Type(s): Paperback and Kindle.
Psychiatric comorbidities such as depression, anxiety and substance use are extremely common amongst people with schizophrenia. They add to poor clinical outcomes and disability, yet are often not at the forefront of the minds of clinicians, who tend to concentrate on assessing and treating the core symptoms of schizophrenia, notably delusions and hallucinations. There is an imperative to assess every patient with schizophrenia for psychiatric comorbidities, as they might masquerade as core psychotic symptoms and also because they warrant treatment in their own right. This volume addresses these issues using a clinical lens informed by the current literature. Published as part of the Oxford Psychiatry Library series, the book serves as a concise and practical reference for busy clinicians.
Best Practices and Barriers to Engaging People with Substance Use Disorders in Treatment.
Author(s): Peggy O’Brien, Erika Crable, Catherine Fullerton, and Lauren Hughey.
Year: March 2019.
Edition: First (1st).
Publisher: US Department of Health and Human Services.
In 2015, 20.8 million people aged 12 years or older (7.8% of the United States population) had a substance use disorder (SUD) in the previous year. Approximately 75% of this group, or 15.7 million Americans, had an alcohol use disorder, 2.0 million had a prescription opioid use disorder (OUD), and about 0.6 million had a heroin use disorder.
Since 1999, opioid-related overdose deaths in the United States have quadrupled, with more than 15,000 individuals experiencing prescription drug-related overdose deaths in 2015. Even though evidence-based SUD treatments are effective, rates of treatment receipt are quite low. In 2015, only 18% of the population with SUDs, or 3.7 million people, received SUD treatment – a number that has not increased significantly since 2002.
Only about 48% of patients who enter SUD treatment actually complete it.
Author(s): National Institute on Drug Abuse (NIDA).
Edition: First (1st).
Publisher: US Government Printing Office.
Dual disorders recovery counselling (DDRC) is an integrated approach to treatment of patients with drug use disorders and comorbid psychiatric disorders.
The DDRC model, which integrates individual and group addiction counselling approaches with psychiatric interventions, attempts to balance the focus of treatment so that both the patient’s addiction and psychiatric issues are addressed.
The DDRC model is based on the assumption that there are several treatment phases that patients may go through.