Substance dependence
The word dependence describes a biopsychological state where an individual's functionality relies on the repeated consumption of a psychoactive substance. This reliance stems from an adaptive condition within the person that develops through drug use and results in withdrawal symptoms when the substance stops. A distinct concept called addiction exists alongside this definition, characterized by compulsive and out-of-control drug use despite negative consequences. An addictive drug is one that provides both reward and reinforcement to the user. The International Classification of Diseases categorizes substance dependence as a mental and behavioral disorder. In 2013, the Diagnostic and Statistical Manual of Mental Disorders eliminated the separate diagnoses of substance abuse and substance dependence. These were replaced with a single diagnosis known as substance use disorders. Medical professionals noted that tolerance and withdrawal are normal responses to prescribed medications affecting the central nervous system. They do not necessarily indicate the presence of an addiction.
When a person dependent on a substance ceases its use, the body reacts with an unpleasant state known as withdrawal. This reaction promotes continued drug use through negative reinforcement because the individual uses the drug to escape or avoid re-entering the associated withdrawal state. The withdrawal state may include physical-somatic symptoms representing physical dependence and emotional-motivational symptoms representing psychological dependence. Chemical and hormonal imbalances arise if the substance is not reintroduced into the system. Psychological stress also results from the absence of the substance. Infants experience substance withdrawal known as neonatal abstinence syndrome when their mothers used drugs during pregnancy. This condition can have severe and life-threatening effects on the newborn. Addiction to drugs such as alcohol in expectant mothers causes neonatal abstinence syndrome and other issues that affect the infant throughout their lifetime.
Two factors play pivotal roles in psychological dependence: the neuropeptide corticotropin-releasing factor and the gene transcription factor cAMP response element binding protein. The nucleus accumbens is one brain structure implicated in the psychological component of drug dependence. In this area, CREB activates immediately after a high triggers changes in gene expression affecting proteins like dynorphin. Dynorphin peptides reduce dopamine release into the nucleus accumbens by temporarily inhibiting the reward pathway. A sustained activation of CREB forces a larger dose to be taken to reach the same effect. It leaves the user feeling generally depressed and dissatisfied while unable to find pleasure in previously enjoyable activities. Koob and Kreek hypothesized that drug use activates the hypothalamic, pituitary, adrenal axis and other stress systems in the extended amygdala. As drug use escalates, so does the presence of CRF in human cerebrospinal fluid. Upregulation of the signal transduction pathway in the locus coeruleus has been implicated as the mechanism responsible for certain aspects of opioid-induced physical dependence.
Substance dependence defined in the DSM-IV can be diagnosed with physiological dependence evidence of tolerance or withdrawal without physiological dependence. Specific codes include 303.90 Alcohol dependence and 304.00 Opioid dependence. Other categories cover sedative hypnotic or anxiolytic dependence including benzodiazepine dependence and barbiturate dependence. Cocaine dependence carries code 304.20 while Cannabis dependence is listed under 304.30. Amphetamine dependence appears as 304.40 and Hallucinogen dependence as 304.50. Inhalant dependence uses code 304.60 and Polysubstance dependence is coded 304.80. Phencyclidine dependence falls under 304.90 along with Other substance dependence. Nicotine dependence holds code 305.10. The DSM-5 released in 2013 eliminated these separate diagnoses to create a unified diagnosis of substance use disorders. This change occurred because tolerance and withdrawal are normal responses to prescribed medications affecting the central nervous system. They do not necessarily indicate the presence of an addiction.
Addiction is a complex but treatable condition 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. Residential drug treatment can be broadly divided into two camps: 12-step programs and therapeutic communities. 12-step programs are nonclinical support-group and spiritual-based approaches including Alcoholics Anonymous Narcotics Anonymous and Pills Anonymous. Cognitive-behavioral therapy looks at the relationship between thoughts feelings and behaviors addressing the root cause of maladaptive behavior. Opiate replacement therapy has been a medical standard of treatment for opioid addiction for many years. Methadone or buprenorphine replaces an interfering opioid like illicitly-obtained heroin reducing cravings without producing a high. Benzodiazepines prevent delirium tremens during alcohol detoxification while clonidine helps with opioid detoxification. In 1997 the American Medical Association adopted policy regarding alternative therapies including acupuncture. New research revealed that 80% of smokers quit for six months following psilocybin treatment and 60% remained smoking free for five years.
The phenomenon of drug addiction has occurred to some degree throughout recorded history as seen in Opium usage. Modern agricultural practices improvements in access to drugs advancements in biochemistry and dramatic increases in the recommendation of drug usage by clinical practitioners exacerbated the problem significantly in the 20th century. 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. Many people did become addicted to morphine despite prevailing medical opinions. Addiction to opium became widespread among soldiers fighting in the Civil War who very often required painkillers and were thus frequently prescribed morphine. Women were also very frequently prescribed opiates which 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 meant this increased demand for heroin in the US could now be met while more drugs were synthesized and discovered opening up new avenues to substance dependency.
Internationally the U.S. and Eastern Europe contain countries with the highest substance abuse disorder occurrence at 5-6%. Africa Asia and the Middle East contain countries with the lowest worldwide occurrence between 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 reports on substance dependence rates across population demographics. American Indian/Alaskan Natives had the highest rates at 14.9% while Asians had the lowest rates at 4.6%. Males had a higher substance dependence rate than females but the difference was not apparent until after age 17. Dependence rates were greater in unemployed populations ages 18 and older and in metropolitan-residing populations ages 12 and older. Most countries have legislation bringing various drugs under control of licensing systems covering opiates amphetamines cannabinoids cocaine barbituates benzodiazepines anesthetics hallucinogenics derivatives and modern synthetic drugs. Unlicensed production supply or possession is a criminal offence. In jurisdictions where addictive drugs are illegal they are generally supplied by drug dealers often involved with organized crime. The federal government transitioned from using taxation of drugs in the early 20th century to criminalizing drug abuse with legislations and agencies like the Federal Bureau of Narcotics mid-20th century.
Common questions
What is substance dependence and how does it differ from addiction?
Substance dependence describes a biopsychological state where an individual's functionality relies on the repeated consumption of a psychoactive substance. This reliance stems from an adaptive condition that develops through drug use and results in withdrawal symptoms when the substance stops. A distinct concept called addiction exists alongside this definition, characterized by compulsive and out-of-control drug use despite negative consequences.
When did the Diagnostic and Statistical Manual of Mental Disorders eliminate separate diagnoses for substance abuse and substance dependence?
In 2013, the Diagnostic and Statistical Manual of Mental Disorders eliminated the separate diagnoses of substance abuse and substance dependence. These were replaced with a single diagnosis known as substance use disorders. Medical professionals noted that tolerance and withdrawal are normal responses to prescribed medications affecting the central nervous system and do not necessarily indicate the presence of an addiction.
How does neonatal abstinence syndrome affect infants born to mothers who used drugs during pregnancy?
Infants experience substance withdrawal known as neonatal abstinence syndrome when their mothers used drugs during pregnancy. This condition can have severe and life-threatening effects on the newborn. Addiction to drugs such as alcohol in expectant mothers causes neonatal abstinence syndrome and other issues that affect the infant throughout their lifetime.
What specific codes identify different types of substance dependence in the DSM-IV?
Specific codes include 303.90 Alcohol dependence and 304.00 Opioid dependence. Other categories cover sedative hypnotic or anxiolytic dependence including benzodiazepine dependence and barbiturate dependence. Cocaine dependence carries code 304.20 while Cannabis dependence is listed under 304.30.
Which countries had the highest occurrence of substance abuse disorder internationally according to global data?
Internationally the U.S. and Eastern Europe contain countries with the highest substance abuse disorder occurrence at 5-6%. Africa Asia and the Middle East contain countries with the lowest worldwide occurrence between 1-2%. Across the globe those that tended to have a higher prevalence of substance dependence were in their twenties unemployed and men.