Drink, Drugs and Dependence

From Science to Clinical Practice

Woody Caan, Jackie de Belleroche

• Publisher: Routledge
• Year: 2003
• eBook ISBN: 9781134468263
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

At a world level addiction and the fall-out from substance use is affecting more and more lives. Professionals are increasingly being confronted with puzzling, multifaceted aspects of substance use, whether they work in a clinic, the laboratory or the community.
If you are a member of any caring profession, sooner or later you will encounter problems caused by drugs, alcohol and tobacco. In order to understand substance use and substance users, no single discipline can provide all the answers. In a novel way, this book integrates biological science, social science and clinical experience. It draws together contributions from experts in these diverse and rapidly growing fields, providing the reader with a deeper capacity to engage with problems effectively.
Drink, Drugs and Dependence includes thought-provoking examples, illustrations and test questions to support problem-based learning. Designed to be read consecutively or as a reference text, it will be a welcome resource for all those working in the field of addiction.

Chapter 1
What is a drug and what is addiction?

John Shanks

Key points

• For both alcohol and illicit drugs, the patterns of use and the patterns of harm can be related across a defined population.
• Careful use of terminology helps to clarify this relationship.
• Good-quality epidemiological information about the patterns of drug use and the resultant drug problems can contribute significantly to designing better health policies.

Introduction

Many societies have a chosen drug or chemical whose use is incorporated in social rituals, such as coming of age, marriage and other rites of passage. In Europe and North America, alcohol fulfils some of these functions for most members of the population. In other cultures, different drugs, such as opium or cannabis, are the socially sanctioned choice.

The use and misuse of alcohol and drugs affects everyone in our society, even those people who do not themselves consume these substances. The alcohol industry is a huge business that provides employment for those involved in agriculture, manufacturing, distribution and serving of alcoholic beverages. In the UK, we spent over £25 billion buying alcoholic drinks in 1994 and about £180 million advertising them. Revenue from taxes on alcohol raised more than £9 billion for the Exchequer. During 1993–94, the UK government spent at least £526 million on tackling drug misuse: about £350 million of this went on law enforcement while about £165 million was spent on education, prevention and treatment. The economic costs of illicit drug consumption have risen rapidly, with over 2 per cent of total consumer spending in the UK (£10 billion: Butler 1998) expended on drugs. The health problems and crime associated with the misuse of alcohol and drugs impose a heavy burden on individuals, families, communities, law enforcement agencies, health and social services; for example, in France the recent report of Pierre Kopp for the Office of Drugs found 2.68 per cent of the gross national product (over £21 billion annually) was spent on social problems caused by alcohol and tobacco (summarized in Webster 1999).

Terminology

Discussion or reading about alcohol and drug use is complicated by the use of terms such as addiction, dependency, abuse and misuse which are often left undefined and which can be employed with differing and overlapping shades of meaning.

Terms in common use:

• misuse
• abuse
• dependency
• addiction
• problem use
• alcoholism

Among drug users themselves, there is a highly local and frequently changing street language to describe specific drugs and methods of taking them. Unfortunately, there is no universally accepted set of terms or definitions but the terminology proposed by the World Health Organization has achieved fairly wide acceptance in official circles.

What is a drug?

A simple definition of a drug would be any substance that alters the functioning of the body or the mind. This definition of a drug would include alcohol and also substances such as tobacco or caffeine. For the purposes of this chapter, we will exclude tobacco and caffeine from further consideration because of their different status in our society. For similar reasons, we will consider alcohol separately from other drugs. The generic term ‘substance’ is often used to include both alcohol and drugs.

What is addiction?

The term ‘addiction’ is often used interchangeably with related terms such as ‘dependence’, ‘abuse’, ‘misuse’ or ‘problem use’. All these terms can be applied equally to drugs or to alcohol, which has, additionally, its own specific term ‘alcoholism’. The World Health Organization in its disease classification schemes has proposed some distinct categories, which may be useful.

Drug abuse

Persistent or sporadic excessive use of a drug inconsistent with, or unrelated to, medical practice.

Drug dependence

A psychic and sometimes physical state, resulting from taking a drug, characterized by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects and sometimes to avoid the discomfort of its absence. This rather unwieldy definition of drug dependence introduces the notion of withdrawal effects resulting from withholding the accustomed drug and implies that the state of drug dependence can be either psychological or physical or both.

Definitions of terms such as these may not be adequate to decide in any particular instance whether an individual can be regarded as having a significant problem with drug or alcohol use. There are, therefore, a range of operational definitions which allow people to be more precisely categorized on the basis of some quantified measure of drug or alcohol use which is then compared with a threshold level agreed to constitute problem use. Population surveys of alcohol consumption, for example, may count the numbers of people who report drinking at levels above the current upper limits of sensible consumption recommended by the UK’s medical royal colleges (21 units per week for men, 14 units per week for women). There are also a variety of standardized questionnaires, which produce a score based on the presence of identifiable characteristics thought to be associated with definite alcohol or drug misuse. The CAGE questionnaire is one such short questionnaire, which enquires about four characteristics that are judged to occur in moderately severe problem drinking. A positive response to two or more of the four questions is often taken to indicate a likely severe drinking problem.

The CAGE questionnaire for identifying alcohol problems:

1. Have you ever felt you should Cut down on your drinking?
2. Have people Annoyed you by criticising your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (an ‘Eye-opener’) ?

The experiences of people addicted to drugs or alcohol, to the extent of suffering physical withdrawal symptoms when they cannot get the next dose of their chosen substance, may seem very unfamiliar to the majority of people who never develop such a problem with use of either substance. But a degree of dependence on something is almost universal. It may be another person or a pleasant experience rather than a drug, which induces the intense anticipation of repetition and a mixture of psychological and physical symptoms of distress when the object of desire is unavailable.

Epidemiology

We can consider the impact of alcohol and drugs either at the level of the individual or the population to which that individual belongs. The epidemiological approach considers the distribution of patterns of drug use and their consequences in a population. It is useful to distinguish between

• Epidemiology of use: how patterns of drug or alcohol consumption are distributed through populations;
• Epidemiology of harm: how problems related to drug or alcohol use are distributed through populations

Alcohol

Epidemiology of use

Information about people’s drinking habits comes from a range of sources, including surveys which ask people to remember how much alcohol they have consumed over a defined period of time, such as the preceding week, from official statistics produced by Customs and Excise and based on the amount of alcohol on which duty has been paid. Neither of these can be entirely accurate: people may be reluctant to admit or unable to remember just how much they really drink, while Customs and Excise returns do not include alcohol which is smuggled in, bought duty free or produced at home. It is possible to test for underestimation in self-reported surveys by comparing the consumption of alcohol per head of population predicted from the admitted drinking of the surveyed sample with the per capita consumption derived from Customs and Excise returns for the same period. The Office of Population Censuses and Surveys carried out in 1987 a national survey of drinking habits in England and Wales. This survey estimated that the average annual per capita consumption of pure alcohol was 4.2 litres. Customs and Excise returns for the same year give an average figure of 7.4 litres per year. The reasons for this discrepancy are a tendency for people, especially heavy drinkers, to underestimate their own consumption and for a lower rate of response to surveys from heavy and problem drinkers. Interestingly, people seem to give a more accurate response to questions about drinking habits when a doctor or other health professional is enquiring as part of a clinical consultation. This greater accuracy in the clinical setting may indicate that people perceive it as being more in their own interests to be honest with their doctor than in a population survey where there is no personal gain for the respondent from admitting the true extent of their drinking.

Overall levels of alcohol consumption can be expressed as weight or volume of pure alcohol but are now often described in ‘units’ of alcohol, since this is a more convenient measure for people to understand and use in everyday life. One ‘unit’ of alcohol corresponds to 9 grams of pure ethanol. More importantly, a unit matches fairly closely the standard measures in which alcoholic drinks are sold in pubs and bars. So, a unit of alcohol is equivalent to half a pint of normal strength beer, a single measure of spirits or a glass of wine.

A unit of alcohol (equivalent to 10ml [9 grams] of pure alcohol) is contained in:

• half a pint of beer of normal strength (4 per cent)
• one standard pub measure (one-sixth of a gill) of spirits
• one glass of wine (125 ml)

Data from a number of such population surveys suggest that, in the UK, the vast majority of adults drink alcohol at least occasionally. Only about 5 per cent of men and 8 per cent of women describe themselves as tee-totallers. This average figure conceals a great deal of variation between men and women, different age groups and different communities. Men and women in the 18–24 age group tend to have the highest consumption levels, declining progressively to those in the 65+age group who have the lowest levels of consumption. Older adults are less likely to be drinkers and there are a number of ethnic and religious groups who maintain a tradition of abstinence. Men usually drink more than women, but there is evidence from recent surveys that the drinking habits of younger women are becoming more similar to those of men.

How much alcohol we drink overall, and in what form, varies between one country and another and across time within each country. Britain has a relatively low level of alcohol consumption compared with most European countries. Historically, average levels of alcohol consumption were high in the eighteenth century and dropped to very low levels during World War II and the 1950s. Since then, consumption has risen quite a bit and we are now drinking about as much as at the beginning of the twentieth century. Economic and social factors play an important part in determining these trends; the high consumption of beer in the eighteenth century was partly enforced by the difficulty of obtaining a supply of clean water fit for drinking. The low levels of consumption in the early part of the twentieth century were largely the result of wartime rationing and a severe economic recession during the 1930s. The Family Spending survey of 1998 showed that spending on alcohol has risen by 40 per cent in real terms over the last 30 years in Britain. This increase has not been evenly distributed across British society: the biggest rise occurred in the poorest fifth of the population, where alcohol spending went up by 80 per cent.

Britain is still predominantly a beer-drinking culture, although the popularity of wine has increased greatly in recent years. This pattern of preference is similar to countries such as Denmark, Germany and Ireland. It contrasts with countries such as France, Italy and Spain, where wine has always been the preferred beverage, and another group of countries such as Poland and Sweden, where spirits are the most popular choice for drinkers.

The pattern of drinking varies between countries as well. Britain shares with Scandinavian countries a pattern of alcohol consumption which has sometimes been described as episodic or binge drinking. People will often go for several days without drinking at all but will then drink a relatively large amount in a single session (e.g. at the weekend). This contrasts with wine-drinking countries, where there is a pattern of steady drinking spread more evenly throughout the week. People may have a small amount to drink with each meal but will not usually consume a large amount in a single session. One very obvious implication of these differences is in the amount of drunkenness. Episodic or binge drinking is more likely to lead to intoxication and drunken behaviour.

How much should we drink?

Current recommendations mostly concentrate on defining what is a sensible upper limit. The UK’s medical royal colleges recommend an upper limit of sensible consumption of 21 units per week for men and 14 units per week for women. More recently, the UK Department of Health produced a higher figure of up to 28 units per week for men or up to 21 units per week for women. The fact that recommended levels for women are less reflects both their lower average body weight and their lower proportion of body water compared with men. These upper limits of sensible consumption are somewhat arbitrary since there is no...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Figures and illustrations
• Tables
• Contributors
• Foreword
• Preface
• Abbreviations
• Chapter 1: What is a drug and what is addiction?
• Chapter 2: Systemic effects of excess alcohol consumption
• Chapter 3: Alcohol and genetic predisposition
• Chapter 4: Alcohol and the brain
• Chapter 5: Alcohol on the mind
• Chapter 6: The sociology of alcohol abuse
• Chapter 7: Alcohol and society
• Chapter 8: Smoking and the lung
• Chapter 9 Smoking: addiction to nicotine
• Chapter 10: Helping people to stop smoking
• Chapter 11: Molecular basis of addiction
• Chapter 12: Ecstasy
• Chapter 13: Adolescent drug use and health
• Chapter 14: The nature of heroin and cocaine dependence
• Chapter 15: Benzodiazepineabuse
• Chapter 16: Treatment options across the addictions
• Chapter 17 Rehabilitation: the long haul
• Chapter 18: Policing drug abuse
• Chapter 19: Prevention
• Horizon scanning