Substance Use and Addiction: Definitions, DSM, and Perspectives

Even occasional cannabis use or experimental use of hard drugs doesn't usually raise concern.
Drinking two glasses of wine at a party is co nsidered normal and harmless.

Coffee Consumption: Drinking six pots of coffee a day from morning till night may indicate addiction.
Social Drinking:
- Initially, alcohol is consumed at social events on Friday nights.
- Later, alcohol is used after work to cope with stress, leading to daily consumption.
Cannabis Use:
- Daily cannabis use raises questions about normalcy.
- If used for chronic pain relief, the perspective changes.

A dimensional representation of substance use corresponds with its prevalence in the population.
Most people abstain or engage in occasional light substance use.
A smaller proportion consists of heavy or binge drinkers.
Only a small fraction engages in chronic heavy alcohol use, leading to dependence and alcohol use disorder.
The term "addiction" is debated even among experts.

It's important to study the entire spectrum of substance use.
Focusing solely on occasional users neglects the disproportionate impact of heavy users on society and healthcare costs.
Harms associated with occasional drinking are minor compared to heavy drinking and alcohol use disorder.
Addiction causes significant harm and debates in society.
Research focuses on addiction prevention and treatment.
The gray area of drinking should not be ignored.

The concept of pre-addiction, similar to prediabetes, suggests early intervention for those showing warning signs.

Terms like "addiction," "alcohol use disorder," and "substance use disorder" are often used.
Addiction is a debated term with specific meanings in scientific literature.
It is not synonymous with substance use disorder, which is a descriptive syndrome in the DSM.
Addiction is a theoretical construct with assumptions about its causes.
Different cultures have different perspectives on the term "addiction."

Addictive disorders are highly stigmatized, and language plays a significant role.
Problematic language choices in the media perpetuate stigma.

Use person-first language to avoid labeling people.
Instead of "addict," say "person who experiences addiction."
Replace "alcoholic" with "someone who drinks alcohol" and "smoker" with "someone who smokes."
Avoid terms like "dirty" vs. "clean" and "drug abuser" due to their stigmatizing qualities.

Focus on strength-based approaches rather than deficits.
Shift the discourse from "mental illness" to "mental health."
Talk about "substance use health" to address healthy and unhealthy relationships with substances.

Dependence: A need for a drug.
Physical Dependence:
- Tolerance: The drug becomes less effective over time. $(Tolerance)$
- Withdrawal: Adverse effects when the drug is removed. $(Withdrawal)$
- Brain changes in response to repeated drug use are a sign of physical dependence.

Psychological dependence involves compulsion, craving, and relapse.
Physical dependence is not necessary or sufficient for addiction.
Behavioral addictions, like gambling, lack physical ingestion.
- Example: Someone with tolerance to caffeine may not necessarily have an addiction.
- Compulsive use and inability to control are key factors.
- Psychological dependence alone may not be problematic if it doesn't impact daily functioning.

Addiction is defined by drug use that causes problems for the individual.
Drug misuse, hazardous or problem drug use: Can lead to difficulties in health, mental health, relationship health etc.
- Example: Excessive alcohol use leading to fights, lateness for work, or loss of license.
- Consequences are significant when considering a diagnosis of addiction.
This includes the frequency over both time and contexts, e.g. university students making mistakes.

DSM defines substance use disorder as a problematic pattern leading to clinically significant distress or impairment, reflected in two or more symptoms over 12 months.
Diagnoses are substance-specific (e.g., alcohol use disorder, cannabis use disorder).
Severity is determined by the number of symptoms:
- Mild: two to three symptoms.
- Moderate: four to five symptoms.
- Severe: six or more symptoms.
Symptoms span psychological dependence, physical dependence, and misuse.
The DSM may diagnose substance use disorder even in the absence of addiction if a person only had a tolerance or withdrawl. This is an area of debate.
There are 200+ symptom combinations. Resulting in heterogeneity.
DSM includes substance-specific withdrawal and intoxication criteria.
There is no diagnosis of caffeine use disorder, though caffeine withdrawal is recognized.

Doesn't take into account broader context i.e. Western Perspective, Holistic Context, lack of comorbidity.

DSM-5 introduced gambling disorder as a non-substance addictive disorder.
Criteria for gambling disorder differ from substance use disorder.
Gambling disorder criteria include preoccupation, unsuccessful attempts to cut back, restlessness, and lying to conceal gambling extent.

Antwan Example: a 37 year old man who injured his back, he experienced withdrawl after trying to stop medication $(nausea, sweating, anxiety and insomnia)$ . He says this hasn't casued any personal or work problems. Diagnosis? Doesn't meet substance abuse disorder as he demonstrates physical dependence.
Taylor Example: a 19 year old gender-fluid student who has a social life, fails tests and argues with their partner due to alcohol. Denies they are struggling and they have no physical reactions. Diagnosis? Shows early signs but is in denial. There isn't enough evidence of a substance abuse disorder.