Substance abuse

• ALSO KNOWN AS: Drug abuse
• DEFINITION: Substance abuse is the ingestion, inhalation, or injection of a product that is harmful to one’s health, usually for psychoactive (mood-altering) purposes. Legal substances that are commonly abused include alcohol, tobacco, prescription drugs, and over-the-counter medications. Illegal substances of abuse include marijuana (legal in some places), cocaine, hallucinogens, methamphetamine, and heroin. Other substances of abuse include inhalants, solvents, and anabolic steroids.

Overview

According to the 2022 National Survey on Drug Use and Health (NSDUH), conducted by the US Department of Health and Human Services' Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 168.7 million Americans aged twelve years and older (59.8 percent of the population) had used tobacco products, alcohol, or illicit drugs within thirty days of the survey. This total includes psychoactive prescription drugs used for nonmedical reasons.

Marijuana was the most commonly used illicit drug in 2022 by a significant margin, with 61.9 million users ages twelve and older (22 percent of the population) in the year before the survey; in comparison, the second-most commonly used illicit drug was opioids (including prescription pain relievers and heroin), with 8.9 million users (3.2 percent) in the past year. Many abused substances have addictive properties; the user becomes dependent on the regular use of the substance and experiences withdrawal symptoms when use is discontinued. Symptoms of withdrawal range from depression and anxiety to seizures, depending on the substance of abuse and the length of use.

Society has determined that the use of illegal substances is harmful; thus, laws are applied to protect both the individual and society from the harmful consequences of their use.

Abuse of Legal Substances

Tobacco

Tobacco can be smoked or chewed. Nicotine, contained in tobacco, is highly addictive; it is a psychoactive substance that produces temporary physical and mood-altering effects in the brain. Nicotine is also a vasoconstrictor (blood vessel constrictor); thus, it increases the risk of cardiovascular disease.

Tobacco is also a well-known carcinogen, and tobacco’s use is the leading cause of preventable illness and death in the United States. There are a number of known tobacco-related cancers. In addition to lung, throat, and mouth cancer, tobacco has been associated with cancers of the nasal cavity, esophagus, stomach, pancreas, breast, kidney, bladder, and cervix. The smoking of tobacco results in lost time at work either because of smoking breaks or because of respiratory illnesses, which are more common in smokers.

According to the National Cancer Institute and the Centers for Disease Control and Prevention (CDC):

• Cigarette smoking causes an estimated 480,000 deaths each year, including approximately 41,000 deaths from exposure to secondhand smoke (CDC 2023).

• Lung cancer is the leading cause of cancer death among both men and women in the United States. About 80–90 percent of all lung cancer deaths in the United States are caused by tobacco smoking (National Cancer Institute 2024).

• Individuals who smoke are about twenty times more likely than nonsmokers to get lung cancer, and the risk increases with the number of cigarettes smoked. Smoking also causes heart attacks and most cases of chronic lung disease, including chronic obstructive pulmonary disease (COPD).

• In 2021, approximately 11.5 percent of adults in the United States (13.1 percent of men and 10.1 percent of women) were cigarette smokers. (CDC 2023).

• In 2023, nearly 2 percent of high school students reported having smoked cigarettes in the past thirty days. However, 10 percent reported the use of electronic cigarettes. (CDC 2023).

Alcohol

Alcohol consumption involves the ingestion of ethanol (C₂H₅OH), which is a component of alcoholic beverages (beer, wine, and hard liquor). Alcoholism is a chronic condition in which a person is dependent upon regular ingestion of alcoholic beverages. Alcoholics are unable to control their drinking and continue to drink even though doing so interferes with their health, interpersonal relationships, or work.

Alcohol abuse refers to excessive drinking—enough to cause problems in daily life—without complete dependence upon the substance. The combination of alcohol abuse and tobacco use markedly increases the risk of cancers of the oral cavity. Approximately 50 percent of cancers of the mouth, pharynx (throat), and larynx (voice box) are associated with heavy drinking. Even in nonsmokers, a strong association exists between alcohol abuse and cancers of the upper digestive tract, including the esophagus, the mouth, the pharynx, and the larynx.

Prescription Medication

Prescription drug abuse involves the ingestion of medication that has been obtained without a prescription or that is used inappropriately (that is, not according to prescription instructions). According to the 2022 National Survey on Drug Use and Health, approximately 8.5 million Americans age twelve and older misused prescription pain relievers within the past year.

Not infrequently, prescription drug abusers take medication with alcohol or combine stimulants and depressants. These combinations increase the risk of permanent damage to the user’s health or death. Commonly abused types of prescription medications include opioids such as hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), and morphine; central nervous system depressants, including benzodiazepines such as alprazolam (Xanax) and diazepam (Valium), barbiturates such as phenobarbital (Luminal Soduim and pentobarbital (Nembutal), and non-benzodiazepine sleep medications such as zolpidem (Ambien) and eszopiclone (Lunesta); and stimulants such as dextroamphetamine (Dexedrine) and methylphenidate (Ritalin). Narcotics and central nervous system depressants cause drowsiness and respiratory depression; stimulants can cause seizures, irregular heartbeat, paranoia, and dangerously elevated body temperatures.

In some cases, a prescription may be obtained from a health care professional by feigning symptoms such as pain; however, most health care professionals are adept at spotting a drug abuser. Most abused prescription medication is purchased from a drug trafficker or stolen by the user.

Abuse of Illegal Substances

Illegal substances have the added risk of containing contaminants, which can increase the health risk. For example, marijuana may be mixed with phencyclidine (PCP). PCP was developed as an anesthetic, but its medical use was discontinued a few years after its introduction because of its harmful effects on the brain. It is not uncommon for an abuser of illegal substances to combine a drug with other illegal substances, prescription drugs, or alcohol.

Marijuana

Smoked marijuana and smoked tobacco are chemically similar; thus, like cigarettes, the greatest health hazard of marijuana is from smoking the substance. The psychoactive component of marijuana leaves is delta-9-tetrahydrocannabinol (THC), which is a relatively safe drug. However, smoked marijuana is a health risk. Scientific analyses have identified a minimum of six thousand of the same chemicals in marijuana smoke that are present in tobacco. The chief difference between the two plants is that marijuana contains THC and tobacco contains nicotine. Moreover, one of the most potent carcinogens in tobacco smoke, Benzo[a]pyrene, is present in larger quantities in marijuana smoke.

Another factor increasing the carcinogenic risk is in the way it is inhaled. Marijuana smokers frequently inhale and hold the smoke in their lungs for an extended time to increase the drug’s effects; this practice increases the amount of tar deposited in the respiratory tract by about a factor of four.

Cocaine and Crack Cocaine

Cocaine is the most abused central nervous system stimulant in the United States and is a frequent cause of emergency room visits. Ingestion of cocaine can produce seizures, strokes, or heart attacks. Some users claim that it is not addictive because it does not produce physical withdrawal symptoms, which do occur with alcohol or heroin addiction. However, cocaine has powerful psychological addictive properties. Users will often go to extraordinary lengths to obtain the drug.

Methamphetamine

Methamphetamine is a highly addictive street drug that can be readily and inexpensively manufactured from the ingredients of common household products. Psychological effects of the substance include agitation, depression, euphoria, mood disturbances, psychosis, and violent behavior. In addition to being less expensive than cocaine, its effects are longer lasting.

The use of methamphetamine can result in permanent injury to the brain, heart, and lungs. Furthermore, the volatile substances used in its manufacture can lead to fires and explosions.

Heroin

Heroin (diacetylmorphine) is a potent analgesic (painkiller). It is abused for the intense euphoria it produces. It is highly addictive, as tolerance to the drug develops quickly. As a result, users need more of the drug to achieve the same effects. When injected intravenously, heroin produces a greater degree of euphoria than other opiates, such as morphine.

Treatment

Many substance abusers either deny that they have a problem or simply state that the pleasure derived from the substance outweighs the negative impact on their life; thus, treatment is often initiated by a triggering event or by the urging of another person.

A triggering event may be conviction for driving under the influence, a health condition (such as pancreatitis or cirrhosis of the liver), a threat of divorce, a threat of a job loss, or a threat of loss of child custody. A spouse, relative, coworker, or boss may be influential in initiating treatment. However, some substance abusers ignore a triggering event or advice from others and continue to abuse substances.

A number of treatment options are available to substance abusers. These vary markedly by the type of substance and by individual circumstances. In some cases, a brief intervention by a health care professional may be sufficient. Other cases require enrollment in an outpatient program, which includes counseling. More severe cases require an inpatient program.

The following steps are involved in treatment for persons requiring inpatient or intensive outpatient treatment:

Detoxification. For most drug addictions, detoxification (also called detox) is necessary. Sedatives are often necessary to reduce withdrawal symptoms, which may include shaking, confusion, or hallucinations. Withdrawal may last one or two weeks and may require inpatient care at a hospital or a treatment center.

Reprogramming. A recovering substance abuser, with the help of professionals skilled in substance abuse treatment, learns new skills and formulates a treatment plan. The plan should include behavior-modification techniques, counseling, goal setting, and use of self-help manuals or Internet resources.

Psychological counseling. Counseling on an individual or a group basis is an essential treatment component. Group therapy is particularly valuable because it allows interaction with other substance abusers. It promotes the idea that one’s problems are not unique. Therapy may include the presence of a spouse or other family members. Family support is a significant component of the recovery process.

Medication. Following medication for detox, long-term pharmaceutical treatment may be used in some cases. Oral medications such as disulfiram, acamprosate, and naltrexone are used for the treatment of alcoholism. These medications produce unpleasant physical reactions such as flushing, headaches, nausea, and vomiting. Methadone is commonly used in the treatment of heroin addiction; however, its use is controversial. Critics claim that treating recovering addicts with methadone is simply substituting one addictive drug for another. Despite this opinion, many former addicts claim that they never could have ended their heroin habit without help from methadone.

Follow-up support. Aftercare programs and support groups are essential for the recovering substance abuser. These programs help the abuser to avoid (or manage) relapses and deal with the necessary lifestyle changes to maintain a drug-free existence. For alcoholics, regular attendance at a support group such as Alcoholics Anonymous (AA) is often an important component of follow-up care. Follow-up often includes psychological and medical care.

Substance abuse is commonly a component of other mental health disorders. For persons with mental health issues, psychological counseling or psychotherapy may be recommended. Substance abusers can also have medical conditions that require treatment. These conditions include hypertension (high blood pressure), diabetes, heart disease, and liver disease (such as cirrhosis of the liver). If a substance abuser remains drug-free, some medical conditions may decrease in severity or may resolve. Treatment for depression or anxiety also may be a part of follow-up.

Beyond counseling and medication, other modalities may be helpful. For example, in September 2010, researchers at the University of California, Los Angeles, released the results of a clinical trial involving a unique new therapy that applies electrical stimulation to a major nerve emanating from the brain. The technique, trigeminal nerve stimulation, achieved an average of a 70 percent reduction in depression in the eight-week study period.

Inpatient treatment. For persons with a serious substance abuse problem, inpatient care is often necessary. These programs include detox followed by counseling, group therapy, and medical treatment. A benefit of an inpatient program is that it greatly reduces the risk of a patient gaining access to harmful substances. Regular outpatient follow-up is also essential.

Many medical centers include treatment for substance abuse. Stand-alone facilities are also present throughout the United States and other developed nations. Some provide care in a basic, clinical setting, while others function in a resort-like setting. One well-known facility is the Betty Ford Center in Rancho Mirage, California, which was founded by former US first lady Betty Ford. The nonprofit residential facility offers inpatient, outpatient, and day treatment for recovering substance abusers and addicts. It also provides prevention and education programs for family members (including children) of substance abusers and addicts.

Support groups. A variety of support groups are available to a substance abuser who admits he or she has a problem. Treatment centers may have their own support groups or may refer patients to outside programs they deem suitable. A recovering alcoholic may have to try various resources before finding the best fit.

Religious support. Churches and synagogues often sponsor support for recovering alcoholics. Members can use available services, which are often integrated with other organizations and social services in the community. Although nonsectarian and nondenominational, AA is a faith-based organization as exemplified by its twelve-steps program, which includes the acknowledgement of the existence of a "higher power."

Genetic Factors

Significant evidence exists that genetic factors are involved in the development of substance abuse and addiction, particularly alcoholism. The interaction of genes and environmental factors that influence substance dependence is a complex scientific topic.

Since 1989, the US-government-funded Collaborative Studies on the Genetics of Alcoholism (COGA) has been tracking alcoholism in families. COGA researchers have interviewed more than fourteen thousand people and sampled the DNA of at least three hundred extended families. They have found evidence for the existence of several alcohol-related genes. COGA researchers are increasingly convinced that different types of alcoholics are representative of a number of genetic variations.

Social Implications

Substance abuse has a tremendous impact on society. For example, many people are injured or killed by substance abusers who drive under the influence of one or more psychoactive substances. Family members of substance abusers suffer from the emotional and financial burden placed on them by a substance abuser. Furthermore, substance abusers accrue countless hours of lost and unproductive work.

All developed nations have extensive legislation regarding substance abuse and age limits for legal substances. For example, in the United States the legal drinking age is twenty-one years and the legal smoking age is eighteen years. However, some nations have more lenient restrictions. Some substances deemed illegal by one government are considered legal by another.

An example of a substance with varying degrees of legality is marijuana. The substance is deemed illegal by the US federal government; however, the recreational use of marijuana became legal in a growing number of states in the twenty-first century, including Colorado, Washington, Oregon, Nevada, California, Maine, Alaska, Massachusetts, and Virginia. The use of medical marijuana remained a contentious topic, but state laws have also increasingly legalized its use. In 2024, medical marijuana had been legalized in thirty-seven US states, plus the District of Columbia, Guam, and Puerto Rico, to allow usage for legitimate medical reasons, such as for glaucoma or for pain relief from cancer. However, there is a concern that the substance will be dispensed for frivolous, nonmedical reasons or diverted for illegal use.

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