Definitions of Abuse/Dependence/Addiction

1. DRUG ABUSE
DRUG DEPENDENCE
DRUG ADDICTION
Tahar AbdAlaziz MD, PhD

2. Terminology Problems
The terms drug dependence & drug addiction are often
used interchangeably, but this leads to confusion
regarding the diagnostic effects of these terms.
The definitions of 1957 & 1964 regarding addiction,
dependence and abuse persist to the present day in
medical literature.
In 1957 WHO defined addiction and habituation as
components of drug abuse.
In 1964 WHO found these definitions to be inadequate,
and suggested using the term "drug dependence”.

3. In 2000, the Diagnostic Statistical Manual of Mental
Disorders (DSM-IV-TR) introduced specific criteria for
defining abuse and dependence.
(DSM-IV-TR) uses the term substance dependence instead of
addiction, and defined it as
A maladaptive pattern of substance abuse, leading
to clinically significant impairment or distress, as
manifested by three (or more) specified criteria,
occurring at any time in the same 12-month period.

4. Criteria of Dependence & Abuse according to DSM-IV-TR
Dependence
(3 or more in a 12-month period)
1) Tolerance (marked increase in
amount; marked decrease in
effect)
2) Characteristic withdrawal
symptoms; substance taken to
relieve withdrawal
3) Substance taken in larger amount
and for longer period than
intended
4) Persistent desire or repeated
unsuccessful attempt to quit
5) Much time/activity to obtain,
use, recover
6) Important social, occupational,
or recreational activities given
up or reduced
7) Use continues despite knowledge
of adverse consequences (e.g.,
failure to fulfill role obligation,
use when physically hazardous)
Abuse
(1 or more in a 12-month period)
Symptoms must never have met criteria for
substance dependence for this class of substance.
1) Recurrent use resulting
in failure to fulfill major
role obligation at work,
home or school
2) Recurrent use in
physically hazardous
situations
3) Recurrent substance
related legal problems
4) Continued use despite
persistent or recurrent
social or interpersonal
problems caused or
exacerbated by
substance

5. New Changes 2013

6. • DSM-5 consolidates substance abuse and
dependence into one disorder:
substance use disorder
• Criteria are nearly identical to DSM-IV with
exception of:
-Recurrent substance-related legal problems
criterion has been deleted from DSM-5.
-And new criterion: craving, or a strong desire or
urge to use a substance added.
• The threshold is set at 2 or more criteria vs. 1
or more for abuse and 3 or more for dependence
in the DSM-IV.

7. Severity of the problem (NEW)
In DSM-5 severity for substance use
disorders is based on the number of
criteria endorsed:
– MILD= 2-3 criteria
– MODERATE= 4-5 criteria
– SEVERE= 6 or more criteria
•

8. In 2001,
• American Academy of Pain Medicine
• America Pain Society
• American Society of Addiction Medicine
jointly issued "Definitions Related to the
Use of Opioids for the treatment of pain”.

9. Drug abuse
The substance is used in a manner
that does not conform to social
norms; the motivation to use the
substance may or may not be
particularly strong compared with
other motivators.

10. Drug addiction
• A behavioral syndrome
characterized by behaviors that
include one or more of the
following:
– Impaired control of drug use
– compulsive drug use
– continued use despite harm
– craving

11. Drug dependence
A state where the individual is
dependent upon the drug for
normal physiological functioning.
Abstinence from the drug produces
withdrawal reactions which
constitute the only evidence for
dependence.

12. Comparison
Some substances may produce
physical dependence without
producing an addiction
• The therapeutic uses of
certain steroids and some
antihistamines produce
characteristic withdrawal
syndromes when abruptly
discontinued without
motivation to continue
the use of these
substances for most
patients.
Some substances may produce
psychological dependence
without producing an addiction
• substances can
produce a notable
psychological
dependence without
producing an
exceptionally strong
motivation to avoid
abstinence such as
caffeine or nicotine.

13. Risk Factors
Drug abuse can lead to drug dependence or
addiction. People who use drugs for pain relief
may become dependent.
The exact cause of drug abuse and
dependence is not known. However, a person's
genes, the action of the drug, peer pressure,
emotional distress, anxiety, depression, and
environmental stress all can be factors.

14. Risk factors
Peer pressure can lead to drug use or abuse,
but at least half of those who become
addicted have depression, attention deficit
disorder, PTSD, or another mental health
problem.
Children who grow up in an environment of
illicit drug use may first see their parents
using drugs. This may put them at a higher
risk for developing an addiction later in life
for both environmental and genetic reasons.

15. Risk factors
People who are more likely to abuse or
become dependent on drugs include
those who:
• Have depression, bipolar disorder, anxiety
disorders, and schizophrenia
• Have easy access to drugs
• Have low self-esteem, or problems with
relationships
• Live a stressful lifestyle, economic or emotional
• Live in a culture where there is a high social
acceptance of drug use

16. Theories of Addiction
1) MEDICAL MODEL
2) PSYCHODYNAMIC MODEL
3) SOCIAL MODEL
4) MORAL MODEL
5) BIO‐PSYCHO‐SOCIAL MODEL

17. Medical TheoryThis theory describes
addiction as a disease.
It attributes addiction to
changes in dopaminergic
(mesolimbic) pathway
Addiction as a “brain
disease” due to
Neurotransmitter
imbalance
•Disease Model:
•Agent: drug
•Vector: dealers
•Host: addict

18. 1
10
100
Child Teen Young Adult Adult
1.5%
67%
5.5%
<12 12-17 18-25 >25
Addiction is a Developmental Disease:
It Starts Early
26%

19. Copyright ©2004 by the National Academy of Sciences Gogtay, Giedd, et al. (2004) Proc. Natl. Acad. Sci. USA 101, 8174-8179
MRI Scans of Healthy Children and Teens Over Time

20. MRI Scans of Healthy Children and Teens Over Time
brain development through early adulthood, with blue indicating the mature state
Prefrontal cortex (white
circles), which governs
judgment and decision-
making functions, is the
last part of the brain to
develop.
•This may help explain:
• why teens are prone to
risk-taking
•vulnerable to drug abuse
•why exposure to drugs at
this critical time may affect
propensity for future
addiction.

21. that starts in adolescence and childhood
National Epidemiologic Survey on Alcohol and Related Conditions, 2003.National Epidemiologic Survey on Alcohol and Related Conditions, 2003.
AgeAge
Age at tobacco, alcohol and cannabis dependence per DSM IV
0.0%0.0%
0.2%0.2%
0.4%0.4%
0.6%0.6%
0.8%0.8%
1.0%1.0%
1.2%1.2%
1.4%1.4%
1.6%1.6%
1.8%1.8%
55 1010 1515 2121 2525 3030 3535 4040 4545 5050 5555 6060 6565
%ineachagegroupwhodevelop
first-timedependencefirst
CANNABIS
ALCOHOL
TOBACCO
Addiction Is A Developmental Disease

22. Circuits Involved In Drug Abuse and Addiction
PFC – prefrontal cortex; ACG – anterior cingulate gyrus; OFC – orbitofrontal cortex; SCC – subcallosal
cortex; NAc – nucleus accumbens; VP – ventral pallidum; Hipp – hippocampus; Amyg – amygdala
The developing strategies to treat addiction must put in
consideration these areas for better results

24. Pshychodynamic Model
Psychodynamics is the theory and
systematic study of the
psychological forces that underlie
human behavior.
It is especially interested in the
dynamic relations between
conscious motivation & unconscious
motivation.

25. • In Freudian thought,
psychodynamics is the study of
transformations and exchanges of
“psychic energy” in the personality
• The psychodynamic model explains
behaviors through the interactions
of Freud’s innate emotional forces,
the id, ego, and super-ego.

26. Social Theory
• This theory hypothesizes that substance
addiction is a learned behavior and it
develops as a result of social problems
such as poverty, violence, family
dysfunction.
• These forces are believed to act as social
stressors and substance addiction is
considered to be an adaptation to the
resultant misery and unhappiness.

27. Moral Theory
• The moral theory denotes substance
addiction as a vice ‫الرذيلة‬ or a sin ‫الخطيئة‬ .
• The theory implies that some
individuals, through their own free will,
make a conscious choice to become
substance addicts.
• According to this theory drug abusers
choose to use drugs and they are
anti‐social and should be punished

28. Bio-psycho-social Theory
• Substance addiction is the net result of a
complex interaction between a combination of
all of the factors:
– Biological
– Psychological
– Social
– Spiritual
• Each person’s drug use is a result of some
aspects of some or all the other models.
• Treatment and recovery require addressing the
body, mind, social environment, and spiritual
needs of an individual (including nutrition,
employment, family issues, psychological
issues, etc.).

29. The highest Risk Periods for Children
• The high risk periods for drug abuse among children
occur during major transitions in children’s lives.
• Transitions include:
– Significant changes in physical development (for
example, puberty)
– Social situations (such as moving or parents divorcing)
– When they leave the security of the family and enter
school
– When they advance from elementary school to middle or
high school, they often experience new academic and
social situations, such as learning to get along with a
wider group of peers and having greater expectations for
academic performance.
•

30. Incidence of Addiction
Worldwide, 149-271 (million) people used an illicit drug at least once in
2009; which equals 1 in 20 people aged 15 to 64 who have used an illegal
drug.
In North America, nearly 11% of population aged 15 to 64 used cannabis in
2009.
Worldwide, 14-56 (million) people aged 15 to 64 used amphetamine-type
stimulants, such as speed and crystal meth.
Cocaine had 14 million to 21 million users worldwide.
Opioid use, including heroin, had an estimated 12 million to 21 million users
globally. The highest rates of use were in the Near and Middle East, where up
to 1.4% of the population aged 15 to 64 had tried the drug at least once in
2009.
Worldwide, 11 million to 21 million people inject drugs. The Lancet

31. Classification of Addictive Drugs
1) Narcotic Analgesics: drugs with opium like effects.
2) Stimulants: drugs which excite the central nervous system.
3) Depressants: drugs which depress the functions of the central nervous system.
4) Hallucinogens: drugs which affect perception, emotions and mental processes.
5) Cannabis
6) Volatile Solvents: volatile hydrocarbons, Petroleum derivatives
7) Other drugs of abuse: medically used drugs that do not fall into any of the above
categories, such as
• Muscle relaxants
• Painkillers
• Anti-histamines
• Anti-depressants / anti-psychotics

32. Commonly Used Psychoactive Substances
SOURCE: National Institute on Drug Abuse.
SUBSTANCE EFFECTS
Alcohol
(liquor, beer, wine)
euphoria, stimulation, relaxation,
lower inhibitions, drowsiness
Cannabinoids
(marijuana, hashish)
euphoria, relaxations, slowed
reaction time, distorted
perception
Opioids
(heroin, opium, many pain meds)
euphoria, drowsiness, sedation
Stimulants
(cocaine, methamphetamine)
exhilaration, energy
Club Drugs
(MDMA/Ecstasy, GHB)
hallucinations, tactile sensitivity,
lowered inhibition
Dissociative Drugs
(Ketamine, PCP, DXM)
feel separated from body,
delirium, impaired motor function
Hallucinogens
(LSD, Mescaline)
hallucinations, altered perception
32

33. Examples of Addictive Drugs
Alcohol
• alcohol abuse causes over 100,000 deaths in the
USA and Canada each year. It is the drug most
commonly abused by children ages 12 to 17.
Alcohol-related motor vehicle accidents are the
leading cause of death in teenagers. People who
drink alcohol are more likely to engage in deviated
sexual behaviors .
Heroin
• It is a diacetylmorphine that functions as a
morphine prodrug. It can be used for medical
purposes as analgesic to treat severe pain with the
name diamorphine. The name "heroin" is only used
when being discussed in its illegal form.

34. Tramadol
Tramadol hydrochloride (Tramal) is a
centrally acting synthetic analgesic
used to treat moderate to moderately
severe pain. Tramadol is converted to
O-desmethyltramadol (potent μ-opioid
agonist).
The opioid agonistic effect of tramadol
and its major metabolite(s) is almost
exclusively mediated by μ-opioid
receptors.

35. Vicodin
• Hydrocodone or dihydrocodeinone is a
semi-synthetic opioid
• It is an orally active narcotic analgesic &
antitussive.
• It acts at μ-opioid receprors.
• It is metabolized to hydromorphone
• About 53% of patients in rehabs across USA
were chemically dependent on Vicodin.

36. Ecstasy
• MDMA
(3,4-methylenedioxy-N-
methylamphetamine)

38. • an empathogenic (entactogenic) drug of the
phenethylamine & amphetamine class.
• MDMA has become widely known as "ecstasy"
(shortened to "E", "X", or "XTC), usually
referring to its street pill form.
• MDMA can induce euphoria, a sense of
intimacy.
• MDMA is criminalized.
• For 2008 the UN estimated between 10–25
million people globally used MDMA at least
once in the past year.
Ecstasy

39. Desomorphine (Krokodil)
• Desomorphine is a synthetically derived
morphine isomer.
• Animal trials of desomorphine showed
that, by comparison with morphine:
– Stronger and more rapid analgesic effect
– Longer effect duration
– Quicker addiction

40. GHB (Gama Hydroxybutyric Acid)
• Asynthetic depressant available as a
prescription for sleep disorders
• In some countries was banned (in
the U.S.) by the FDA in 1990
because of the dangers associated
with its use.
• GHB and its analogs are considered
"date rape" drugs because they can
be mixed with liquids (even water)
and a victim wouldn't notice by
smelling or looking at it.
• GHB, by itself, has a soapy or salty
taste--but when mixed in a drink it
may be difficult to detect.

41. Dextromethorphan (DXM)
• DXM is a cough-suppressing ingredient
in a variety of over-the-counter cold
and cough medications.
• Dextromethorphan, a semisynthetic
narcotic, is an ingredient found in
more than 70 different products.
• DXM acts centrally to elevate the
threshold for coughing.
• At high doses dextromethorphan
produces dissociative effects similar to
those of PCP and ketamine.

42. Benzodiazepines
• About 35 members of this group are presently marketed in different
countries.
• Shorter-acting benzodiazepines used to manage insomnia include estazolam
(ProSom)
• Benzodiazepines with a longer duration of action are utilized to treat
insomnia in patients with daytime anxiety. These benzodiazepines include
alprazolam (Xanax®), chlordiazepoxide (librium®), clorazepate (Tranxene®),
diazepam (Valium)
• Rohypnol (flunitrazepam), most commonly known as a
date-rape drug.
• One of the significant effects of the drug is anterograde
amnesia, a factor that strongly contributed to be one of
the drugs used in rape.
• Anterograde amnesia is a condition in which events that
occurred while under the influence of the drug are
forgotten.

43. Ketamine (“Special K”)
Anesthetic developed to replace PCP, manufactured by
Pfizer
Used in human and veterinary medicine
Injected or dried and snorted
“Vitamin K”
“K”
“Bump”

44. FENTANYL
• Illicit use of pharmaceutical fentanyls first
appeared in the mid-1970s in the medical.
• The biological effects of the fentanyls are
indistinguishable from those of heroin, with
the exception that the fentanyls may be
hundreds of times more potent.
• Fentanyls are most commonly used by IV
administration, but like heroin, they may
also be smoked or snorted.

45. ABUSE OF ANABOLIC STEROIDS
• Anabolic Steroid abuse has become
an international concern.
• These drugs are used illicitly by
weight lifters, body builders, long
distant runners, cyclists, and others
who claim that the drugs give them a
competitive advantage and/or
improve their physical appearance.
• The American Controlled Substance
Act (CSA) defines anabolic steroids as
any drug or hormonal substance
chemically and pharmacologically
related to testosterone (other than
estrogen, progestins, and
corticosteroids), that promotes
muscle growth.

46. Menace of Drug Abuse
Nitrosun

47. Peer Pressure

50. SCARRY BODY OF AN ADDICT