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MD III 2001

Substance dependence – Conceptual issues

A drug or substance: In the context of this lecture and in its broadest sense is a chemical other then
those required for maintenance of normal health. A distinction is made of non-medical drug use when
a medical drug is used in the absence of medical advice as substantiated by an authorized prescription.
The boundaries between medical and non-medical use are often not sharp, and medicinal products that
have good and needed medical effects on the CNS often have other effects. Opiates for example not
only induce euphoria and analgesia, but also reduce gut motility.

Drugs or substances may be further distinguished on the basis of their effects on bodily systems, and
our focus will be on psychoactive substances.

A psychoactive substance (PAS): is any substance that if taken by a person modifies perception (what
we perceive with our five senses – sight, hearing, taste, touch and smell), mood, cognition (the
thinking process), mood, behaviour or motor functions.

This is a broad definition that includes:

• Licit substances (e.g. nicotine, alcohol etc)
• Illicit substances (e.g. heroin, mandrax)
• Substances that lead to dependence
• Substances that do not cause dependence

Further more, some PAS's may be taken in the form of pharmaceutical preparations as occurs with
diacetylmorphine, or as raw opium and illicit heroin powder. Some PAS are less likely to be self-
administered than other PAS's such as neuroleptics and antidepressants and rarely become drugs of
dependence. The term misuse is often used when referring to drugs/substances
 Substance intoxication: Reversible substance-specific syndrome due to recent ingestion

What is misuse and abuse?

WHO, 1981: Includes several aspects when considering misuse:
Unsanctioned use: Use of a substance that is not approved by a society, or group within a
society. When the term is used, one must specify who is responsible for the disapproval.
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Hazardous use: Use of a substance that will probably lead to harmful consequences for the
user – either to dysfunction or to harm; similar to the idea of risky behaviour.
Dysfunctional use: Use of a substance that is leading to impaired psychological or social
functioning (loss of job or marital problems)
Harmful use: Use of a substance that is known to have caused tissue damage or mental illness
in the particular person.
The Royal College of Psychiatrists (1987) also adds to the definition of misuse by drawing more
broadly on outcome criteria:
Substance misuse: is any taking of a drug which threatens to harm the physical or mental
health or social well-being of an individual, or other individuals, or of society at large, or
which is illegal.
The Diagnostic and Statistical Manual (Version 4; 1994) defines the substance abuse as being:
Substance abuse: A maladaptive pattern of substance use, leading to clinically significant
impairment or distress, manifest by one or more of the following, occurring within a 12 month
period:
1) Recurrent substance use leading to failure to full-fill major role obligations at work, school,
or home
2) Recurrent substance use in situations in which it is physically hazardous
3) Recurrent substance-related legal problems e.g. drunk and disorderly
4) Continued substance use despite having persistent or recurrent social and interpersonal
problems caused or exacerbated by the effects of substances.

What is dependence?
A rounded definition of dependence should draw on physical sociological and psychological factors.
This is because several aspects related to these factors influence the development of dependence. For
example, a heroin addict may have used 0.5 grams for several years and any interruption of the habit
causes physical and mental distress. On the other hand, another subject with similar duration of use
may require 5 grams daily to avoid distress. The expression and severity of dependence is influenced
by:
• Internal factors: e.g. ability to tolerate discomfort, personality of user
• External factors: e.g. Societal expectations, norms, values etc
• And the interactive or dynamic contributions of the individuals relationships with peers and
society as a whole
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WHO definition, 1964:

A state, psychic and sometimes also physical resulting from interaction between living organisms and
a drug/substance characterised by behavioural and other responses that always include a compulsion
to take the drug on a continuous or periodic basis in order to experience its psychic effects, and
sometimes to avoid the discomfort of its absence. Tolerance may or may not be present and a person
may be dependent on more than one drug.

Relationship between the psychological and physical aspects of dependence - COMPLEX:

• Drugs cause physical effects that have psychological manifestations
• Psychological factors (e.g. anxiety, expectations) precede the physical effects
• Withdrawal from some drugs can cause psychological effects e.g. depression on withdrawal
from cocaine
Psychological and physical dependence is thus not polar opposites but different aspects of the same
phenomenon, the former expressed in terms of thoughts, feelings and drives and the latter in terms of
cellular functioning.

Contribution of physical factors to the phenomenon of dependence:

Tolerance: Use of drugs, while generating central effects for the user upsets the chemical equilibrium
within the brain. The nervous system responds in such a way as to reduce the effects of
repeated administration of the drug. This leads to tolerance; where the user finds the brain
habituates to the onslaught and higher doses of the drug are required to produce a given effect
be it euphoria, drowsiness or alertness depending on the drug used. Several mechanisms have
been postulated to bring about the tolerance:
Neuro adaptation: The ability of brain cells to adapt to the presence of a drug that is considered
the most important aspect in the build up of tolerance. This is thought to lead to a
characteristic withdrawal syndrome when the drug is withdrawn. Drugs that result in build up
of tolerance and a characteristic withdrawal syndrome on relative or total abstinence are said to
cause physical dependence.
Withdrawal states: If Neuro adaptation follows the use of a drug, then withdrawal leads to
decompensation or rebound symptoms. Withdrawal symptoms have characteristics that tend to
counterbalance the effects of the drug itself. For example: withdrawal from a stimulant drug
such as cocaine or amphetamine leads to lethargy, low mood and sleepiness. Depressant drugs
such as alcohol and benzodiazepines are associated with excitatory withdrawal symptoms such
as agitation, tremor, fits, hallucinations etc. Withdrawal states of some drugs may not be
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associated with marked physiological symptoms but might cause dysphoric states, such as
occurs with cannabis and nicotine.
Though these physical aspects of dependence are powerful motivators for drug taking, they do not
explain the whole phenomenon as though tolerance and withdrawal are in many ways related they do
not always go together. Cannabis induces tolerance, but has no characteristic withdrawal syndrome.
Dependence can occur without withdrawal and withdrawal without dependence. The physical aspects
of dependence can only be appreciated when set in the context of psychological and social factors.

Psychological factors:
The acquisition and maintenance of dependence is influenced by a range of psychological factors
Learning theory: Food, sex and drugs have "reinforcement" potential. Those consequences
that increase the frequency of behaviour are called reinforcers. In animal experiments
dependence can be caused as an operantly conditioned behaviour. Learning plays an important
role in initiating and maintaining drug use behaviours that generate dependence. While
anticipated effects that are learnt initially of first use might maintain future use, learnt factors
related to environmental stimuli maintain drug use by becoming cues or triggers for craving
and withdrawal states.
For example:
• The alleviation of anxiety in social settings of a shy young man after taking
alcohol may reinforce the use of alcohol in such settings.
• Craving in an alcoholic might be reinforced by a chance meeting with drinking
partners; an injecting drug user, abstinent for a few months, might find that seeing
a syringe and needle provokes physical symptoms of withdrawal and acts as an
environmental reminder of his own drug use.
Personality characteristics: Individual personality characteristics contribute to the onset and
maintenance of dependence. People differ in their desire to experiment, need for stimulation
and responses to stress/adversity. Some people do appear to use drugs for these reasons. How
a person perceives himself in relation to his drug use may also maintain drugs use; a heroin
user who perceives himself as an "addict" and believes this to be a life-long state will tend to
perpetuate the dependence. However, it is important to emphasize that a specific dependent
personality does not exist. The stereotype of the "junky" is a result of the higher visibility of a
sub-group of abusers rather than a personality type. It is true in Tanzania as well as elsewhere
that executives exist, who are drug dependent and not at all in keeping with this stereotype in
their daily appearance and behaviour.
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Sociological factors:
Both the acceptance of drug use by an individual and the immediate availability of drugs are
predominantly determined by peer groups, and other social factors such a normative values and
attitudes in society and its subgroups in relation to drug use (e.g. alcohol and smoking). Additionally
specific roles within the sub-culture of abusers may be rewarding to some people by contributing to a
sense of personal identity or identification with the cultural subgroup; e.g. member "kijiweni". The
task of coaxing a drug user away from dependence is unlikely to succeed if the social contexts are
ignored.

The dependence syndrome

While the compulsive drive or craving for drugs is known as dependence, the drug taking behaviours,
which follow are described as the dependence syndrome.

The Diagnostic and Statistical Manual (Version 4: 1994) defines the dependence syndrome as being:
A maladaptive pattern of substance use, leading to clinically significant impairment or distress,
manifest by three of more of the following, occurring at any time in the same 12 month period:
1) Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the substance to achieve intoxication or
desired effect.
b. Markedly diminished effect with continued use of the same amount of the
substance.
2) Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for the substance
b. The same or closely related substance is taken to relieve withdrawal symptoms
3) Substance often taken in larger amounts or longer periods than intended.
4) Persistent desire or unsuccessful attempts to cut down or control use.
5) Great deal of time spent in activities necessary to obtain the substance, or recover from its
effects.
6) Important social, occupational or recreational activities are given up or reduced because of
substance abuse.
7) Use continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by the substance.
One needs to specify if dependence is physiological or not (item 1 or 2 is present)
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Course of dependence specifiers includes: Four remission specifiers and two treatment related
specifiers.
Early full remission:
Early partial remission:
Sustained full remission:
Sustained partial remission:
On agonist therapy:
In a controlled environment.
No dependence criteria met for 1-12 months
One or more dependence or abuse criteria met in 1-12 months; but full
criteria for dependence not met.
No dependence criteria met for a period of 12 months or longer
Full criteria for dependence not met in duration of 12 months or more
however one or more criteria for dependence or abuse have been met.
Prescribed agonist medication and no criteria for dependence or abuse
(except tolerance to or withdrawal from the agonist) has been met for at
least a month; restricted to those on treatment for dependence using a
partial agonist or an agonist/antagonist.
In environment where access to controlled substances and alcohol is
restricted and no criteria for dependence or abuse has been met for at
least a month

Epidemiology
Alcohol
 USA: substantial proportion of the adult population drink alcohol, males more so than females.
 Epidemiological Catchment Area Study (1992), Western study sites – 23.8% males Vs 4.6%
females with life time prevalence (LTP) of alcohol abuse M:F = 5.5: 1,
 LTP abuse in the US > in Hispanic-Americans (16.6%) than Caucasians (13.6%) and Black
Americans (13.8%)
 LTP and one year prevalence rates > in low SES
 Remission rates > in high than low SES brackets
 Cor-mobidity with other psychiatry disorder is high with 47% having a 2nd life time psychiatric
diagnosis (other studies as high as 78%, with 65% having current other psychiatric disorder)
 Limits of use: Fatty liver change is the first indication of medical harm and occurs at weekly
consumption of 12 units in females and 16 units in males.
Drugs
 There are changes in prevalence and types of drugs used by geographical location as well as over
time. Trend monitoring is hence important for planning health-related interventions. Data sources
include enforcement statistics (drug seizure and drug related offences statistics), educational,
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health, and occupational group specific data as well as defined geographical area and national
surveys.
 Use of illicit drugs is a function of age hence, life-time use higher in older age groups, marriage
and other experiences facilitate reduction of use
 Data from National Institute of Drug Abuse Monitoring in the US of use of any illicit substance -
41% late adolescence Vs 80% 31-32 year olds in the US.
 Annual prevalence rates in the US are however higher in high school adolescents (27%), peek in
late adolescents when compared to 31-32 year olds (22%)
 Variations exist in prevalence rates by type of drug use and age of use
 Unlike other drugs lifetime, annual and current use of cocaine is higher amongst older
than younger age groups. Used more by people in their late 20s than adolescents (LTP use of
crack cocaine 1992 8% Vs 2.6% respectively)
 Annual prevalence of LSD > younger age groups; 6% 18 year olds Vs 1% 31-32 year olds.
 Hypnosedative use: Prescription drugs lower in younger than older age groups.
 Men more likely to abuse illicit drugs than females; females more likely to abuse prescription
drugs than men.
 High-risk professions: Rates in medical profession (doctors, nurses and others) higher than normal
population (Western data) – factors include high knowledge, access and occupational stress.
 Variety of SES groups UK studies higher prevalence in III, IV and V, though no clear evidence to
support poverty as important determinant. Opiate use in the UK has been associated with social
deprivation while in Scotland relationship exists between drug use/abuse and unemployment
(policy implications in setting such as Tanzania).

Table depicting dependence and complications of selected common drugs of abuse in Tanzania
Substance Intoxication Withdrawal Abuse Dependence Complications
syndrome Phys. Psychological
Alcohol Yes Yes Yes Yes Yes Alcoholic Hallucinosis,
anterograde amnesia,
Delirium Tremens (withdrawal psychosis)
Amphetamine Yes Yes Yes Yes Yes Stimulant psychosis
Caffeine Yes Yes Yes Yes
Cannabis Yes Yes Yes Bad trip – adverse reactions in first time users
– anxiety and panic may present with
aggression as well.
Precipitant of functional psychoses
(worsening of course of illness)
Toxic psychosis when used in high amounts.
A motivational syndrome with long term use.
Flash-back experiences documented.
Cocaine Yes Yes Yes Yes Yes Cocaine psychosis
Hallucinogens Yes Yes Yes Bad trips, psychosis
Flash-back experiences
Inhalants Yes Yes Yes Yes
Nicotine Yes Yes Yes
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Opioid Yes Yes Yes Yes Yes Shut down of central opioid systems during
remission – inability to experience pleasure
may last awhile and hinder maintenance of
abstinence.
Phencyclidine Yes Yes Yes PCP psychosis
Sed/Hyp – Yes Yes Yes Yes Yes Rebound insomnia and irritability.
anxiolytics
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Causes of substance abuse/dependence:

 For each individual assessed there is often no single cause, several factors may operate in
combination to bring about abuse behaviour.
 Biomedical, psychological and social factors interact and play a role in development of substance
abuse.

Biomedical:
Genetic; Twin, genetic marker and adoption studies provide evidence for hereditary factors in
alcohol, opioid and cocaine abuse
 Alcoholism: Adopted children with biological parents with alcoholism are more
likely to develop disorder that those with biological parents who are not alcoholics.
Type 1 alcoholism (milieu limited alcoholism) both genetic and environmental factors
play a role (>Females than males; present > 25 years, not associated with criminality,
associations with passive dependent personality traits). Type 2 alcoholism (male-
limited alcoholism: more genetic predisposition, more criminality and earlier age at
onset; associations with socio-pathic personality traits). Low-level response to alcohol
prior to development of dependence is indicative of lack of warning signals that inform
more normal drinkers that they have had enough.
Physiological:
 Alcoholism has been correlated with hypofunction of the adrenal cortex and
thyroid gland. Unclear if causal or a complication of alcohol abuse
 Genetic lack of aldehyde dehydrogenase (primary metabolic enzyme in the
liver) leads to a high-level response to alcohol characterized by symptoms related to
raised acetaldehyde (anti-abuse response); 30-50% of Asians flushing, tachycardia,
headaches, itching.
Biochemical: The observed links between alcoholism and depressive disorder are the basis of
research into biochemical aetiological factors.
 Alcoholism has been called a depressive equivalent. As in depressives, MAO
levels in platelets lower in alcoholics; Because MAO levels in platelets are strongly
influenced by genetic factors it is speculated this may be an important biochemical link
between hereditary influences and the affective state of alcoholics
 Other brain proteins that have been implicated include the neurotransmitter
GABA, glycine and glutamate but research is in early stages.
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 Dopamine has been implicated in activity of the psycho-stimulants

amphetamine and cocaine: The cocaine receptor appears to be located at a site on the
dopamine transporter for dopamine nerve terminals. It is postulated that dopaminergic
mechanisms may be a final common pathway for many substances that produce
dependence behaviours.
Prenatal factors: Infants of abusing mothers – decreased size and weight. Foetal Alcohol
Syndrome (neuro-physiological dysfunction with anatomic malformations) and withdrawal
states amongst infants of abusing mothers for opiates, benzodiazepine's, cocaine, nicotine.

Psychological; supporting evidences from psychoanalytic case studies, personality assessment

using psychological testing and theories of learning.
 Emotional conflicts: Early developmental deprivations and traumas result in painful
repressed conflicts; activated by stress/similar events, generate anxiety/depression when
they enter consciousness. Alcohol and drugs as releasing inhibitions and allowing
expression of repressed conflicts, or/and a return to normal / relief from emotional pain –
the self-medication hypothesis: the drugs of abuse of choice titrate experienced negative
emotions: i.e.: sedatives for rage; stimulants for depression/low SE.
 Personality traits: Alcoholics – many score highly on depressive and psychopathic
deviance scales; many having oral-dependent and depressive character traits. Antisocial
character traits have also been found to predominate amongst opiates and cocaine abusers:
Problems in interpretation of such findings: chick and egg phenomenon – what came first,
the abuse or the trait?
 Learned behaviour – Links between effects of drugs and decrease in anxiety levels:
Significance of learnt behaviour of “reminders” (cues) in the environment that trigger
craving and facilitate relapse “cue reactivity”

Social factors: sex, age, and ethnicity have been covered in epidemiology section. Family structure
plays an important role in abuse behaviour. Under general systems theory the abusers family can
be considered a maladaptive systems whose stability depends on one member fulfilling a sick role.
Such a dysfunctional family is often in a homeostatic state because a member is an abuser.
Awareness of this perspective helps in some cases to understand resistance in such families when
treatment is instituted as change in the abusive behaviour may disturb other family members and
create or increase anxiety. This view has important implications for treatment because the entire
family should be considered in the management plan.
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Role of stress: – important as precipitant of both heavy drinking and abuse/dependence.

Bereavement, redundancy, job loss etc. Stress plays an additional role in increasing substance
abuse and development of dependence. Complications of substance abuse create additional stress
that feeds into a viscous cycle.

Management of substance abuse/dependence

Similar general rules apply for all substances of abuse and are outlined as follows with the exception
of maintenance therapies.

☺ Targeting the stage of dependence

☺ Identifying important complications.

☺ Exploring and modifying predisposing causes.

☺ Maintenance therapies (nicotine and opiates)

The diagnostic work-up depends on adequate knowledge of the general and drug specific biomedical,
psychological and social complications of drug abuse (see photocopy for alcohol) as well as signs and
symptoms of intoxication states, withdrawal states and chronic use states of the various drugs.
Adequate history taking is a cornerstone for good management protocol development.
Taking a drug use history:
 Patient's responses differ according to the situational context of the interview i.e. a self-referral Vs
bought by parent/other relative, emergency Vs scheduled new cases clinic.
 Type of substance or substances used. Licit substances and prescription drugs are more readily
acknowledged then illicit substances. List to go through:

☺ Alcohol, cigarettes and other nicotine containing substances

☺ Sedative-hypnotics especially benzodiazepines and barbiturates

☺ Opiates and opioids

☺ Stimulants such as amphetamines and cocaine

☺ Hallucinogens LSD, phencyclidine and cannabis.

☺ Inquire about poly-substance abuse: Stimulant use (uppers) may generate a need for
sedatives or alcohol (downers) and vice versa.
 Level of psychoactive substance consumption: Non-judgmental inquiry about consumption of drugs
that have been acknowledged: Start using general terms becoming gradually more specific. "How
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much alcohol do you drink daily?" "How much do you spend in a day on heroin?" Rather than a
more direct "Is alcohol/heroin a problem for you?"
For alcohol 1Unit = 12-15 ml of ethanol = one 12 oz can of beer (4% ethanol) = one 1 oz shot of
spirits – licit or illicit (43% ethanol) = one 4 oz glass of wine (12% ethanol); approx. 1L of a
traditional brew e.g Komone, Mbege etc.
High level of consumption is only one indicator that a substance use problem exists and should be
used in conjunction with other symptoms and signs in making a diagnosis. Quantifying drugs used
on a daily basis may be difficult for illicit substances, as often the abuser buying illicit drugs from
a drug peddler may not know how much he/she has bought. The amount of money used to
purchase the drug per day relative to daily income gives a good indication of dysfunction. If a
porter at the harbour wharf at Dar es Salaam Port earns 10-15,000 per day and on average used 7-
10,000 per day on heroin, this is very obviously dysfunctional use of the illicit substance.
 Patterns of drugs use: A five tier approach is often used for patterns of illicit and non prescription
use of psychoactive substances, arranged in order of increasing abuse behaviour:

☺ Experimental use: short term non-patterned trials of use of the drug often found in
adolescence

☺ Social-recreation use: use in social settings amongst friends

☺ Circumstantial-situational or self-limited use of variable pattern, frequency, duration

and intensity.

☺ Intensified or long-term patterned use at least once a day

☺ Compulsive or frequent and intense use for a relatively long duration.

Descriptions of patterns of use are important in understanding any changes in patterns of use over
time.
 Drug use related dysfunction: Patients often under-report, or may deny links between dysfunction
and drug use, while patients seeking more powerful drugs or hospitalisation may overstate their
problem. Hence it is important that the physician is aware of which substance produces what
psychological and physical symptoms to help focus the questions on the psychoactive substance
use reported. Denial may be:
 A characteristic of the abusers defence mechanisms in other contexts.
 a reaction to stress from past traumatic events
 a complication of alcoholism or use of other drugs
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The intensity of denial may vary, and confronting it too vigorously may result in counterproductive
anxiety and anger in the abuser – flight from treatment. Confrontation should be modified by the
health workers assessment of the patient's ability to face the problem.
 Exploration for any medical or psychiatric complications of psychoactive substance use: It is
important to assess the current status. Is the patient:
 Under the influence (intoxicated)? e.g. Smelling of alcohol
 In withdrawal? E.g. trembling, hallucinated or having residual effects of the drug? E.g.
blackouts – unable to recall events that occurred during a bout of drinking though appeared
conscious and active.
 Motivational assessment
 Premise: Most people are ambivalent about need to change their drug taking behaviour
when they consult: Stages of change model underlies this premise
• Pre-contemplation
• Contemplation
• Preparation for new health promoting behaviours
• Action
• Maintenance of new health promoting behaviours
 Aims: To help individuals in a non-confrontational manner to be aware of the reasons for
concern and arguments for change
 Methods 1: Exploring good and less good things about the behaviour.
• Exploration of good and less good things about the behaviour
• Exploration to elicit areas where the client is concerned as focal points that can
motivate individual to change
• Summarize in clients own words focusing on the areas of concern mentioned.
 Methods 2: Exploring life satisfaction
• Probe for how things are, were and could be with the aim to elicit discrepancies
from the clients perspective
• Summarize past and future aspirations in relation to the present with emphasis on
the effect of the behaviour
 Methods 3: Assisting decision-making
• Summarize concerns raised
• Facilitate client to explore what next? in order encourage planning future actions
• Explore range of options with client – what options he/she feels comfortable with
and support through process of action
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 Important Techniques:
o Guiding client through stages of change
o Understanding and working with client’s ambivalence – to be a new me or
to remain the old me?
o Empathic listening – do not fall asleep!!
o Eliciting self-motivational statements from client Vs providing them
o Counseling skills – being able to probe with open ended questions, listen
reflectively, affirm what has been said, summarize what has been said
o Dealing with resistance (arguing, interrupting, denying, ignoring)
 Simple reflection – responding with non-resistance by affirming
 Amplified reflection – exaggerated statement response to elicit the
other side of a persons ambivalence
 Double sided reflection –summarizing one side of the clients
ambivalence but also reflecting the other side.