This article has been taken from a MSc module initially written by Dr Brian Jenkins, Senior Lecturer in Anaesthetics and Intensive Care and Honorary Consultant Anaesthetist, Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff University and has subsequently been updated and expanded by Dr Sarah Fox. Sarah is currently working in Psychiatry of Older Adults, and she continue her longstanding interest in pain management (Sarah previously worked in a pain clinic and then Bath Centre for Pain Services).
Sarah is involved in a project with Bristol PCT, called PAIN (Pain Assessment in Nursing homes) looking at more effective management of pain in people with dementia. She also has an interest in pain and depression/anxiety disorders in patients of all ages. Through her own personal experience and her ongoing work with support groups for patients with chronic pain around the world, she has interests in iatrogenic conditions and medically unexplained symptoms.
This article discusses the historical aspects of drug abuse, provides some interesting statistics to illustrate the problem, describes the legal issues and defines key terms including substance or drug abuse and misuse, dependency, experimental drug users, recreational drug users and defines addiction.
This article introduces the subject of substance misuse which may present in the community or in secondary care. Therefore, an awareness of the various types of substances that can be misused is important as well as strategies to help and support patients and staff when managing patients who are substance abusers.
Drugs that alter perception and mood have been used for millennia. Indeed, psychedelic drugs were used in ancient civilisations: in India in the Vedic Soma, in shaman ceremonies and in Ancient Greece as part of the Eleusian Mystery Rites. Contemporary uses are cross-cultural and include magic mushrooms (psilocybin) and cannabis.
Alcoholic drinks have been ingested since 6000 B.C. References to the effects of poppy extracts are made in Assyrian idiograms dating back to 4000 B.C. and medical uses are described in Sumerian records from the 7th Century. The use of cannabis is thought to have originated in ancient China, around 2700 B.C. It was certainly used for medicinal effects (predominantly analgesic and sedative), but there has been speculation that it may have also been used ritualistically for its psychoactive properties at this time.
Individuals who take illicit drugs face potential health risks, as the drugs are not controlled or supervised by medical professionals. Illicit drug users are also at risk of being poisoned by drugs, and overdosing which can lead to a fatality.
In 2008/09 there were 5,668 admissions to hospital in England with a primary diagnosis of a drug-related mental health and behavioural disorder.
In 2008, there were 1,738 deaths reported as being due to drug misuse. Of those who died, 78% were male. Compared to 1993 the number of male deaths has increased by around 136% in 2008 compared to a 48% increase for females. The highest numbers of deaths due to drug misuse occurred in the 30 to 39 age group for both males and females.
Comparison of the perceived harm for various psychoactive drugs from a poll among medical psychiatrists specialising in addiction treatment 
Attitudes towards recreational drugs
Attitudes towards recreational drugs have varied significantly between cultures and changed over centuries. Tea, coffee, nicotine and alcohol are socially acceptable in our current society, but use of cannabis and opium has been outlawed or heavily regulated.
These days, the issue of drug abuse is emotive, well-publicised and politically charged. Opinion remains polarised between experts in the field and also amongst the public at large.
The widespread perception of substance abuse in the UK is loaded with legal and moralistic overtones, failing to take into account that the problem is not confined to those of lower socio-economic status.
Many people who misuse drugs do not present to drug treatment services, only around 50% seeking treatment, which is however a significant improvement from the early 1990s, when perhaps only 20% of people who misused drugs sought treatment. This may in part be due to the stigma of drug abuse.
“There is no easy solution to the problem of stigma associated with drug addiction and its treatment…”
—Institute of Medicine
Substance (drug) abuse (misuse)
What is a drug? A common perception is of a tablet or liquid sold by a pharmacist for a therapeutic purpose. However, many abused drugs do not fit this conception; some have never been used for a therapeutic effect. Others, such as solvents do not seem to fit any common definition of a drug. Usually the less specific word ‘substance’ is often used in preference to the value-laden term ‘drug’.
World Health Organisation defines substance abuse as ‘a pattern of psychoactive drug use that causes damage to health, either mental or physical’.
The Psychiatric Diagnostic Manual DSM-IV uses the following definition:
“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….”
Patterns of abuse are usually considered as experimental, recreational and dependent. These are convenient categories for descriptive use and have the advantage of simplicity, but imply a progression, both in terms of time and also harmful effects that probably does not fit in with the experiences of most drug abusers.
Experimental users use drugs occasionally, sometimes motivated by peer pressure  and the desire to become part of a culture where drug self-administration is an integral part. Use may be motivated by curiosity or self-education, and because of these factors experimental use is often observed in adolescents and young adults. Experimental use is often short-lived, and for many people it may be a habit that is abandoned when social circumstances change. It often results in harm with accidental overdose, cross-infection and adverse reactions all major risks.
Recreational drug use is the use of a drug (often psychoactive) with the intention of creating or enhancing experience. It may include illicit and medicinal drugs, alcohol, tobacco and even caffeine. Siegel  refers to intoxication as the ‘fourth drive’, alongside hunger, thirst and need for shelter.
Recreational use tends to be on a regular basis, whether as an aid to relaxation following a hard day’s work, reward for a certain level of achievement at work, associated with social gatherings or with particular forms of activity. It tends to involve use of one or two drugs and self-control is retained. Therefore there are usually fewer adverse consequences.
Substance dependence can be diagnosed with or without physiological dependence i.e. evidence of tolerance or withdrawal.
Some authors use the terms dependence and addiction to mean the same, but not all physiological dependence results in addictive behaviours (this is particularly important when considering chronic opioid prescription for non-malignant pain).
Users in this group misuse on a regular basis and may escalate into taking multiple drugs. In addition to drug taking and the attendant risks, individuals may take part in risky activities to obtain their drugs, putting themselves at risk of injury etc. This addictive behaviour is highly deleterious to all aspects of life.
Definition of addiction
The American Society of Addiction Medicine notes that addiction causes the individual to pursue “reward and/or relief by substance use and other behaviors. Addiction is characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviors and interpersonal relationships. ”Thus primarily, addiction is a dysfunctional behavioural problem.
Addiction involves cycles of relapse and remission. Without treatment or engagement in recovery activities, it is progressive and may result in disability or premature death.
Legal measures to regulate drug use are by no means new. The 1868 Pharmacy Act and the 1908 Poisons and Pharmacy Act reserved the sale of narcotics to the self-regulating monopoly of professionally qualified men. After 1908, prescription of opium, morphine and cocaine required a signature in the pharmacy’s poisons book. Due to concern about cocaine use by troops on leave during the First World War, control measures were instituted in 1916 under the Defence of the Realm Act. Later the Dangerous Drugs Act was passed in 1920. In 1931, the League of Nations held a convention in Geneva for limiting the manufacture and regulating the distribution of narcotic drugs. More recently the Misuse of Drugs Act was passed in 1971 to legislate for a number of illegal substances.
International laws are interpreted and influenced by national governments, giving rise to quite different emphasis in drug control policies between different countries, such as the more liberal attitudes towards recreational drugs in other European countries compared with the UK.
The Home Office in the UK has recently taken a hard line on all drugs, sometimes at odds with their scientific advisers.
The present UK government plans to publish a new drug strategy in late 2010. There will be a targeted consultation on the upcoming strategy to provide an opportunity for drugs sector organisations and other key partners to influence the development of the new drug strategy. The key themes and objectives include:
- preventing drug use
- strengthening enforcement, criminal justice and the legal framework
- rebalancing treatment to support drug-free outcomes
- supporting recovery to break the cycle of drug addiction
This article has introduced you to some of the issues with substance abuse. If you would like to complete a CPD course, please consult the other components.
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- Allen, K., 1998. Essential concepts of addiction for general nursing practice. Nurs Clin North Am, Nurs Clin North Am 33, 1-13.
- Siegel, R.K., 2005. Intoxication: The universal drive for mind-altering substances.. Park Street Press, Vermont.
- Behrendt, S., Wittchen, H.U., Hofler, M., Lieb, R., Beesdo, K., 2009. Transitions from first substance use to substance use disorders in
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- Hanson, G.R., Venturelli, P.J., Fleckenstein, A.E., 2005. Drugs and Society, 9thth ed. Jones & Bartlett Learning, Sudbury, MA.
- McBride, O., Teesson, M., Slade, T., Hasin, D., Degenhardt, L., Baillie, A., 2009. Further evidence of differences in substance use and dependence between Australia and the United States. Drug Alcohol Depend, Drug Alcohol Depend 100, 258-64.