Substances of Dependence and Abuse
Use of psychoactive substances to experience pleasurable effects is not a recent phenomenon, but has been indulged in by human kind for hundreds, even thousands of years. Terminology in the field of substance abuse has changed frequently leading to a great deal of confusion. Therefore, it is necessary to begin this section by defining currently used terms, and to clarify the differences between them. The nomenclature and diagnostic schemes mentioned here -in are based on the 4th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), and the 10th edition of International Classification of Diseases and Related Health Problems (ICD-10).
Substance dependence arises out of a maladaptive pattern of substance use, leading to a cluster of behavioural, cognitive, and physiological phenomena that develop after repeated intake. It includes a strong desire to take the drug, difficulties in control-ling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.
This term is reserved for behaviour during a 12-month period in which the person was repeatedly using at least 3 groups of substances (not including caffeine and nicotine), but no single substance predominated. Further, during this period, the dependence criteria were met for substances as a group, but not for any specific substance in isolation.
It must be mentioned here that sometimes certain non-dependence producing substances are abused by way of prolonged, unnecessary, or excessive intake, which cannot be covered by the term “substance dependence”. For instance, drugs such as analgesics, laxatives, antidepressants, antacids, vitamins, steroids, or hormones, and specific herbal or folk remedies.
· Substance abuse arises out of a maladaptive pattern of substance use, manifested by recurrent and significant adverse consequences related to the repeated intake of the substance. These problems must occur recurrently during the same 12-month period. The criteria for substance abuse do not include tolerance, withdrawal, or a pattern of compulsive use, and instead include only the harmful consequences of repeated use.
The DSM-IV criteria for substance abuse are listed in Table 34.1.
It is to be noted that the term “abuse” when used by itself, merely refers to the use of an illicit drug, or the use of a licit drug outside of legitimate medical practice.
According to DSM-IV, this term refers to unwanted physiolog-ical or psychological effects that cause maladaptive behaviour. ICD-10 specifies that intoxication must produce disturbances in the level of consciousness, cognition, perception, affect, or behaviour that are clinically significant.
Use of certain psychoactive substances can induce syndromes (formerly called “organic mental disorders”) which include the following: substance intoxication (vide supra), substance withdrawal, intoxication delirium, withdrawal delirium, dementia, amnestic disorders, psychotic disorders, mood disorders, anxiety disorders, sexual dysfunctions, and sleep disorders.
As per DSM-IV, “substance withdrawal” should be restricted to major symptoms resulting from the cessation of substance abuse, accompanied by a maladaptive behaviour change. There should be clinically significant distress or impairment in social, occupational, or other important areas of functioning. DSM-IV does not recognise withdrawal from caffeine, cannabis, or phencyclidine. ICD-10 recognises cannabinoid withdrawal state, as well as a withdrawal state from other stimulants, including caffeine.
The term “physical” or “physiological” dependence is defined as an alteration in neural systems which is manifested by tolerance and the appearance of withdrawal phenomena when a chronically administered drug is discontinued or displaced from its receptor.
The 1980 ADAMHA-WHO* working group recommended substituting the term “neuroadaptation” for physical depend-ence.
The term “addiction” denotes a chronic disorder characterised by compulsive use of drugs (craving ) resulting in physical, psychological, and social harm, and continued use despite evidence of that harm (denial).
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