Substance abuse: Wikis


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Substance abuse
Classification and external resources

Comparison of the perceived harm for various psychoactive drugs from a poll among medical psychiatrists specialized in addiction treatment[1]
MeSH D019966
Drug abuse
Drug addiction
Substance abuse
Substance abuse prevention
Substance-abuse rehabilitation
Substance abuse treatment

Although the term substance can refer to any physical matter, substance abuse has come to refer to the overindulgence in and dependence of a drug or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others.[2]

The disorder is characterized by a pattern of continued pathological use of a medication, non-medically indicated drug or toxin, which results in repeated adverse social consequences related to drug use, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. There are on-going debates as to the exact distinctions between substance abuse and substance dependence, but current practice standard distinguishes between the two by defining substance dependence in terms of physiological and behavioral symptoms of substance use, and substance abuse in terms of the social consequences of substance use.[3]

Substance abuse may lead to addiction or substance dependence. Medically, physiologic dependence requires the development of tolerance leading to withdrawal symptoms. Both abuse and dependence are distinct from addiction which involves a compulsion to continue using the substance despite the negative consequences, and may or may not involve chemical dependency. Dependence almost always implies abuse, but abuse frequently occurs without dependence, particularly when an individual first begins to abuse a substance. Dependence involves physiological processes while substance abuse reflects a complex interaction between the individual, the abused substance and society.[4]



Substance abuse is sometimes used as a synonym for drug abuse, drug addiction, and chemical dependency, but actually refers to the use of substances in a manner outside sociocultural conventions. All use of controlled drugs and all use of other drugs in a manner not dictated by convention (e.g. according to physician's orders or societal norms) is abuse according to this definition, however there is no universally accepted definition of substance abuse.

The physical harm for twenty drugs was compared in an article in the Lancet (see diagram, above right). Physical harm was assigned a value from 0 to 3 for acute harm, chronic harm and intravenous harm. Shown is the mean physical harm. Not shown, but also evaluated, was the social harm.

Substance use may be better understood as occurring on a spectrum from beneficial to problematic use. This conceptualization moves away from the ill-defined binary antonyms of "use" vs. "abuse" (see diagram, lower right) towards a more nuanced, public health-based understanding of substance use. capish.

Mediators & Moderators

When a predictor variable and an outcome variable have a significant relationship, which is, in turn, influenced by a third variable, the relationship is said to be mediated by the third variable. In this relationship the predictor variable influences the mediating variable in a causal manner. This mediating variable then leads to the outcome, creating the relationship between the predictor and outcome. It is only because of this mediating variable that a relationship between the predictor and outcome exists. Also, quasi-causal inferences may be drawn from mediated relationships. Mediation is best illustrated by the following model:

Mediator Model

As demonstrated by the chart below, numerous studies have examined factors which mediate substance abuse or dependence. In these examples, the predictor variables lead to the mediator which in turn leads to the outcome, which is always substance abuse or dependence. For example, research has found that being raised in a single-parent home can lead to increased exposure to stress and that increased exposure to stress, not being raised in a single-parent home, leads to substance abuse or dependence[5]. The following are some, but by no means all, of the possible mediators of substance abuse.

Predictor Variables Mediator Variables Outcome Variable
Single-parent Home[5] Exposure to Stress, Association w/ Deviant Peers Substance Abuse or Dependence
Child Abuse/Neglect[6] PTSD symptoms, Stressful Life Events, Criminal Behavior Substance Abuse or Dependence
Parental Substance Abuse[7]

Witnessing Violence

Physical/Sexual Abuse

Delinquency Status

Substance Abuse or Dependence

When a variable indicates the conditions under which a specific effect occurs as well as displays how the direction or strength varies within a given relationship, the variable is said to moderate the relationship. Another explanation is that a moderator variable indicates that an effect only occurs under specific conditions. Unlike a relationship containing a mediator variable, the impact of the predictor variable on the outcome is dependent on the value of the moderating variable. Also unlike a relationship involving mediation, no causal inferences can be drawn from a moderated relationship; relationships can only be described as correlated. However, moderated relationships do identify interaction effects between predictor and moderator variables. Moderation is best illustrated by the following model:

Moderator Model

As demonstrated by the chart below, numerous studies have examined factors which moderate substance abuse or dependence. In these examples, the moderator variable impacts the level to which the strength of the relationship varies between a given predictor variable and the outcome of substance abuse or dependence. For example, there is a significant relationship between psychobehavioral risk factors, such as tolerance of deviance, rebelliousness, achievement, perceived drug risk, familism, family church attendance and other factors, and substance abuse and dependence. That relationship is moderated by familism which means that the strength of the relationship is increased or decreased based on the level of familism present in a given individual.[8]

Predictor Variables Moderator Variables Outcome Variable
Psychobehavioral Risk[8] Familism

Family Church Attendance

Substance Abuse or Dependence
Victimization Effects[7] Race/Ethnicity

Physical/Sexual Abuse

Substance Abuse or Dependence
Family History of Alcoholism[9] Gender Substance Abuse or Dependence

Mediation and moderation research continues to inform the field’s knowledge and understanding of a pervasive and dangerous threat to public health, substance abuse and dependence. As the relationships between various predictor variables and the factors which influence them are more closely scrutinized, clinicians and researchers are provided with the necessary information to create more sophisticated and relevant methods of prevention and intervention. While these factors are important to the development of SUDs, there are plenty of other factors both known and unknown that influence the development of this disorder. As such, continued research is both necessary and invaluable.

Additional Mediators and Moderators of Substance Abuse

Mediators and Moderators Defined: Baron and Kenny (1986) define a moderator as, “a qualitative (e.g., sex, race, class) or quantitative (e.g., level of reward) variable that affects the direction and/or strength of the relation between and independent or predictor variable and a dependent or criterion variable” (p. 1174)[10]. Moderators may operate as protective factors, decreasing the strength of the relationship between the predictor variable and the outcome. Conversely, moderators may heighten risk levels and strengthen the effects of the predictor on the outcome. In either instance, moderators do not explain why the connection exists, but rather affect the strength and direction of the relationship between the variables. A mediator, as defined by Baron and Kenny (1986), “represents the generative mechanism through which the focal independent variable is able to influence the dependent variable of interest” (p. 1173)[10]. Unlike moderators, mediators can explain the relationship between the predictor variable and outcome. Holmbeck (1997) elaborated on Baron and Kenny’s definition by adding, “the nature of the mediated relationship is such that the independent variable influences the mediator which, in turn, influences the outcome” (p. 600)[11]. Examples of mediators and moderators in empirical research: Examples of mediators and moderators can be found in several empirical studies. For example, Pilgrim et al.’s hypothesized mediation model posited that school success and time spent with friends mediated the relationship between parental involvement and risk-taking behavior with substance use (2006)[12]. More specifically, the relationship between parental involvement and risk-taking behavior is explained via the interaction with third variables, school success and time spent with friends. In this example, increased parental involvement led to increased school success and decreased time with friends, both of which were associated with decreased drug use. Another example of mediation involved risk-taking behaviors. As risk-taking behaviors increased, school success decreased and time with friends increased, both of which were associated with increased drug use. A second example of a mediating variable is depression. In a study by Lo and Cheng (2007),[13] depression was found to mediate the relationship between childhood maltreatment and subsequent substance abuse in adulthood. In other words, childhood physical abuse is associated with increased depression, which in turn, in associated with increased drug and alcohol use in young adulthood. More specifically, depression helps to explain how childhood abuse is related to subsequent substance abuse in young adulthood.

A third example of a mediating variable is an increase of externalizing symptoms. King and Chassin (2008)[14] conducted research examining the relationship between stressful life events and drug dependence in young adulthood. Their findings identified problematic externalizing behavior on subsequent substance dependency. In other words, stressful life events are associated with externalizing symptoms, such as aggression or hostility, which can lead to peer alienation or acceptance by socially deviant peers, which could lead to increased drug use. The relationship between stressful life events and subsequent drug dependence however exists via the presence of the mediation effects of externalizing behaviors. An example of a moderating variable is level of cognitive distortion. An individual with high levels of cognitive distortion might react adversely to potentially innocuous events, and may have increased difficulty reacting to them in an adaptive manner (Shoal & Giancola, 2005).[15] In their study, Shoal and Giancola investigated the moderating effects of cognitive distortion on adolescent substance use. Individuals with low levels of cognitive distortion may be more apt to choose more adaptive methods of coping with social problems, thereby potentially reducing the risk of drug use. Individuals with high levels of cognitive distortions, because of their increased misperceptions and misattributions, are at increased risk for social difficulties. Individuals may be more likely to react aggressively or inappropriately, potentially alienating themselves from their peers, thereby putting them at greater risk for delinquent behaviors, including substance use and abuse. In this study, social problems are a significant risk factor for drug use when moderated by high levels of cognitive distortions.


Disability-adjusted life year for drug use disorders per 100,000 inhabitants in 2002.
     no data      less than 40      40-80      80-120      120-160      160-200      200-240      240-280      280-320      320-360      360-400      400-440      more than 440


In the early 1950s, the first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders grouped alcohol and drug abuse under Sociopathic Personality Disturbances, which were thought to be symptoms of deeper psychological disorders or moral weakness.

The third edition,in the 1980s, was the first to recognize substance abuse (including drug abuse) and substance dependence as conditions separate from substance abuse alone, bringing in social and cultural factors. The definition of dependence emphasised tolerance to drugs, and withdrawal from them as key components to diagnosis, whereas abuse was defined as "problematic use with social or occupational impairment" but without withdrawal or tolerance.

In 1987 the DSM-IIIR category "psychoactive substance abuse", which includes former concepts of drug abuse is defined as "a maladaptive pattern of use indicated by...continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the use (or by) recurrent use in situations in which it is physically hazardous". It is a residual category, with dependence taking precedence when applicable. It was the first definition to give equal weight to behavioural and physiological factors in diagnosis.

By 1988, the DSM-IV defines substance dependence as "a syndrome involving compulsive use, with or without tolerance and withdrawal"; whereas substance abuse is "problematic use without compulsive use, significant tolerance, or withdrawal". Substance abuse can be harmful to your health and may even be deadly in certain scenarios

By 1994, The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association ,the DSM-IV-TR, defines substance dependence as "when an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed." followed by criteria for the diagnose[16]

DSM-IV-TR defines substance abuse as:[17]

  • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
  1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household)
  2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
  4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  • B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

The fifth edition of the DSM, planned for release in 2010, is likely to have this terminology revisited yet again. Under consideration is a transition from the abuse/dependence terminology. At the moment, abuse is seen as an early form or less hazardous form of the disease characterized with the dependence criteria. However, the APA's 'dependence' term, as noted above, does not mean that physiologic dependence is present but rather means that a disease state is present, one that most would likely refer to as an addicted state. Many involved recognize that the terminology has often led to confusion, both within the medical community and with the general public. The American Psychiatric Association requests input as to how the terminology of this illness should be altered as it moves forward with DSM-V discussion.

See also


  1. ^ Nutt D, King LA, Saulsbury W, Blakemore C (March 2007). "Development of a rational scale to assess the harm of drugs of potential misuse". Lancet 369 (9566): 1047–53. doi:10.1016/S0140-6736(07)60464-4. PMID 17382831.  edit
  2. ^ (1998). Mosby's Medical, Nursing, & Allied Health Dictionary. Edition 5.
  3. ^ Pham-Kanter, Genevieve. (2001). "Substance abuse and dependence." The Gale Encyclopedia of Medicine. Second Edition. Jacqueline L. Longe, Ed. 5 vols. Farmington Hills, MI: Gale Group.
  4. ^ [1]
  5. ^ a b Barrett AE, Turner RJ (January 2006). "Family structure and substance use problems in adolescence and early adulthood: examining explanations for the relationship". Addiction 101 (1): 109–20. doi:10.1111/j.1360-0443.2005.01296.x. PMID 16393197. 
  6. ^ White HR, Widom CS (May 2008). "Three potential mediators of the effects of child abuse and neglect on adulthood substance use among women". J Stud Alcohol Drugs 69 (3): 337–47. PMID 18432375. 
  7. ^ a b Kilpatrick DG, Acierno R, Saunders B, Resnick HS, Best CL, Schnurr PP (February 2000). "Risk factors for adolescent substance abuse and dependence: data from a national sample". J Consult Clin Psychol 68 (1): 19–30. doi:10.1037/0022-006X.68.1.19. PMID 10710837. 
  8. ^ a b Brook JS, Pahl K (September 2005). "The protective role of ethnic and racial identity and aspects of an Africentric orientation against drug use among African American young adults". J Genet Psychol 166 (3): 329–45. doi:10.3200/GNTP.166.3.329-345. PMID 16173675. 
  9. ^ Ohannessian, C.M., Hasselbrock, V.M. (1999). Predictors of substance abuse and affective diagnosis: Does having a family history of alcoholism make a difference?. Applied Developmental Science, 3, 239-247.
  10. ^ a b Baron RM, Kenny DA (December 1986). "The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations". J Pers Soc Psychol 51 (6): 1173–82. doi:10.1037/0022-3514.51.6.1173. PMID 3806354. 
  11. ^ Holmbeck GN (August 1997). "Toward terminological, conceptual, and statistical clarity in the study of mediators and moderators: examples from the child-clinical and pediatric psychology literatures". J Consult Clin Psychol 65 (4): 599–610. doi:10.1037/0022-006X.65.4.599. PMID 9256561. 
  12. ^ Pilgrim CC, Schulenberg JE, O'Malley PM, Bachman JG, Johnston LD (March 2006). "Mediators and moderators of parental involvement on substance use: a national study of adolescents". Prev Sci 7 (1): 75–89. doi:10.1007/s11121-005-0019-9. PMID 16572302. 
  13. ^ Lo CC, Cheng TC (2007). "The impact of childhood maltreatment on young adults' substance abuse". Am J Drug Alcohol Abuse 33 (1): 139–46. doi:10.1080/00952990601091119. PMID 17366254. 
  14. ^ King KM, Chassin L (September 2008). "Adolescent stressors, psychopathology, and young adult substance dependence: a prospective study". J Stud Alcohol Drugs 69 (5): 629–38. PMID 18781237. 
  15. ^ Shoal GD, Giancola PR (November 2005). "The relation between social problems and substance use in adolescent boys: an investigation of potential moderators". Exp Clin Psychopharmacol 13 (4): 357–66. doi:10.1037/1064-1297.13.4.357. PMID 16366766. 
  16. ^ DSM-IV & DSM-IV-TR:Substance Dependence
  17. ^ American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC.

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