Substance "Abuse"??

Addict-L Listserv
"Academic and Scholarly Discussion of Addiction-Related Topics"

Discussion: Substance use is not necessarily substance abuse, and certainly not "addiction".

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     What is the REAL justification for the War on Drugs?

     While we as clinicians limit the use of the term "addiction" to the criteria in the DSM-IV for dependence, the general public is being fed a line that all users of drugs are abusers/addicts. This seems to indicate to me that it is a political agenda that is being advanced, and not a public health/ medical agenda.

     Do any of the 200+ subscribers to this list ever feel uncomfortable with being an accomplice to the demonisation of all users of illicit drugs as either abusers or addicts? Is this even what most practicing treatment providers believe? Please, educate me as to the prevailing mindset......

Stephen R. King, BSW, BA

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     My colleagues, Tom Nicholson, John White, and I have been conducting an Internet-based study of non-abusing drug users for several years now. In presenting our findings to various groups we have found that many clinicians have as much trouble as the general public in recognizing that most illicit drug use is not abuse. Most researchers and some clinicians ask why we are boithering to study such a self-evident fact, while most clinicians in our audiences have seemed inclined to lynch us for even suggesting such an idea.

David F. Duncan, DrPH
Clinical Associate Professor of Medical Science
Brown University

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David Duncan,

     How do you find these non-problem drug users on the internet? Do they respond to calls for people who use, but don't abuse, illicit drugs? Are they mentally stable?

     And how do you determine that they have no problems with their drug use? Do you take their word for it? Does owning a PC qualify them?

     I know many individuals who admit that they at one time were addicted to heroin but firmly deny that they ever had a problem. I know many addicts who continue to use drugs and feel if they can get away with it that they have no problem. Of course they are oblivious to the damage their substance abuse causes others (or themselves for that matter).

     My mother-in-law (an admitted alcoholic) explained to me it was all right (no problem) for her to drink a six pack a day because she could handle that amount. She died a few years later (in her forties) of cirrhosis of the liver. She left two minor children(no problem). As a clinician I have to say that I seldom find a substance abuse victim who appreciates the seriousness of their situation. Should we wait until they are on their death beds and can recognize they have a problem before providing help?

David Heyer

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     David Heyer had questions about the online study of drug users that I mentioned. The subjects for Drugnet are volunteers who have responded to announcements on various newsgroups, discussion groups, and Wired online magazine. After entering the survey through an "anonymizer" they complete a lengthy online questionnaire which includes a drug use history, mental health assessment, and a variety of social factors. This is all self-report, of course, but many decades of experience have shown that most people are both relatively honest and reasonably accurate in giving such self-report under conditions of anonymity. Subjects are screened out if they meet or nearly meet or in the past met or nearly met DSM criteria for a substance abuse disorder.

     We have just changed internet servers and Drugnet is not online at present. Once the changeover has been ironed out, I will post the URL at which you can read some of the reports of our study.

     While we are using self-report from volunteers to build a picture of non-abusing drug users -- in continuation of work by Norman Zinberg -- there are many studies which bear on this issue that are not reliant solely on self-report. The NIMH's Epidemiologic Catchment Area Study, for instance, interviewed a random sample of the population of selected catchment area performing a DSM diagnosis in much the same manner as any clinician, including questioning alternate informants, such as spouses, parents, etc. They found that 17% of persons who used illicit drugs either currently qualified for a substance abuse diagnosis or had done so in the past. For alcohol the percentage was essentially the same at 20%. In other words, eight out of ten were using illicit drugs or alcohol without past or present abuse. Other population studies have consistently found the same pattern -- most users of alcohol or the currently illicit drugs never become abusers, and most of those who do, recover entirely through their own efforts without any need for treatment, self-help groups, or "fellowships."

     [Most] clinicians see only a tiny percentage of drug users who have the most serious problems and the poorest personal resources for dealing with those problems. This results in the classic problem of the distortion of the "clinical picture." Clinical experience consistently leads to a distorted view of the problem under treatment, with a tendency to see the problem as both more serious and less recoverable than is really true. While the principle was established in the study of infectious disease, it is even more true in our field.

     The myth of "denial" is perhaps part of that clinical picture -- people who deny that they have a problem are presumably less likely to solve the problem on their own. But my experience as a clinician tells me that it is mainly a result of poor clinical skills. I have worked with a great many alcoholics and many more drug abusers and have rarely encountered any meaningful degree of denial. The counselor who is open and non-judgemental does not see a great deal of denial. The counselor who expects denial and sets out in a confrontational fashion to get the patient to admit he is an alcoholic/addict creates the conditions in which denial is a healthy, normal response.

David F. Duncan, DrPH
Clinical Associate Professor of Medical Science
Brown University

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