Criteria for Substance Abuse
Substance dependence is defined as a maladaptive pattern of substance use, leading to clinically significant tolerance, impairment, or distress. At The Ranch Mississippi, we utilize certain criteria for determining substance dependence for alcohol and drug treatment. Our focus is on healing the whole person, not just the problem.
These criteria are used in assessing various components including physiology, increased substance usage, tolerance or withdrawal , stressors, cravings and obsessions, and evidence of consequences, i.e., DUI’s. Substance dependence is defined as a maladaptive pattern of substance use, leading to clinically significant tolerance, impairment, or distress, as manifested by three (or more) of the following occurring at any time in the same 12-month period:
Defined by either of the following:
– A need for markedly increased amounts of the substance to achieve intoxication or desired effect
– Markedly diminished effect with continued use of the same amount of the substance
Manifests by either of the following:
– The characteristic withdrawal syndrome for the specific substance
– The same substance, or one closely related, is taken to relieve or avoid withdrawal symptoms
- The substance is often taken in larger amounts or over longer periods of time than was intended
- There is a persistent desire or unsuccessful efforts to cut down or control the substance use
- Loss of control
- Important social, occupational, or recreational activities are given up or reduced because of the substance use
- The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Physiologic Dependence vs. Without Physiologic Dependence
Anyone can become physiologically dependent on any number of substances if taken for purely medical reasons for a period of time and at a certain amount that is I individual to each person. This does not make you an addict or dependent. This is the reason a distinction is made between physiologic dependence and without physiologic dependence. If you have these two criteria you must have a least one of the other five criteria. Conversely you can have three of the criteria listed in blue (out of 3-7) and have no physiologic dependence and be addicted or dependent.
Most of the portrayals of addicts in the media, including TV, movies, and news shows, are either in withdrawal or trying to get “a fix”. Physical dependence is not addiction by itself. Any person can develop physical dependency. Many patients who are admitted to the acute care hospitals for major illnesses, or major accidents that require multiple surgeries and narcotics for an extended period, can develop tolerance over time. If their narcotics are stopped abruptly, as opposed to being tapered off gradually, they would develop severe withdrawal symptoms.
At The Ranch Mississippi, we take people who have become accustomed to high potency intravenous narcotics and “step them down” to less potent intramuscular or intravenous narcotics, and then to lesser potency oral pain medications over time to prevent withdrawal symptoms.
Everything that we think, do, and perceive is the result of chemical reactions in the brain. This does not negate the existence of a soul or spirit; it is simply how the physical body works. Each person’s brain chemistry is the result of the years of development that human beings take to begin the process of becoming mature and whole. Genetic, social, physical, and psychological influences contribute to the process. We are mind, body, and spirit, and these influences vary at different times in importance but come together to create a physiology in the brain.
This physiology constantly changes and adapts to stressors; that is the process of maturation and growth in the human being. We are the products of everything that has happened to us, every person that has touched us, everything we have thought, everything we have done, everyone we have touched, and every choice we have made. Physiology determines how we feel, how we think, and even how we move. It controls all of the regulatory processes from thyroid gland to pulse and blood pressure. It is the repository of automatic responses that we don’t have to think about such as blinking.
When we introduce stressors to the physiology, it changes the physiology. We must, therefore, look at behavior in context and assess the presence of stressors (not stress) that can change this physiology. They may be events such as marriage, divorce, graduation, birth, death, or job change. Illnesses and injuries can be stressors. Ingestion of a mood altering substance is a stressor. Applying a stressor to alter our current physiology, and causing it to change, results in a new or different physiology and unusual behaviors can result that differ from what the person had before.
As we grow as human beings, we constantly have exposure to stressors that alter our physiology and cause new behaviors that become part of our current physiology. Everything we think and everything we do is the result of these chemical reactions in the brain, and all of this is equally shaped by psychological, genetic, and social inputs. This combination of influences, including our physiology, impact the outcome of our current state. We are learning that this is true of most of medicine. Many medical illnesses are the result of our behaviors (the stressor) plus a genetic predisposition.
Patients with substance dependency (addiction, chemical dependency) are constantly, and unsuccessfully, making efforts to control, cut down, or stop their use of the substance. This may include switching to a different substance, or beginning to hide their use of the substance to give the impression of cessation of use. They may stop for a period – a day, a week, a month, or even a year. Often this discontinuation is accompanied by resolutions, a change in health practices such as going to the gym and eating healthy, and a conversion or renewal of spiritual or religious practices i.e.” I’m going to start going to church again,” or “I answered the call and joined the church.”
Once stopped, however, the patient often manifests a series of predictable traits:
- They begin to think about and “crave” the substance (which can either be a conscious or unconscious desire).
- This craving increases over time as the patient encounters people, situations, events, and, most importantly, feelings that were previously medicated with substances.
- The person develops irritability; disgruntlement, restlessness, and discontent from not having an easy way to medicate their feelings (take them away).
- This emotional discomfort and discontent with life initiates ever-increasing thoughts of the substance and its perceived capacity to take away difficult feelings.
- The patient begins obsessing about the substance and it gradually takes precedence over all other concerns in life, until the point where he or she cannot tolerate the feelings any more and begins using again.
People without a problem do not have most of their conscious thought around alcohol or a drug. People that are addicted think about the substance all the time. Once the patient uses, he is still obsessed and thinks about how to hide the relapse, how to get more of the drug, how not to get stopped again, and how to get out of trouble. The patient’s life is centered on getting, using, and recovering from the effects (or withdrawal symptoms) of the substance. This is a summation then of criteria four and five.
If a patient has significant life problems attributed to the use of a mood altering substance and continues to use the substance in spite of these consequences, then they most likely meet criteria 6 and 7.
Criteria 6 talks about important areas in any person’s life that have become reduced, or given up totally, as a result of substance use i.e. “I can’t go on vacation because I might run out of pills,” or “I don’t want to go out. That restaurant does not serve drinks.”
Criteria 7 discusses psychological or physical problems caused by or made worse by the substance use. Many depressed patients have tried drinking to help their depression and found that, since alcohol is a depressant, it makes them more depressed and they quit. Most likely, if a patient states that they are drinking heavily because they are depressed, it is the alcohol causing or exacerbating the depression.
Consequences include things like:
- Legal problems related to the use of the substance i.e. DUI’s or possession charges
- Financial problems i.e. financial instability secondary to money spent on drugs, bad checks, pawning possessions, spending sprees while using.
- Hospitalizations/ER visits/doctor’s visits secondary to the drug or alcohol use i.e. motor vehicle accidents while using, overdoses, elevated liver function tests, hepatitis, seizures, illnesses from impure drugs, fights, AIDS, heart disease.
- Relationship problems: i.e. If my drinking bothers my spouse and i make the decision to keep drinking despite the strain on the relationship, i have just put alcohol above what should be the primary relationship in my life. Many have strained relationships with parents, children, siblings, and have lost boyfriends and girlfriends secondary to their use. They become isolated and stay away from friends that they did things such as golf, tennis or fishing with. Their are divorces, separations, and custody battles.
- Job and occupational consequences: i.e. Losing or quitting a job secondary to chemical use. Patients will change jobs, move geographically, go to work late, go home early, and have poor performance.
- Educational consequences: i.e. Younger patients who go to college or professional school and make poor grades, drop out, or fail out secondary to the chemical usage.
- Withdrawal/tolerance: Withdrawal and tolerance are physical or medical consequences of a certain amount and frequency of use, which is individual to each person.
- Hallucinations/seizures/blackouts/memory loss: these consequences could probably be listed under medical consequences and are the result of a certain frequency and amount of use which will be unique to each patient.
- DUI’s: DUI’s are a good example to illustrate the concept of consequences. Somewhere between fifty and seventy five percent of first time DUI offenders if followed for five years would eventually meet the criteria for alcohol dependence. Most lay persons would think this to be higher and a few lower but not every person that gets a first time DUI is alcoholic. This is the reason that first time DUI offenders are not sentenced to treatment but to alcohol education or defensive driving courses. If, however, you follow persons who have just gotten their 2nd DUI and follow them for five years, applying the criteria for alcohol dependence, we would find that over 90% would meet the criteria. If we look at third time DUI offenders almost 100% would meet the criteria for alcohol dependence. Patients with dependence cannot alter their behaviors and therefore continue to do the same things despite adverse life consequences.