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Article Contents

I. introduction, ii. three motivations and two desiderata, iii. pharmacological definitions, iv. functional-kind definitions, v. social-kind definitions, vi. discussion, acknowledgments.

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Sam Baron, Sara Linton, Maureen A O’Malley, On Drugs, The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine , Volume 48, Issue 6, December 2023, Pages 551–564, https://doi.org/10.1093/jmp/jhad035

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Despite their centrality to medicine, drugs are not easily defined. We introduce two desiderata for a basic definition of medical drugs. It should: (a) capture everything considered to be a drug in medical contexts and (b) rule out anything that is not considered to be a drug. After canvassing a range of options, we find that no single definition of drugs can satisfy both desiderata. We conclude with three responses to our exploration of the drug concept: maintain a monistic concept, or choose one of two pluralistic outcomes. Notably, the distinction between drugs and other substances is placed under pressure by the most plausible of the options available.

Medicine in both its current and historical forms is almost inconceivable without drugs. Virtually every aspect of medical care, from diagnosis to cure, involves the prescription and administration of drugs. But what exactly are drugs in the modern medical sense of the term? According to Benedetti, a pioneer of mechanism-based work on placebos, “defining a drug is an easy task" ( 2014 , 329). A drug:

…is a molecule delivered to the body to produce a biological effect. Its mode of action is to alter one or more biochemical pathways, for instance, by binding to a receptor or by modifying the activity of an enzyme. ( Benedetti, 2014 , 329)

In contrast, our account shows that the task of defining medical drugs is far from easy. Not only is Benedetti’s definition too narrow, but there is no viable definition of what drugs are that includes all and only those substances that are considered to be drugs in modern medicine.

Our paper is thus a first salvo against a conceptually monistic view of medical drugs: the idea that there is a single set of necessary and sufficient conditions that defines the medical drug concept. Why target a monistic account of drugs? Why not simply assume a degree of conceptual pluralism from the outset? This would, after all, fit a growing trend within philosophy of science toward pluralism for a number of scientific concepts from a range of domains, including “concept” itself (e.g., Dupré, 1999 ; Stotz, Griffiths, and Knight, 2004 ; Weiskopf, 2009 ).

One reason we begin with a monistic view is that conceptual monism seems to underlie much of the thinking about drugs within medicine and biomedical science. This is certainly evinced in Benedetti’s confident assertion above of what drugs are, but he is not alone. Most pharmacology textbooks begin with a brief but broad definition of drugs (see Section III ) and then quickly move on to the task of explaining how drugs work.

A second reason for focusing initially on a conceptually monistic view of drugs is that it could be true in the restricted medical context we investigate. If legal and recreational drug concepts were also part of our inquiry, then a pluralistic view of drugs might seem a reasonable starting point. Currently, however, there is no existing body of work in philosophy that strongly suggests a plurality of drug concepts operating within medicine. Indeed, there has been very little philosophical work on the nature of medical drugs, despite their central role in medical practice. A consideration of the drug concept needs to start somewhere, and investigating the case for conceptual monism is an efficient way to begin an overdue philosophical discussion of drugs.

Even if a singular account of drugs fails, which we ultimately show to be the case, there is value in starting our investigation from a monistic basis. An examination of this sort proceeds by offering an overarching definition of what drugs are and then testing it against various criteria of adequacy. The fault-lines of various definitions tried in this manner are likely to reveal the contours of any underlying plurality of concepts. The failure of any single drug definition to do what is required of it tells us something about where distinct but related drug concepts may lie in relation to one another.

In this paper, we canvass a range of options for defining drugs and show that none of them is adequate. We begin, in Section II , by saying a bit more about the motivations behind our project before identifying two desiderata for an adequate definition of the drug concept. In Section III , we look to pharmacology for guidance, and analyze existing pharmacological definitions to draw out a list of properties that might be used as a basis for developing a definition of the drug concept. We also briefly consider natural-kind definitions before, in Section IV , pressing on to look at functional-kind definitions. Finally, in Section V , we consider social-kind definitions. In all cases, we find no definition of drugs that satisfies the basic desiderata laid down in Section II . We conclude, in Section VI , by presenting three responses to our exploration of the drug concept: one revisionary monistic conception, and two pluralistic accounts of drugs. We suggest that on the two most plausible options, a distinction between drugs and some putatively non-drug substances is difficult to sustain.

Our conceptual analysis of drugs has three main motivations. First, drugs play a major role in treatment, which is probably the core and very rationale of medicine, and is thus important to any philosophy of medicine. While it is unlikely that treatment can be defined exclusively in terms of drugs, the administration of a drug for therapeutic purposes does appear to be at least a sufficient condition for medical treatment. A drug may also feature as part of a necessary condition on treatment. Medical treatments might simply consist of a certain set of therapies, one of which is drug therapy. This does not, of course, serve as anything like a deep account of treatment, and we are not offering a conceptual analysis of it. The point is merely that drug therapy is central to treatment in medicine, and so a clearer understanding of what drugs are is likely to help us better understand the philosophical nature of treatment.

Drugs, via their connection to treatment, may also play a role in clarifying notions of health and normal functioning, which are probably the most debated issues in philosophy of medicine (e.g., Ereshefsky, 2009 ; Griffiths and Matthewson, 2018 ). Consider a diabetic who takes insulin. When a person’s body produces insulin of its own accord in the course of normal functioning, the chemical is not considered to be a drug. However, once the body stops producing insulin and that chemical is subsequently administered to the body, at that point insulin is a drug. One sign of abnormal functioning, then, is the need to replace a chemical produced by the body with a drug. Drugs are capable of restoring normal function in specific circumstances. A similar point can be made about health. One marker of ill health is the chronic need to take a drug. Taking a drug is thus potentially sufficient to identify both abnormal functioning and ill health.

A definition of what drugs are can also help us shed light on certain pressing demarcation questions. This is our second motivation. One demarcation question concerns the relationship between drugs and placebos. Much of the literature on placebos, both within medicine and within philosophy, sets placebos up in fundamental opposition to drugs ( Miller and Brody, 2011 ). One fairly natural line of thought is that the difference between drugs and placebos lies in their mode of action. While both placebos and drugs can bring about therapeutic benefits, the main causal action of a placebo is via our beliefs, whereas the main causal action of a drug is via some biochemical pathway. To put the point somewhat provocatively, as others have (e.g., Colloca and Benedetti, 2005 ), placebos alter the mind, whereas drugs alter the body.

Whether this distinction holds up to scrutiny depends on how drugs and placebos work. It has long been acknowledged how difficult it is to define the concept of a placebo and, in particular, to identify placebo effects ( Kienle and Kiene, 1997 ; Miller and Brody, 2011 ). However, because placebos are set up in opposition to drugs, it may be the case that the conceptual difficulties surrounding the notion of a placebo are partly due to a corresponding lack of clarity surrounding drugs. Thinking about drugs might help us not only to answer the question of whether placebos are drugs, but also to understand what placebos are . Matters are complicated by the fact that many placebo chemicals (e.g., lactose, fatty acids) can produce physiological effects of the kind that are normally associated with drugs ( Golumb et al., 2010 ). If the relevant chemical that is being administered as a placebo has the potential for a positive health outcome, and that outcome can be linked to the chemical action of the placebo, then the gap between placebos and drugs would seem to be narrowed ( Benedetti, 2014 ).

Aside from posing a conceptual conundrum, the contrast between placebos and drugs influences how we think about the use of placebos as a control substance in clinical trials. Trials to establish the efficacy of a specific drug are often measured against the efficacy of a placebo. Clinicians often see such comparisons as a way of comparing the drug to an “inert” or “non-active” substance ( Miller and Brody, 2011 ). There is a question, then, about whether placebos are an appropriate control substance. If they are drugs, and this has not been properly recognized, then the failure to view placebos as potential drugs, with chemical pathways of their own, may lead to misinterpretations of clinical trial results.

There is also the question of why placebos with demonstrated efficacy are not generally recommended as drug-based therapies alongside whatever drug they were tested against in clinical trials. Anti-depressants are a case in point. In a now-famous meta-analysis, Kirsch et al. (2002) argued that more than 80% of the effect of anti-depressants is a placebo effect. The authors concluded that anti-depressants are not, in fact, very effective. An alternative conclusion is that there are two categories of anti-depressant drug, one of which is more effective than the other (i.e., the placebo “drug”), but that line of thought is not taken very seriously. Drugs clearly occupy a position in medical treatment that placebos do not. A conceptual analysis of drugs can help us to understand this perceived difference between placebos and drugs and even challenge it (if, for instance, a conceptual distinction between drugs and placebos is ultimately unsustainable).

Another demarcation challenge arises for excipients. Excipients are constituents of medicines that aid in the delivery of a particular chemical to a physiological system (e.g., the material in an aspirin tablet, apart from the acetylsalicylic acid, that helps in the drug’s stability, gastric disintegration, and systemic absorption). As with placebos, there is a tendency to draw a distinction between excipients and drugs. The excipient is the “inert” or “inactive” component of a medicine, whereas the drug is the “active” component of the medicine ( Jivraj, Martini, and Thomson, 2000 ).

There is, however, an increasing awareness that excipients are not as “inert” as previously thought. Excipients can and do interact with the rest of the chemical constituents of a medication to produce unwanted or unexpected effects ( Pifferi and Restani, 2003 ; Haywood and Glass, 2011 ). Moreover, excipients can sometimes be used for therapeutic purposes in other contexts. For instance, stearic acid is a commonly used excipient because of its low toxicity. However, it has also been used therapeutically as a topical cream for burns in mice ( Khalil et al., 2000 ). This raises a similar question to the one in the placebo case, namely: are excipients drugs? If the answer is “yes,” then this has clear implications for how to view the supposedly inert substances that are coupled with drugs for the purposes of administration. If the answer is “no,” then it would be useful to know exactly why.

Finally, determining what drugs are would help to distinguish pharmacology from other sciences. Pharmacology is supposed to be the distinctive science of drugs. However, without an account of what drugs are, it is difficult to differentiate pharmacology from the broader study of chemical interactions within biological organisms (biochemistry) or even from the study of chemicals (chemistry). Such a distinction would also shed light on certain normative questions: why should we apportion funding and resources to pharmacology per se over biochemistry or chemistry more broadly?

To frame our investigation into all these questions, we suggest two desiderata for an adequate definition of the drug concept. Although there may be other criteria that could be included, satisfying these two desiderata is a condition on the minimal adequacy of a definition. We thus offer these desiderata not as a comprehensive guide to what the drug concept should be, but rather as a starting point for investigating that concept from an initially monistic outlook.

First, a definition of medical drugs should capture everything that is considered to be a drug in medical contexts. It should not be the case, for example, that under a candidate definition paracetamol is in whereas antacids are out. If substances commonly taken to be medical drugs are excluded by any supposedly unifying definition, the consequences of that exclusion should be justifiable and acceptable to pharmacological and medical practice. Likewise, if the definition brings in substances that are normally excluded, their inclusion should be similarly justifiable and acceptable.

How do we determine whether a definition of drugs covers the relevant substances? This can be done by consulting a comprehensive drug compendium, which lists substances that are used medically. A prominent example is the drug bank compiled by the government-funded Canadian Institutes for Health Research (DrugBank Online). 1 This list contains over 13,000 drug entries, which are searchable by molecular structure, therapeutic use, and countries where the drug is approved or actively used for medical purposes. 2 Ideally, an overarching drug concept would be applicable to everything on this list.

Second, a definition of what medical drugs are should capture only those things that are considered to be drugs in medical contexts. They should thus not include anything that is not considered to be a drug. Insofar as there is any consensus on how to define drugs, it appears to be that food and nutrients are always deemed not to be drugs ( Dale and Haylett, 2009 ; Ritter et al., 2020 ). An adequate definition of what drugs are should thus not allow food or nutrients to qualify. Relatedly, it should not follow from a drug concept that eating food is a way of taking drugs, except when drugs are added to food. Ideally, criteria for dealing with food will illuminate other supposed non-drug substances currently categorized as placebos and excipients.

A basic definition of medical drugs should thus include all the substances taken to be medical drugs and exclude all the substances that are not. An obvious place to begin our search for an overarching definition of the drug concept is pharmacology. We might even hope for some sort of pharmacological law that underpins the designation of every substance that counts as a drug. Unfortunately, when we look to pharmacology textbooks, we find very little agreement over what drugs are, even though pharmacologists recognize the importance of giving a clear and encompassing definition. From an analysis of pharmacological textbooks, we collated 24 explicit definitions of the drug concept. 3 From these definitions, we can identify 10 components that are used to define drugs, either in combination with one another or on their own:

(1) Drugs are chemicals.

(2) Drugs affect biological or physiological function.

(3) Drugs have a specific manner of effect (i.e., through chemical action by interaction with specific molecular components, thus modifying the response of a cell or tissue to its environment).

(4) Drugs are used for the diagnosis or treatment of disease.

(5) Drugs are administered.

(6) Drugs extend life.

(7) Drugs alleviate pain or suffering.

(8) A drug is a constituent of a medicine.

(9) A drug is not a food or nutrient.

(10) A drug is or could be listed in a pharmacopeia.

A quick glance at these components reveals two things. First, definitions of drugs are surprisingly varied. Current definitions range from the exceedingly general definition of a drug as “a chemical that affects living tissues” ( Bryant, Knights, and Salerno, 2011 , 2–3) to the more specific definition of drugs in terms of “molecules that interact with specific molecular components of an organism to cause biochemical and physiologic changes within that organism” ( Alenghat and Golan, 2017 , 2). There is also a detectable cleavage in existing definitions between whether emphasis is placed on the biochemical or on the social features of drugs. Compare the above two definitions with the definition below that emphasizes therapeutic use:

Any substance or combination of substances presented as having properties for treating or preventing disease in human beings; Any substance or combination of substances which may be used in, or administered to, human beings, either with a view to restoring, correcting or modifying physiological functions by exerting a pharmacological, immunological or metabolic action, or to making a medical diagnosis. (Directive 2001/83/EC of the European Parliament, as cited in MRHA [2020] )

Another notable feature of existing drug definitions is the tendency to try and rule out food by fiat. This not only speaks to the importance of identifying a concept that achieves the desired contrast with food, but also to the difficulty with which this contrast may be achieved in a principled way. For example:

A drug can be defined as a chemical substance of known structure, other than a nutrient or an essential dietary ingredient , which, when administered to a living organism, produces a biological effect (our emphasis; Ritter et al., 2020 ; ch. 1).

Although pharmacology fails to provide a single cohesive definition of what drugs are, it does provide a great deal of source material on which a viable definition might be based. We can thus use the 10 components identified above to examine how a definition of the drug concept might work.

A standard first move in the conceptual analysis of scientific concepts is to appeal to natural kinds. A traditional natural kind definition is one according to which there is some intrinsic physical property or cluster of intrinsic properties that are features of all drugs. Natural-kind definitions are worth briefly considering because definitions along these lines do appear to underwrite some thinking about drugs. They are, for example, found in some pharmacology textbooks. In general, however, definitions of this kind in the case of drugs tend to be either far too broad or far too narrow.

For instance, we could take the first component on the pharmacological list and just define drugs as chemicals. However, while it is plausibly a necessary condition on being a drug that it is a chemical, it can hardly be considered sufficient. There are clearly many chemicals that are not drugs (e.g., graphite, cobalt nitrate). Or, to take another example, suppose we say that all drugs are chemicals that share a certain structure. There is a range of molecular structures that drugs can have. These include inorganic salts (such as potassium chloride), small to moderate organic compounds (such as aspirin and other salicylates), and large complex proteins (such as insulin glargine). The trouble is that there is no common molecular structure that all drugs have in common, even though there are classes of drugs that share a particular molecular structure. 4 Determining such structure helps with drug classification, but not for defining what drugs, in general, are.

There is one natural-kind-style definition that we are particularly keen to set aside. We mention it only because it seems to be a popular way to think about medical drugs outside the medical community. This definition appeals to a distinction between drugs and “natural” substances. It claims that the common property of all drugs is that they are manufactured or artificially produced chemicals and so are unnatural. Non-drugs—like food and nutrients—by contrast are natural substances, containing only chemicals that arise in nature. This definition fails, however, because the distinction between drugs and natural substances is open to numerous straightforward counterexamples. Acetylsalicylic acid (aspirin), for instance, can be derived from willow bark, and many other substances now considered drugs have similarly “natural” origins. Indeed, according to Bade, Chan, and Reynisson (2010) , around 10% of drugs on the market are unaltered natural substances.

A much more plausible account of drugs focuses not on any intrinsic nature but, instead, on their functional biological properties: the specific manner in which they interact with biological organisms. In the next section, we consider functional-kind-based accounts of drugs that do precisely this.

Using the functions of drugs to define them means we need to focus not on what drugs are , intrinsically, but on what they do . In pharmacology, receptor theory has been the primary candidate for defining drugs in terms of their functional role. Historical discussion in the field reveals a quest for an underlying biological principle that not only distinguishes drugs from other chemicals but also explains and predicts how they work therapeutically in human bodies (e.g., Parascandola and Jasensky, 1974 ; Kenakin, 2004 ). Indeed, according to Rang, “Receptors lie … at the heart of pharmacology … they provide the basic framework and are [its] ‘Big Idea’” ( 2006, S9 ).

As receptors transformed during the twentieth century from unknown theoretical entities into specific biological molecules (historically proteins), their role in drug action seemed to illuminate the nature of drugs. The basic idea is that there are certain proteins inside physiological systems that are either activated to bring about a certain effect when chemicals bind to regions on proteins, or are blocked from bringing about an effect via the same process of binding. These receptor proteins are separated into four distinct classes of drug “targets,” which have binding sites that drugs act on: G-protein-coupled receptors, ion channels, enzymes, and transporter proteins ( Ritter et al., 2020 ).

One option for defining drugs in terms of their functional role, then, is to define drugs in terms of receptor binding with respect to these four molecular targets.

Definition 1 (D1): Drugs are chemicals that bind to one of four receptor molecules found within biological organisms.

Now this definition has many exceptions: there are drugs that operate without binding to one of these four receptors (e.g., carboplatin, which interferes with DNA in cancer cells to inhibit growth; or bisphosphonates used in the treatment of osteoporosis).

These exceptions might indicate that we should try expanding the definition of what receptor molecules are. One broadened definition of a receptor is a “recognition molecule for a chemical mediator through which a response is transduced” ( Ritter et al., 2020 ; ch. 2). The identification of several classes of receptor proteins thus offers a way to narrow the definition of drugs. Only certain chemicals bind to certain receptors. Not all chemicals are capable of binding to all or even some receptors in the relevant sense. A drug, from this perspective, is a chemical that binds to a particular receptor inside a physiological system (e.g., Neubig et al., 2003 ; Maehle, 2009 ).

Definition 2 (D2): Drugs are chemicals that bind to receptor proteins inside biological organisms.

D2 has the virtue of retaining receptor theory at the heart of the drug concept and thus capturing a widely held view about drugs in pharmacology, in which receptors are “the seminal concept that all classes of therapeutic agents produce their effects by acting as ‘magic bullets’ at discrete molecular targets [receptors]” ( Winquist, Mullane, and Williams, 2014 , 7).

Unfortunately, D2 is too narrow. There are drugs that function without binding to anything, either protein or non-protein. Concentrated electrolytes, such as potassium salts, are an example. They work by creating, restoring, or minimizing a charge gradient across a cell membrane. Osmotic laxatives work in a similar way. Antacids are also considered drugs but they alter the pH of the stomach via chemical reaction rather than by binding to anything.

Conversely, many processes in cells operate via binding mechanisms and yet the chemicals involved are not considered drugs. For instance, ATP, the energy conversion molecule in cells, binds to a variety of proteins in the everyday course of cellular activity and organismal function. Antibodies bind to receptors on foreign entities but are not drugs, at least not when they occur endogenously. Likewise, enzymes—the workhorses of the cell—bind to all kinds of chemical substrates in the process of carrying out a huge range of basic cellular processes. Despite the centrality of binding to their activity, these endogenously produced molecules are not drugs. As Rang puts the point:

Is there anything about drug–receptor interactions that distinguishes them, as a class, from other kinds of biochemical goings‐on, that might justify the use of the specific term “receptor theory”? Not obviously. ( Rang, 2006 , S14)

We could try expanding the definition of a drug even further, away from receptor theory and protein binding. We could focus only on the causal action of the drug in the most general terms. A drug is thus a chemical that induces a physiological change inside an organism (D3).

Definition 3 (D3): Drugs are chemicals that induce physiological changes inside organisms.

While D3 (or something like it) is a common enough definition to be found in pharmacology textbooks, it is far too broad. It easily includes essential nutrients, all of which have physiological effects on organisms. Food is a way of introducing chemicals—namely, nutrients—into an organism to bring about a physiological change.

Can we find a “sweet spot” between the too narrow definition of a drug as one that binds to receptors, and the too broad definition of a drug as something that induces a physiological change inside an organism? Put another way, can we give a functional-kind definition of what drugs are that achieves the desired contrast between drugs, on the one hand, and food and nutrients, on the other? One option might be to try and rule food out via an appeal to medicines, and in particular to the notion of drugs as the active component of medicines (D4).

Definition 4 (D4): Drugs are the active ingredients of medicines.

There are two problems with D4, however. First, it presumes some prior notion of a medicine that cleaves it apart from food. The notion of a medicine is no less in need of conceptual clarification than the notion of a drug itself. Second, at least some chemicals considered to be drugs do not straightforwardly contain an active ingredient. Consider, for instance, pro-drugs. Pro-drugs are substances that are introduced into the body but which have to be metabolized into another substance to carry out their designated activity ( Rautio et al., 2008 ). It is the chemical outcome of the metabolic process that has the sought-after affect. Pro-drugs, according to the active ingredient view, cannot count as drugs because they do not contain the active ingredient, even though they ultimately help generate it. Of course, this depends on what “active ingredient” means. But that is precisely our point: it is not entirely clear how to specify the “active” part of “active ingredient” in such a manner that does not exclude various pro-drugs.

Another difficulty with D4 is that it is far from obvious that the drug is always the active ingredient rather than the entire medicine. Consider medical uses of cannabis. Cannabis contains at least 400 different chemical compounds, of which 61 are considered to be cannabinoids ( National Center for Biotechnology Information, 2020 ). Of these 61, the two most well-known are Tetrahydrocannabinol (THC) and Cannabidiol (CBD). But many of the other cannabinoids are thought to modify the physiological effects of cannabis. It is not clear that there is a single active ingredient in cannabis, so much as a range of different chemicals having a systemic effect on an organism. Classifying drugs in terms of their active ingredients alone would cause considerable problems for cannabis and other such substances.

Another way to try and achieve the desired contrast between drugs and nutrients might be to try and define drugs in terms of a very specific type of causal pathway. Thus, one might accept that drugs and nutrients do the same thing in some cases, but the way in which drugs achieve their outcome is distinctive. Since we cannot use receptor theory to get the desired contrast, we would need some other way to differentiate the type of causal action. But hypothetically, at least, we could say:

Definition 5 (D5): A drug is a chemical with a specific type of causal action inside physiological systems.

Aside from leaving the causal action of drugs dangerously underspecified, D5 faces a potential counterexample in the form of pro-drugs. As already noted, the type of causal pathway that leads from a pro-drug towards its effect is very similar, and plausibly of the same type, as the causal pathway that leads from some foods to nutrition.

Indeed, for at least some pro-drugs, the particular metabolic process that it undergoes mirrors the catabolic process involving glucose that produces ATP. A central aspect of the production of ATP involves the phosphorylation of glucose, in which a phosphoryl group is added to the glucose molecule. Some pro-drugs achieve their effects via a similar process. A drug used to treat COVID-19, remdesivir, is actually a pro-drug that, when administered, gets transformed by the addition of new molecular components within the cell via phosphorylation. The resulting chemical compound, which is considered the “active metabolite,” then interacts with a molecular target in order to achieve the desired effect. While remdesivir does not produce ATP, it is difficult to discern a difference in the causal mechanism that transforms remdesivir and the causal mechanism that transforms glucose.

Perhaps another option for achieving the desired contrast between nutrients and drugs in terms of causal action would be to emphasize their different effects. For instance, we might base a definition of what drugs are on a prior distinction between sustaining life and improving health. Thus, a nutrient is a chemical that is needed to sustain the physiological processes that enable an organism to live, whereas a drug is a chemical that induces a physiological change that improves the health of an organism (but the organism does not require the chemical to live).

Definition 6 (D6): Drugs are chemicals inducing physiological changes inside organisms that improve the organism’s health rather than merely sustaining the organism’s life.

Now the problem with D6 is that drugs such as insulin are used to sustain life. This means that the contrast between sustaining life and improving health fails to differentiate drugs from nutrients in terms of their causal outcomes.

Perhaps, instead, we can understand drug outcomes with respect to a baseline of normal functioning (D6).

Definition 6 (D6): A drug is a chemical that restores or improves normal functioning.

The concept of “normal functioning” is a contested notion, but whichever account is used, problems arise. Arguably, the contraceptive pill (a drug), when used to prevent pregnancy, prevents “normal function” of the reproductive system. There are two ways of understanding normal function: statistical normality, and evolved normal function in which certain traits are normal because they are selected effects ( Griffiths and Matthewson, 2018 ). For the first, an assessment is made of what is typical of the reference class (let us say, healthy women between 20 and 40 years old in Western societies). The large majority of these women can conceive and in the “normal” course of affairs would do so. Contraception ends up creating a new normality (not conceiving). Only in the sense of this new statistical fact (that 50% or more of the population are taking contraceptives) are contraceptive drugs “restoring (new) normal function.” But this appears to be vacuous.

The evolutionary case for normal function depends on populations and their reproductive capacities. Human beings and other organisms succeed evolutionarily when they leave more offspring. Evolution can thus be thought of as “rewarding” reproduction, which is a selected normal function. Contraception is in fact preventing the basic “normal” thing human beings have evolved to do: reproduce. Now of course contraception may enable better parental care of fewer offspring, and thus more evolutionary success, but it is not entirely clear that a standard evolutionary explanation can encompass the direct mechanism by which this is achieved (contraceptive drugs).

The normativity of “normal” might be what is preventing D6 from working. What if drug function could be tied to a law, and normativity thus left out of the picture? Pharmacology, it could be argued, supplies a range of pharmacological laws that specify how drugs function within biological systems. A definition could thus be provided in terms of these laws. One difficulty with this move is that the subject matter of pharmacology would have to be specified in order to delimit its laws. However, this specification requires first providing an account of what drugs are. One way to overcome this problem would be to adopt an account of drugs that accepts a dependency between drug concepts and laws. A definition along these lines can be stated as follows: 5

Definition 7 (D7): X is a drug iff X features in a pharmacological law, where Y is a pharmacological law iff it relates drug concepts.

The basic idea is to define drugs and pharmacological laws mutually, rather than using one as a foundation for the other. The definition is circular, but not necessarily in an objectionable sense. Indeed, circularity of this kind may offer a way to bootstrap the analysis into better conceptual territory. It also allows for future updates in that new drugs might invoke existing laws or, in some cases, help establish new laws, and vice-versa.

One way of applying D7 is to start with a clear case of a drug. Any laws that apply to the drug immediately qualify as pharmacological laws in virtue of featuring drugs. We can then work back down from the laws and see what else the laws cover. Anything further that the laws cover is then also classed as a drug. The second way of applying D7 is to start with a clear case of a pharmacological law. Substances that are covered by the law immediately count as drugs. Ideally, through this back and forth, the analysis ends up with a set of substances that contains all and only those things considered to be drugs, along with a group of laws that operate on just those substances.

D7, if made to work, would certainly be a principled way in which to provide a functional analysis of drugs. Unfortunately, it seems to yield the wrong results. Suppose we start with the laws. The best candidates for pharmacological laws are the general principles that govern receptor theory. Such laws include the Hill-Langmuir equations and the Michaelis-Menten equation. Together, these equations form a quantitative model of receptor theory by describing the way in which enzymes bind to molecules over time (in the presence or absence of agonists and antagonists that can reverse the binding process) and how substances change in the presence of enzyme binding ( Chou, 1976 ; Colquhoun, 2006 ). The problem is that these equations describe substances that are not drugs, and processes that are not generally associated with drug effects. The Hill-Langmuir equations, for instance, also apply to food and nutrients that are metabolized by enzymes in the gut, via a metabolic process that binds nutrient molecules to enzyme receptors.

Even if it were possible to specify or otherwise restrict the laws so that they do not apply to food and nutrients, there is also the issue of a great many drugs falling outside the scope of receptor theory. This problem could potentially be addressed by applying D7 in the second manner described above: by using drugs to specify the pharmacological laws. Thus, we start from those drugs that fall outside of receptor theory and work upward to additional pharmacological laws that operate on these substances. The trouble, however, is that there are drugs that when treated in this way will yield laws that encompass substances that are not drugs.

One example is mitotic inhibitors, which are a specific class of cancer drugs. Mitotic inhibitors work by inhibiting cell-division. Such substances are therapeutic because they target the fast-growing cells that give rise to cancerous masses. A general law could be devised that describes the way these substances inhibit cell growth. The trouble, however, is that there are many substances that will also satisfy the law and which are not considered drugs. As Matson and Stukenberg (2011 , 143) note, “it is clear that many compounds that result in mitotic arrest are neither useful therapeutics nor even effective at killing cells.” For instance, benomyl, a carbamate, inhibits mitosis in mammalian cells ( Gupta et al., 2004 ), but it is not a drug; it is a fungicide commonly used in agriculture. In general, chemotherapy drugs are difficult cases because they blur the line between being toxic enough to treat cancer and not so toxic that they ultimately lead to death. There will be many cases in which two very similar substances, with similar functions, lie on different sides of that divide.

In a general sense, then, the problem with functional definitions of drugs is that they are either too narrow, capturing at best receptor-based reactions, or they are too broad, capturing various kinds of metabolic processes or toxifying activities. It is difficult to strike the right balance between these competing demands in a principled way. Although we cannot rule out the possibility of defining drugs functionally via other means, it does not seem likely that focusing on their causal properties sets drugs apart from other kinds of chemicals (and nutrients in particular). Drugs do not seem, therefore, to be good candidates for a plausible account of functional kinds.

So far, we have argued that neither natural-kind nor functional-kind definitions yield a satisfying account of what drugs are. This brings us to another way of defining drugs. Within the ten components of drug definitions that we identified in Section III , there were distinctive social aspects. This suggests that being a drug is not a matter just of being a certain chemical, or of having a certain functional role but, rather, of being used for a particular socially defined purpose. In particular, drugs are administered by healthcare professionals for therapeutic ends (D8).

Definition 8 (D8): A drug is a chemical that is administered within a medical context with the aim of bringing about a positive health outcome.

D8 faces a familiar problem in that food is often prescribed in treatment contexts in order to improve health (e.g., the FOD-MAP diet for irritable bowel disease; low potassium diets for kidney disease). A particularly difficult case is total parenteral nutrition (TPN). 6 TPN is a chemical infusion containing fat, glucose, amino acids, electrolytes, trace elements, vitamins, and minerals. It is given to people who are unable to absorb nutrients in the ordinary way, through their stomachs. It is usually administered continuously over 12–24 hours and can be administered as a short course for several days or on a long-term basis. The goal of administering TPN is clearly to bring about a positive health outcome. However, TPN contains the same nutrients as food (it is just that these nutrients are administered in a way that bypasses the stomach).

The prospects for refining D8 to handle TPN are not good. The definition has two aspects: the notion of administration and the notion of a positive health outcome. TPN is administered in the same manner as a range of intravenous drugs, and so there is no way to draw a distinction between TPN and other substances via administration alone. The notion of a positive health outcome is similarly difficult to refine. The health outcomes related to TPN are analogous to the desired outcomes for many drugs.

In light of the difficulty facing D8, one option might be to shift the emphasis from medical treatment to a different kind of social criterion, namely: regulatory regimes (D9).

Definition 9 (D9): A drug is a chemical that is subject to a specific set of healthcare regulations.

According to D9, a drug is any chemical that is regulated inside a medical context, such as a hospital, surgery, pharmacy, or medical practice in a specific way . What way is that? Presumably, whatever regulatory framework is imposed on drugs in particular as opposed to other aspects of medical care.

The problem with D9 is that there is no single set of healthcare regulations that might be used to give substance to that specification, especially when we consider relevant international regulations. The controversial treatment of acidified sodium chlorite, for example, is not recognized as a drug in the United States, but counts as an “orphan drug” in the EU for a motor neuron disease ( EMA, 2013 ), even if evidence of its benefits is extremely limited.

There is also a deeper problem with regulatory definitions of what drugs are. If we simply define drugs as any chemicals that fall under a certain set of medical regulations, it becomes unclear how we determine what these regulations should apply to in the first place. One option might be just to include a list of chemicals within the relevant regulatory framework. But then there is a question of how we decide what to include on the list and what to exclude from the list. Again, it is not possible to call on a prior conception of what drugs are to decide what the list should contain, because a drug is just anything that is on the list.

A possible way forward might be to define drugs in normative terms. A drug would then be any chemical that should be regulated in a certain kind of way within healthcare contexts, rather than any chemical that is as a matter of fact on a list of regulated substances. Drugs could be defined as substances that should be regulated so as to minimize harm (D10).

Definition 10: A drug is a chemical such that its administration in a healthcare context ought to be regulated in order to minimize health-related harms.

D10 faces at least two challenges. First, it is unclear what “health” actually means. This is a much-contested notion in the philosophy of medicine (e.g., Ereshefsky, 2009 ), and so invoking a notion of health-related harm to define drugs may turn out to be more difficult than defining drugs. For instance, does health-related harm include harms to mental health? Presumably it should in order to include psychiatric drugs, but then we need not only an account of physical health, but of mental health. Any definition of mental health would need to be at least consistent with a definition of physical health, so we still need to know what health is. This is likely to bring us back to the manifold issues of notions like normal functioning that we outlined for D6. There is no agreed-upon notion of normal functioning that we can simply call on to fill out D10.

A second problem is that D10 still seems to be too broad. Once again, TPN is a case in point. TPN is strictly regulated in healthcare contexts, because there are health-related harms associated with the improper administration of this nutrient solution. For instance, TPN carries a risk of blood infection. While there is a risk of a blood infection with any intravenous solution, the length of time that TPN is administered and the high glucose content of the solution makes infection risk a serious concern. In addition, if TPN is improperly formulated by incorrectly balancing the electrolytes in the solution, there is a substantial risk of arrhythmia and seizure. There is therefore just as much need to manage the potential health-related harms associated with nutrient solutions as there is for any drug.

Our 10 definitions of drugs have not taken us any closer to a natural-kind-based definition, functional-kind-based definition, or even a social-kind-based definition of drugs. Any combination of intrinsic, functional, and social factors merely picks and chooses which elements of a basic list of properties to combine and emphasize, and each of those combinations runs into trouble. Although our discussion is by no means exhaustive, we do take it to cast doubt on the prospects for finding a robust definition of drugs that achieves the two desiderata identified in Section II .

One way forward in our conceptual understanding of drugs is to give up or otherwise modify one of these two desiderata in an effort to save a conceptually monistic view of drugs. Recall the two desiderata: (a) everything considered to be a drug should be captured, and (b) everything that is not considered to be a drug should be ruled out. The focus of (b), in particular, was on food and nutrients. A straightforward suggestion then is simply to give up on the contrast between medical drugs on the one hand, and food and nutrients on the other. While giving up the contrast with food will do little to resuscitate a functional or natural-kind definition of drugs, it does seem to bring two of the social-kind definitions back into play, specifically D8 and D10. So, for instance, we could adopt D8 and just concede that, within a medical context, food, and nutrients are drugs because they have a therapeutic benefit. This is not so extreme an outcome, especially once we take into account the comparability in physical action between many drug molecules and nutrients, specifically for nutrient solutions like TPN.

There are two important implications of adopting this response to the arguments presented here, however. First, if the administration of a drug is at least sufficient for medical treatment (as noted in Section II ), then the administration of food and nutrients in a hospital counts as a dimension of medical treatment and care as well. This would not be limited to TPN. Simply feeding a patient in order to ensure a positive health outcome would plausibly fall under the broad rubric of medical treatment. This would lift the ethical stakes when it comes to how food is managed inside a hospital. In addition, insofar as all drugs ought to be regulated in some way within a healthcare setting, it follows that food and nutrients should be subject to a similar regulatory framework. Similar implications carry forward to notions of health and normal functioning. If chronic drug-taking is sufficient to define ill health and abnormal functioning, then patients on prescribed diets may well fall under these notions insofar as the food and nutrients prescribed satisfy the drug concept. This places an additional burden on conceptual analyses of health and disease.

The second implication relates to placebos and excipients. If the drug concept is defined via D8 or, indeed, via any of the social-kind definitions provided in Section VI , then we have clear answers to the two demarcation questions identified in Section II , namely: are placebos drugs? And are excipients drugs? The answer, in both cases, is “yes.” Both placebos and drugs can be administered with an aim of bringing about a therapeutic benefit (though, in the case of excipients, this may be an indirect relationship based on the need for a delivery mechanism for a certain chemical). Similarly, placebos and excipients can have ill effects, and so there is reason to regulate them in the manner that drugs are regulated. If nothing else, this suggests a reconceptualization of placebo-controlled trials. Such trials should not be thought of as experiments in which drugs are compared with non-drugs. These are trials in which one drug is compared with another.

A more positive corollary to these issues is whether “natural” remedies are substances distinct from drugs. D8 suggests they are drugs when they are used with the aim of bringing about a therapeutic benefit. This reclassification would have the virtue of no longer exempting such substances from the risk-benefit analyses to which drugs are subjected. If natural products, such as specific herbal remedies, are exempt from such analyses, this can produce harm when adverse effects outweigh benefit ( Seef et al., 2015 ). In other cases, evidence-based treatments are sometimes replaced with “natural” products with no known benefit. A fairly common example is when chemotherapy or even cancer surgery is rejected in favor of herbal remedies, such as curcumin (an extract of turmeric), because of beliefs that such natural substances are safer than drugs (see Nelson et al., 2017 ). If so-called natural remedies are deemed to be drugs and subjected to standard risk-benefit analysis and oversight, the potential problems of using them would be highlighted and, perhaps, avoided.

For anyone wishing to avoid the implications of including food, placebos, excipients, and other substances as drugs, conceptual monism about drugs will have to be abandoned and pluralism conceded. Has our discussion revealed a plurality of distinct medical drug concepts? There does seem to be a more or less natural cleavage between substances that fall under a particular functional kind—namely, the kind specified by receptor theory and any associated pharmacological laws—and the rest, which share no particular physical or functional features in common. We can thus posit two distinct drug concepts instead of a single definition that captures all and only the substances considered to be drugs.

However, this “receptors and the rest” pluralism faces an important question: is there anything that these two distinct concepts share in common such that they are both concepts of drugs? What would that common ground be? One plausible answer is that both conceptualize drugs as chemicals that are used in a medical setting for a therapeutic benefit. Thus, both concepts have something like D8 as a necessary condition, although they differ in what else they build into the drug concept. The receptor-based concept of drugs adds to D8 the specification of a particular functional kind. The second, looser concept by contrast adds nothing. By being non-specific about causal action, it manages to capture the miscellany of other substances considered to be drugs. If this basic picture is right, however, then yet again it will be difficult to keep food, placebos, and excipients out of the second, non-receptor-based drug concept. For it seems that the necessary condition specified by D8 is also sufficient in this case.

Suppose, instead, that there is nothing that unifies the two drug concepts. It is unclear whether a form of pluralism this weak is deserving of the name. Rather, the situation looks more like a case of polysemy where, for historical reasons, people have come to use the term “drug” to pick out two quite different things within a medical context, with no unifying rationale. Still, pluralism of this kind is possibly the only way to avoid the implications discussed above. If we are forced toward this form of pluralism about drugs, however, then we may need to reconsider whether we should continue talking univocally about drugs in medicine. What we really have is a range of different substances and a single term for them, without any unifying criterion for the use of that term. In that case, it might be better for our conceptual economy to dispense with drug talk and speak directly in terms of the various substances to which the term “drug” is applied. This would still provide a kind of answer to our two demarcation questions concerning placebos and excipients, by showing that those questions are not conceptually viable in the first place.

Ultimately, our goal is not to select between the different options that result from our investigation. It is striking, though, that two of the options we present challenge the distinction between drugs and food/nutrients. We are reluctant to recommend collapsing this distinction, however, because any conceptual understanding of drugs is in its infancy, and—as we noted at the outset—outcomes unacceptable to pharmacologists, clinicians, and medical professionals will need a lot more justification. Furthermore, there may still be a way to rescue a monistic view of drugs despite our failure to find a viable candidate. Or, it could be that there is actually a way to develop a pluralistic account of drugs that manages to cleave them from food and other substances. We thus offer these options in the spirit of starting a broader conversation about drugs and their implications in the philosophy of medicine.

We are grateful for the very constructive comments of our reviewers. Some of their points and examples have been incorporated into the paper, and these generous suggestions greatly improved our argument. Sam Baron thanks David Ripley for useful discussion of the issues surrounding this paper. Research on this paper was partly funded by a Discovery Early Career Researcher Award (DE180100414). Maureen O’Malley thanks the Institute of Advanced Studies at the University of Western Australia for a Visiting Fellowship that allowed the initial research and collaboration.

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There are other lists that we could have used. In the United States, the Drug Enforcement Agency (DEA) administers a list of controlled substances, and a similar list is maintained in the United Kingdom. Both lists, however, are focused on substances that are abused (rather than medically administered). Indeed, the DEA’s list categorizes drugs in terms of their likelihood to be abused (rather than their medical implementation). In Australia, the Therapeutic Goods Administration (TGA) maintains a list that is much closer to the Canadian drug bank list in its scope. The TGA list, however, does not include many experimental drugs, which are part of the Canadian drug bank taxonomy.

These definitions are available from the authors as a supplementary file.

For example, penicillin antibiotics are a family of antibiotics with a core structure of a B-lactam ring joined to a thiazolidine ring; however, unique R side chains differentiate different penicillin members by contributing to different pharmacological and chemical properties.

We are grateful to an anonymous referee for suggesting a definition along these lines.

We thank an anonymous referee for suggesting TPN.

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Drug and Substance Abuse Essay

Introduction, physiology and psychology of addiction, prescription drug abuse, depressants, hallucinogens.

Drug and substance abuse is an issue that affects entirely all societies in the world. It has both social and economic consequences, which affect directly and indirectly our everyday live. Drug addiction is “a complex disorder characterized by compulsive drug use” (National Institute on Drug Abuse, 2010).

It sets in as one form a habit of taking a certain drug. Full-blown drug abuse comes with social problems such as violence, child abuse, homelessness and destruction of families (National Institute on Drug Abuse, 2010). To understand to the impact of drug abuse, one needs to explore the reasons why many get addicted and seem unable pull themselves out of this nightmare.

Many experts consider addiction as a disease as it affects a specific part of the brain; the limbic system commonly referred to as the pleasure center. This area, which experts argue to be primitive, is affected by various drug substances, which it gives a higher priority to other things. Peele (1998) argues that alcoholism is a disease that can only be cured from such a perspective (p. 60). Genetics are also seen as a factor in drug addiction even though it has never been exclusively proven.

Other experts view addiction as a state of mind rather than a physiological problem. The environment plays a major role in early stages of addiction. It introduces the agent, in this case the drug, to the abuser who knowingly or otherwise develops dependence to the substance. Environmental factors range from violence, stress to peer pressure.

Moreover, as an individual becomes completely dependent on a substance, any slight withdrawal is bound to be accompanied by symptoms such as pain, which is purely psychological. This is because the victim is under self-deception that survival without the substance in question is almost if not impossible. From his psychological vantage point, Isralowitz (2004) argues that freedom from addiction is achievable provided there is the “right type of guidance and counseling” (p.22).

A doctor as regulated by law usually administers prescription drugs. It may not be certain why many people abuse prescription drugs but the trend is ever increasing. Many people use prescription drugs as directed by a physician but others use purely for leisure. This kind of abuse eventually leads to addiction.

This problem is compounded by the ease of which one can access the drugs from pharmacies and even online. Many people with conditions requiring painkillers, especially the elderly, have a higher risk of getting addicted as their bodies become tolerant to the drugs. Adolescents usually use some prescription drugs and especially painkillers since they induce anxiety among other feelings as will be discussed below.

Stimulants are generally psychoactive drugs used medically to improve alertness, increase physical activity, and elevate blood pressure among other functions. This class of drugs acts by temporarily increasing mental activity resulting to increased awareness, changes in mood and apparently cause the user to have a relaxed feeling. Although their use is closely monitored, they still find their way on the streets and are usually abused.

Getting deeper into the biochemistry of different stimulants, each has a different metabolism in the body affecting different body organs in a specific way. One common thing about stimulants is that they affect the central nervous system in their mechanism. Examples of commonly used stimulants include; cocaine, caffeine, nicotine, amphetamines and cannabis. Cocaine, which has a tremendously high addictive potential, was in the past used as anesthetic and in treatment of depression before its profound effects were later discovered.

On the streets, cocaine is either injected intravenously or smoked. Within a few minutes of use, it stimulates the brain making the user feel euphoric, energetic and increases alertness. It has long-term effects such as seizures, heart attacks and stroke. Cocaine’s withdrawal symptoms range from anxiety, irritability to a strong craving for more cocaine.

Cannabis, also known as marijuana , is the most often abused drug familiar in almost every corner of the world, from the streets of New York to the most remote village in Africa. Although its addiction potential is lower as compared to that of cocaine, prolonged use of cannabis results to an immense craving for more.

It produces hallucinogenic effects, lack of body coordination, and causes a feeling of ecstasy. Long-term use is closely associated with schizophrenia, and other psychological conditions. From a medical perspective, cannabis is used as an analgesic, to stimulate hunger in patients, nausea ameliorator, and intraocular eye pressure reducer. Insomnia, lack of appetite, migraines, restlessness and irritability characterize withdrawal symptoms of cannabis.

Unlike stimulants, depressants reduce anxiety and the central nervous system activity. The most common depressants include barbiturates, benzodiazepines and ethyl alcohol. They are of great therapeutically value especially as tranquilizers or sedatives in reducing anxiety.

Depressants can be highly addictive since they seem to ease tension and bring relaxation. After using depressants for a long time, the body develops tolerance to the drugs. Moreover, body tolerance after continual use requires one use a higher dose to get the same effect. Clumsiness, confusion and a strong craving for the drug accompany gradual withdrawal. Sudden withdrawal causes respiratory complications and can even be fatal.

Narcotics have been used for ages for various ailments and as a pain reliever pain. They are also characterized by their ability to induce sleep and euphoria. Opium, for instance was used in ancient China as a pain reliever and treatment of dysentery and insomnia. Some narcotics such as morphine and codeine are derived from natural sources.

Others are structural analogs to morphine and these include heroin, oxymorphone among others. Narcotics are highly addictive resulting to their strict regulation by a majority of governments. Narcotics act as painkillers once they enter the body.

They are used legally in combination with other drugs as analgesics and antitussives but are abused due to their ability to induce a feeling of well being. Their addiction potential is exceptionally high due to the body’s tolerance after consistent use, forcing the user to use and crave for more to get satisfaction. Increase in respiration rate, diarrhea, anxiety, nausea and lack of appetite are symptoms common to narcotic withdrawal. Others include; running nose, stomach cramps, muscle pains and a strong craving for the drugs.

Hallucinogens affect a person’s thinking capacity causing illusions and behavioral changes especially in moods. They apparently cause someone to hear sounds and see images that do not exist. Lysergic acid diethylamide (LSD), which commonly abused hallucinogen, has a low addiction potential because it does not have withdrawal effects. They also affect a person’s sexual behavior and other body functions such as body temperature. There are no outright withdrawal symptoms for hallucinogens.

Isralowitz, R. (2004). Drug use: a reference handbook . Santa Barbara, Clif.: ABC-CLIO. Print.

National Institute on Drug Abuse. (2010). NIDA INfoFacts: Understanding Drug Abuse and Addiction . Web.

Peele, S. (1998). The meaning of Addiction : Compulsive Experience and its Interpretation . San Francisco: Jossey-Bass.

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Drug addiction, or substance use disorder, is a mental health condition that can have lifelong impacts. Though it's a treatable illness, substance use disorder recovery often involves a lifelong cycle of relapse (recurrence of use), withdrawal, and abstinence.

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If you or a loved one are struggling with substance use or addiction, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.

For more mental health resources, see our National Helpline Database .

How Is Drug Addiction Defined?

Drug addiction is a brain disease that falls into the category of substance use disorders . Generally, substance use disorders are defined as having no control over substance use or an inability to quit due to tolerance , dependence, and withdrawal symptoms .

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) , substance use disorders are defined as exhibiting:

• One or more abuse criteria within a 12-month period  and  no dependence diagnosis. (This does not include nicotine.)
• Three or more dependence criteria within a 12-month period.
• Two or more substance use disorder criteria within a 12-month period.

People with substance use disorder struggle to stop using the substance and often experience painful physical or psychological symptoms when they try to.

Why Does Addiction Happen?

Biological, psychological, environmental, and socio-cultural factors can play a role in a person developing a substance use disorder.

Experiencing Drug Addiction Symptoms

Substance use disorder symptoms are categorized into addiction and withdrawal symptoms. Addiction symptoms are those that indicate a person may be addicted to a substance. Withdrawal symptoms are those that occur when a person tries to stop using a substance.

Addiction Symptoms

According to the DSM-5 , addiction symptoms include the following:

• An intense craving for the substance.
• Continued use of the substance despite knowing its adverse effects.
• Difficulty controlling substance use.
• Increased tolerance of the substance over time.
• Losing interest in other activities.
• Losing interest in social, family, and work-related activities.
• Unsuccessful attempts to stop using the substance.
• Withdrawal symptoms after stopping usage of the substance.

Withdrawal Symptoms

People with substance use disorder usually experience several withdrawal symptoms when trying to stop their substance use. These might include:

• Feelings of discomfort
• Irritability
• Lack of interest in activities and relationships
• Sleep problems
• Stomach cramping

Severe withdrawal can lead to dangerous and life-threatening health issues. If you experience withdrawal symptoms, seek medical attention for support with withdrawal management.

While increased tolerance and dependence must be present for a formal substance use disorder diagnosis, many people become addicted to substances before developing physical dependence and withdrawal symptoms.

Signs of Drug Addiction in Others

Substance use disorder usually occurs in a cycle with three stages:

• Intoxication : The period when a person has taken a substance and experiences its effects.
• Withdrawal : The period after substance use has stopped. Uncomfortable physical and emotional symptoms usually accompany this stage.
• Preoccupation : The period when a person is not actively using a substance or experiencing withdrawal symptoms when thoughts about the substance consume them and they anticipate their next use.

Over time, a person with an addiction will start to experience these stages more frequently and more intensely. Additional signs that may indicate a person is using or addicted to a substance include:

• Changes in appearance, such as bloodshot eyes, weight changes, or changes in clothing
• Changes in social activities or interests
• Getting defensive when asked about substance use
• Spending or needing money
• Spending time with new people or spending time alone

Prevalence of Addiction

Addiction affects millions of people each year, causing over 11 million deaths from smoking, alcohol abuse, and illegal drugs.

Drug Addiction Treatment Options

Substance use disorder treatment can include various interventions, such as:

• Clinical support groups : Support groups run by mental health providers. Speak to a mental health provider for local or online support group recommendations.
• Inpatient rehabilitation : A person stays at a rehabilitation center for a period—often 30 days or more—to encourage and support recovery. Inpatient treatment can include individual, group, or family therapy, medication, and other treatment approaches.
• Individual therapy : Involves working directly with a licensed mental health professional, such as a certified substance abuse counselor, to identify recovery goals, learn coping tools, and develop a treatment plan.
• Medication : Healthcare providers can prescribe certain medications to help reduce withdrawal symptoms. These medications will differ depending on the type of substance.
• Outpatient rehabilitation : A treatment facility where the person does not live or stay overnight but attends appointments for medical needs, individual therapy, or group support.
• Peer-support meetings : Supportive sessions that are run by others facing addiction. These include groups like Cocaine Anonymous , Crystal Meth Anonymous , Heroine Anonymous , and Narcotics Anonymous .

Regardless of the treatment approach, each method offers education about addiction and recovery. This may include topics like making life changes to support recovery, being honest, seeking help when needed, and practicing self-care.

Steps to Finding Treatment

To locate treatment facilities in your area, try calling the Substance Abuse and Mental Health Services Administration (SAMHSA) for a list of options. You can also visit SAMHSA's treatment locator website , the American Addiction Centers location finder , or, if you have health insurance, call your insurance company for in-network services. For questions about medical detoxification, talk with your healthcare provider.

To locate a substance abuse mental health provider, you can use a therapist-finder tool, such as the NIAA Alcohol Treatment Navigator , or contact your health insurance for a list of in-network providers.

Effects of Drug Addiction

Substance use disorder is dangerous and can be fatal for those who do not seek treatment. Other health risks from substance use include:

• Diseases that result from sharing needles used for injection, such as HIV and hepatitis C
• Heart problems
• Lung disease
• Skin infections

Substance use disorder can negatively affect a person's relationships, finances, employment, and other aspects of their life.

Addiction Causes and Risk Groups

Though anyone can develop substance use disorder, certain people may be at higher risk of addiction. This includes those who:

• Are experiencing significant stress or distress.
• Are from lower socioeconomic households.
• Had behavioral problems as a child, especially with anger.
• Had minimal adult supervision as children.
• Have access to substances.
• Have tried substances before.
• Struggle with low self-esteem or self-worth and find it challenging to say no to peer pressure.

Most people who develop substance use disorder do so for a combination of reasons, including genetics and environmental factors.

Gateway Drugs

Many people develop substance use disorder after first using a gateway drug, which is often a drug that is more widely available and socially acceptable.

Substance use disorder is a lifelong battle. Most people relapse even after stopping substance use for extended periods. There is a risk for recurrence of use at every phase of recovery. The phases of recovery include:

• Abstinence stage : The person is not using the substance. This stage usually lasts one to two years.
• Post-acute withdrawal stage : The person has already experienced physical withdrawal symptoms and starts to have mainly emotional and psychological withdrawal symptoms. This stage often lasts up to two years.
• Repair stage : The person works on repairing any negative experiences from addiction. This stage usually lasts two to three years.
• Growth stage : The person begins working on skills to help them move forward and hopefully avoid a future relapse. This stage often starts between three and five years after initially stopping the substance use.

Relapse Is Common

The relapse or recurrence of use process begins weeks or months before a person actually takes the substance. Early intervention increases the chances of returning to sobriety. About 85% of adults living with substance use disorder will relapse within a year of quitting their substance use.

A person who is recovering from substance use disorder is always at risk of relapse. The stages of relapse include:

• Emotional : The person does not think about using the substance and may experience denial, isolation, and treatment avoidance, such as no longer attending substance use disorder groups or meetings and poor self-care.
• Mental : The person starts to think about using the substance again but may not want to. They may experience cravings, think about the past when they were using the substance, and start to plan their use. It's also common for people to substitute another substance for the one they had been taking in the past.
• Physical : The person takes the substance again.

Drug addiction, or substance use disorder, is a serious mental illness that affects a person's health, relationships, finances, and well-being. People with substance use disorder usually struggle with relapse for their entire lives and often go through continuous cycles of intoxication, withdrawal, and preoccupation with the substance. Though there are risk factors for developing substance use disorder, anyone can develop it. Treatment is available for people struggling with substance use disorder.

Rogers PJ. Food and drug addictions: similarities and differences .  Pharmacol Biochem Behav . 2017;153:182-190. doi:10.1016/j.pbb.2017.01.001

Hasin DS, O'Brien CP, Auriacombe M, et al. DSM-5 criteria for substance use disorders: recommendations and rationale .  Am J Psychiatry . 2013;170(8):834-851. doi:10.1176/appi.ajp.2013.12060782

Jahan AR, Burgess DM. Substance use disorder . StatPearls [Internet].

Wise RA, Koob GF. The development and maintenance of drug addiction .  Neuropsychopharmacology . 2014;39(2):254-262. doi:10.1038/npp.2013.261

American Addiction Centers. Signs of drug use & addiction: how to tell if someone is on drugs .

Chang R, Peng J, Chen Y, et al. Deep brain stimulation in drug addiction treatment: research progress and perspective .  Front Psychiatry . 2022;13:858638. doi:10.3389/fpsyt.2022.858638

National Institute on Drug Abuse. Drugs, brains, and behavior: the science of addiction .

Melemis SM. Relapse prevention and the five rules of recovery .  Yale J Biol Med . 2015;88(3):325-332.

NIDA. 2022. Addiction and health .

Cheron J, Kerchove d'Exaerde A. Drug addiction: from bench to bedside .  Transl Psychiatry . 2021;11(1):424. doi:10.1038/s41398-021-01542-0

By Melissa Porrey LPC, NCC Porrey is a licensed professional counselor and writer based in DC. She is a nationally board-certified counselor.

Drugs, Brains, and Behavior: The Science of Addiction Preface

How science has revolutionized the understanding of drug addiction.

For much of the past century, scientists studying drugs and drug use labored in the shadows of powerful myths and misconceptions about the nature of addiction. When scientists began to study addictive behavior in the 1930s, people with an addiction were thought to be morally flawed and lacking in willpower. Those views shaped society’s responses to drug use, treating it as a moral failing rather than a health problem, which led to an emphasis on punishment rather than prevention and treatment.

Today, thanks to science, our views and our responses to addiction and the broader spectrum of substance use disorders have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of compulsive drug use, enabling us to respond effectively to the problem.

As a result of scientific research, we know that addiction is a medical disorder that affects the brain and changes behavior. We have identified many of the biological and environmental risk factors and are beginning to search for the genetic variations that contribute to the development and progression of the disorder. Scientists use this knowledge to develop effective prevention and treatment approaches that reduce the toll drug use takes on individuals, families, and communities.

Despite these advances, we still do not fully understand why some people develop an addiction to drugs or how drugs change the brain to foster compulsive drug use. This booklet aims to fill that knowledge gap by providing scientific information about the disorder of drug addiction, including the many harmful consequences of drug use and the basic approaches that have been developed to prevent and treat substance use disorders.

At the National Institute on Drug Abuse (NIDA), we believe that increased understanding of the basics of addiction will empower people to make informed choices in their own lives, adopt science-based policies and programs that reduce drug use and addiction in their communities, and support scientific research that improves the Nation’s well-being.

Nora D. Volkow, M.D. Director National Institute on Drug Abuse

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Definition of drug

 (Entry 1 of 3)

Definition of drug  (Entry 2 of 3)

transitive verb

intransitive verb

Definition of drug  (Entry 3 of 3)

dialectal past tense of drag

• pharmaceutical

Examples of drug in a Sentence

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'drug.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

Noun and Verb

Middle English drogge

1611, in the meaning defined at sense 4

1667, in the meaning defined at transitive sense 2

Phrases Containing drug

• designer drug
• date rape drug
• prescription drug
• gateway drug
• feel / look like something the cat brought / dragged / drug in
• performance - enhancing drug
• wonder drug
• orphan drug

drug dealer

• recreational drug
• miracle drug
• drug paraphernalia

Articles Related to drug

An eighth of an ounce of cocaine or some other drug

Dictionary Entries Near drug

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“Drug.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/drug. Accessed 12 Apr. 2024.

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7.4 Explaining Drug Use

Learning objectives.

• Understand the possible biological origins of drug addiction.
• Explain why longitudinal research on personality traits and drug use is important.
• Outline the aspects of the social environment that may influence drug use.

To know how to reduce drug use, we must first know what explains it. The major explanations for drug use come from the fields of biology, psychology, and sociology.

Biological Explanations

In looking at drug use, the field of biology focuses on two related major questions. First, how and why do drugs affect a person’s behavior, mood, perception, and other qualities? Second, what biological factors explain why some people are more likely than others to use drugs?

Regarding the first question, the field of biology has an excellent understanding of how drugs work. The details of this understanding are beyond the scope of this chapter, but they involve how drugs affect areas in the brain and the neurotransmitters that cause a particular drug’s effects. For example, cocaine produces euphoria and other positive emotions in part because it first produces an accumulation of dopamine, a neurotransmitter linked to feelings of pleasure and enjoyment.

Research on identical twins suggests that alcoholism has a genetic basis.

Michael Dorausch – Identical Twins Jedward – CC BY-SA 2.0.

Regarding the second question, biological research is more speculative, but it assumes that some people are particularly vulnerable to the effects of drugs. These people are more likely to experience very intense effects and to become physiologically and/or psychologically addicted to a particular drug. To the extent this process occurs, the people in question are assumed to have a biological predisposition for drug addiction that is thought to be a genetic predisposition.

Most research on genetic predisposition has focused on alcohol and alcoholism (Hanson et al., 2012). Studies of twins find that identical twins are more likely than fraternal twins (who are not genetically identical) to both have alcohol problems or not to have them. In addition, studies of children of alcoholic parents who are adopted by nonalcoholic parents find that these children are more likely than those born to nonalcoholic parents to develop alcohol problems themselves. Although a genetic predisposition for alcoholism might exist for reasons not yet well understood, there is not enough similar research on other types of drug addiction to assume that a genetic predisposition exists for these types. Many nonbiological factors also explain the use of, and addiction to, alcohol and other drugs. We now turn to these factors.

Psychological Explanations

Psychological explanations join biological explanations in focusing on why certain individuals are more likely than others to use drugs and to be addicted to drugs (Hanson et al., 2012). Some popular psychological explanations center on personality differences between drug users and nonusers. These explanations assume that users have personality traits that predispose them to drug use. These traits include low self-esteem and low self-confidence, low trust in others, and a need for thrills and stimulation. In effect, drug users have inadequate personalities, or personality defects, that make them prone to drug use, and once they start using drugs, their personality problems multiply.

One problem with research on personality explanations is methodological: If we find personality differences between drug users and nonusers, should we conclude that personality problems cause drug use, or is it possible that drug use causes personality problems? Most of the research on personality and drug use cannot answer this question adequately, since it studies drug users and nonusers at one point in time ( cross-sectional research ). To answer this question adequately, longitudinal research , which examines the same people over time, is necessary. Among initial drug abstainers at Time 1, if those with the personality traits mentioned earlier turn out to be more likely than those without the traits to be using drugs at Time 2, then we can infer that personality problems affect drug use rather than the reverse. Longitudinal research on personality and drug use that studies adolescents and college students does indeed find this causal sequence (Sher, Bartholow, & Wood, 2000). However, some scholars still question the importance of personality factors for drug use and addiction (Goode, 2012). They say these factors have only a small effect, if that, and they cite research questioning whether personality differences between users and nonusers in fact exist (Feldman, Boyer, Kumar, & Prout, 2011).

Other psychological explanations are based on the classic concept from behavioral psychology of operant conditioning —the idea that people and animals are more likely to engage in a behavior when they are rewarded, or reinforced, for it. These explanations assume that people use drugs because drugs are positive reinforcers in two respects. First, drugs provide pleasurable effects themselves and thus provide direct reinforcement . Second, drug use often is communal: People frequently use drugs (alcohol is certainly a prime example, but so are many other drugs) with other people, and they enjoy this type of social activity. In this manner, drug use provides indirect reinforcement .

Sociological Explanations

Sociological explanations emphasize the importance of certain aspects of the social environment—social structure, social bonds to family and school, social interaction, and culture—or drug use, depending on the type of drug. For drugs like heroin and crack that tend to be used mostly in large urban areas, the social structure, or, to be more precise, social inequality, certainly seems to matter. As sociologist Elliott Currie (1994, p. 3) has observed, the use of these drugs by urban residents, most of them poor and of color, reflects the impact of poverty and racial inequality: “Serious drug use is not evenly distributed: it runs ‘along the fault lines of our society.’ It is concentrated among some groups and not others, and has been for at least half a century.” This fact helps explain why heroin use grew in the inner cities during the 1960s, as these areas remained poor even as the US economy was growing. Inner-city youths were attracted to heroin because its physiological effects helped them forget about their situation and also because the heroin subculture—using an illegal drug with friends, buying the drug from dealers, and so forth—was an exciting alternative to the bleakness of their daily lives. Crack became popular in inner cities during the 1980s for the same reasons.

Social bonds to families and schools also make a difference. Adolescents with weak bonds to their families and schools, as measured by such factors as the closeness they feel to their parents and teachers, are more likely to use drugs of various types than adolescents with stronger bonds to their families and schools. Their weaker bonds prompt them to be less likely to accept conventional norms and more likely to use drugs and engage in other delinquent behavior.

Regarding social interaction, sociologists emphasize that peer influences greatly influence one’s likelihood of using alcohol, tobacco, and a host of other drugs (Hanson et al., 2012). Much and probably most drug use begins during adolescence, when peer influences are especially important. When our friends during this stage of life are drinking, smoking, or using other drugs, many of us want to fit in with the crowd and thus use one of these drugs ourselves. In a related explanation, sociologists also emphasize that society’s “drug culture” matters for drug use. For example, because we have a culture that so favors alcohol, many people drink alcohol. And because we have a drug culture in general, it is no surprise, sociologically speaking, that drug use of many types is so common.

To the extent that social inequality, social interaction, and a drug culture matter for drug use, sociologists say, it is a mistake to view most drug use as stemming from an individual’s biological or psychological problems. Although these problems do play a role for some individuals’ use of some drugs, drug use as a whole stems to a large degree from the social environment and must be understood as a social problem, and not just as an individual problem.

Beyond these general explanations of why people use drugs, sociological discussions of drug use reflect the three sociological perspectives introduced in Chapter 1 “Understanding Social Problems” —functionalism, conflict theory, and symbolic interactionism—as we shall now discuss. Table 7.6 “Theory Snapshot” summarizes this discussion.

Table 7.6 Theory Snapshot

Functionalism

Recall that functionalist theory emphasizes the need for social stability, the functions that different aspects of society serve for society’s well-being, and the threats (or dysfunctions) to society’s well-being posed by certain aspects of society. In line with this theory, sociologists emphasize that drug use may actually be functional for several members of society. For the people who use legal or illegal drugs, drug use is functional because it provides them the various positive physiological effects that drugs have. For the people who sell legal or illegal drugs, drug use is functional because it provides them a major source of income. Illegal drug use is even functional for the criminal justice system, as it helps provide jobs for the police, court officials, and prison workers who deal with illegal drugs. Legal and illegal drugs also provide jobs for the social service agencies and other organizations and individuals whose work focuses on helping people addicted to a drug. At the same time, drugs, whether legal or illegal, have the many dysfunctions for society that this chapter discussed earlier, and this fact must not be forgotten as we acknowledge the functions of drugs.

Conflict Theory

Conflict theory stresses the negative effects of social inequality and the efforts of the elites at the top of society’s hierarchy to maintain their position. This theory helps us understand drugs and drug use in at least three respects. First, and as noted just earlier, much drug use in poor urban areas results from the poverty, racial inequality, and other conditions affecting people in these locations. They turn to illegal drugs partly to feel better about their situation, and partly because the illegal drug market is a potentially great source of income that does not require even a high school degree.

Second, conflict theory emphasizes that racial and ethnic prejudice and inequality help determine why some drugs are illegal as well as the criminal penalties for these drugs. For example, the penalties for crack are much harsher, gram for gram, than those for powder cocaine, even though the two drugs are pharmacologically identical. Crack users are primarily poor African Americans in urban areas, while powder cocaine users are primarily whites, many of them at least fairly wealthy. These facts prompt many observers to say that the harsher penalties for crack are racially biased (Tonry, 2011). Other evidence for this argument of conflict theory is seen in the history of the illegality of opium, cocaine, and marijuana. As we discussed earlier, racial and ethnic prejudice played an important role in why these common drugs in the nineteenth century became illegal: prejudice against Chinese immigrants for opium, prejudice against African Americans for cocaine, and prejudice against Mexican Americans for marijuana.

Third, conflict theory emphasizes the huge influence that multinational corporations have in the marketing and sale of the legal drugs—alcohol, tobacco, and many prescription drugs—that often have harmful individual and societal consequences. To maximize their profits, these companies do their best, as noted earlier, to convince Americans and people in other nations to use their products. They also spend billions of dollars to lobby Congress. As also mentioned earlier, the tobacco industry hid for years evidence of the deadly effects of its products. All these efforts illustrate conflict theory’s critical view of the role that corporations play in today’s society.

Symbolic Interactionism

Symbolic interactionism focuses on the interaction of individuals and on how they interpret their interaction. Given this focus, symbolic interactionism views social problems as arising from the interaction of individuals. As such, it understands drug use as a behavior arising from an individual’s interaction with people who engage in drug use. From this type of social interaction, an individual learns how to use a drug and also learns various attitudes that justify drug use and define the effects of a drug as effects that are enjoyable.

A study of drug use that reflects this approach is Howard S. Becker’s (1953) classic article, “Becoming a Marihuana User.” Becker wrote that someone usually begins smoking marijuana in the presence of friends who are experienced marijuana users. This social interaction, he argued, is critical for new users to wish to continue using marijuana. To want to do so, they must learn three behaviors or perceptions from the experienced users who are “turning them on” to marijuana use. First, new users must learn how to smoke a joint (marijuana cigarette) by deeply inhaling marijuana smoke and holding in the smoke before exhaling. Second, they must perceive that the effects they feel after smoking enough marijuana (spatial distortion, hunger pangs, short-term memory loss) signify that they are stoned (under the influence of marijuana); their friends typically tell them that if they are feeling these effects, they are indeed stoned. Third, they must learn to define these effects as pleasurable; if people suddenly experience spatial distortion, intense hunger, and memory loss, they might very well worry they are having huge problems! To prevent this from happening, their friends say things to them such as, “Doesn’t that feel great!” This and similar comments help reassure the new users that the potentially worrisome effects they are experiencing are not only bad ones but in fact very enjoyable ones.

Key Takeaways

• Biological theories assume that some people are especially vulnerable to drug addiction for genetic reasons.
• A popular set of psychological theories assumes that drug addiction results from certain personality traits and problems.
• Sociological theories attribute drug use to various aspects of the social environment, including peer influences, weak social bonds, and the larger drug culture.

For Your Review

• When you think about the reasons for drug use and addiction, do you think biological factors, psychological factors, or the social environment play the most important role? Explain you answer.
• Write a brief essay in which you discuss a time when your friends influenced you, or someone else you know, to use a legal or illegal drug.

Becker, H. S. (1953). Becoming a Marihuana User. American Journal of Sociology, 59 , 235–242.

Currie, E. (1994). Reckoning: Drugs, the cities, and the American future . New York, NY: Hill and Wang.

Feldman, M., Boyer, B., Kumar, V. K., & Prout, M. (2011). Personality, drug preference, drug use, and drug availability. Journal of Drug Education, 41 (1), 45–63.

Goode, E. (2012). Drugs in American society (8th ed.). New York, NY: McGraw-Hill.

Hanson, G. R., Venturelli, P. J., & Fleckenstein, A. E. (2012). Drugs and society (11th ed.). Burlington, MA: Jones & Bartlett.

Sher, K. J., Bartholow, B. D., & Wood, M. D. (2000). Personality and substance use disorders: A prospective study. Journal of Consulting and Clinical Psychology, 68 , 818–829.

Tonry, M. (2011). Punishing race: A continuing American dilemma . New York, NY: Oxford University Press.

Social Problems Copyright © 2015 by University of Minnesota is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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What Do We Know About Drug Addiction?

• Nora D. Volkow , M.D. ,

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The National Institute on Drug Abuse (NIDA) is marking its 30th year of research in substance abuse. Over this period, significant advances have given us a better understanding of the neurobiology of drug addiction and of its treatment. To start with, scientific findings documenting long-lasting changes in the brain of individuals addicted to drugs have led to the conceptualization of drug addiction as a disease of the brain. Moreover, through the use of animal models and through imaging studies in human subjects, it has become possible to delineate neurotransmitter systems and neuronal circuits that are disrupted by the use of drugs. Ten studies in this issue exemplify some of these advances. This editorial discusses these papers within the framework of NIDA’s top research priorities: prevention, treatment, and HIV/AIDS.

A challenging question is why, when exposed to drugs, some individuals become addicted while others do not. Compton et al. (p. 1494) used epidemiological studies to address this question, which examines the contribution of genetic, environmental, and developmental factors, and their interaction with one another, to facilitate or interfere with drug abuse and addiction. Genetic factors are estimated to contribute to 40%–60% of the variability in the risk of addiction, but this includes the contribution of combined genetic-environmental interactions. The neurobiological mechanisms by which environmental factors interact with genetic factors to affect vulnerability to addiction are just beginning to be investigated. An example of this is provided by Nader and Czoty (p. 1473), who focused on the influence that social environmental factors have on dopaminergic pathways and how these affect the propensity to take drugs.

Brain developmental factors are important in drug abuse. For example, the relatively late development of brain circuits involved with emotion, judgment, and inhibitory control may explain the heightened propensity of adolescents to act impulsively and to ignore the negative consequences of their behavior, both of which increase the risk for substance abuse at this stage of development. Also, since drugs of abuse interact with some neurotransmitter systems that are essential for brain development (i.e., serotonin, acetylcholine), drug exposure during adolescence may be particularly harmful to the still developing brain.

Another major risk factor for drug abuse is the presence of a mental disorder. Children and adolescents suffering from depression, conduct disorder, attention deficit hyperactivity disorder, or schizophrenia are at a much higher risk of abusing drugs than unaffected youth. This can be viewed in two ways: as a high prevalence of drug abuse in the mentally ill or as a high prevalence of mental disorders in drug abusers. Both views suggest that there may be common neurobiological substrates for substance abuse and mental disorders. This is addressed by Brady and Sinha (p. 1483), who discuss how comorbidity has important implications for therapeutic intervention and prevention programs.

The identification of neurobiological substrates in addiction has provided new targets for treatment. Drug-induced increases in dopamine in the nucleus accumbens are considered to underlie the reinforcing responses to drugs of abuse, and repeated drug administration is believed to result in a series of adaptations involved in the loss of control and the compulsive drug administration that characterize addiction. Peter Kalivas and I report on adaptations in the prefrontal-striatal glutamatergic pathway (p. 1403), which modulates the release of dopamine in the nucleus accumbens and thus regulates the magnitude of a response to a given reinforcer. Adaptations in this pathway could explain the enhanced saliency value of the drug and the decreased sensitivity to nondrug reinforcers in addicted subjects. Moreover, the magnitude of dopamine-induced increases could contribute to how the prefrontal cortex attributes and readjusts the value of a given reinforcer as a function of its context, so that disruptions in these regions may underlie the fixated high motivational value of the drug that leads to compulsive drug administration.

Steven Hyman elaborates on the theme of how learning and memory circuits may be involved in addiction (p. 1414). Since dopamine facilitates conditioned learning (a process mediated in part by the amygdala), the association of the drug-induced pleasurable experience with the increases in dopamine will result in strong conditioning, not only to the drug but to the stimuli that predict the drug (e.g., the house of the drug dealer, syringes). Through conditioning, initially neutral stimuli become highly salient and produce neural responses (e.g., dopamine increases) that trigger the motivation to procure the drug. This may account for the enhanced excitement for the drug and drug-related stimuli that overshadow the response to natural reinforcers.

The articles by Vocci et al. (p. 1432) and by O’Brien (p. 1423) review some of the advances in pharmacotherapy that have occurred over the past 10 years. The identification of common neurobiological substrates across various drug addictions suggests that, in some cases, it may be possible to develop medications that are beneficial for more than one type of addiction. In addition, advances in pharmacogenomics are helping identify genetic factors that may predict which individuals may have favorable responses to specific medications as treatments for addiction. An example of this for the treatment of nicotine addiction is provided by Berrettini and Lerman (p. 1441).

The complex behavioral consequences of addiction suggest that pharmacological and behavioral treatments with synergistic effects may be required for effective interventions. Significant advances in the behavioral treatments for drug addiction, reviewed by Carroll and Onken (p. 1452), have increased the options for combination treatments.

HIV/AIDS is also a major priority of NIDA, since drugs of abuse are a major vector in the transmission of HIV. This is due not just to sharing of contaminated syringes, which accounts for approximately 30% of new HIV cases, but to drug-induced changes in mental state during intoxication that favor risky sexual behaviors and to drug-induced physiological changes that may facilitate infection. Comorbid drug abuse and HIV can have deleterious effects on both neuronal and immunological function. Jernigan et al. (p. 1461) report on the consequences of comorbid HIV infection and methamphetamine dependence on brain morphological abnormalities. The findings are surprising in that they don’t reveal a simple additive effect but what appears to be distinct consequences of the combination, highlighting the need to better understand the consequences of these interactions.

The chronic nature of drug addiction and the associated risks that it entails highlight the importance of prevention and early therapeutic interventions. Psychiatrists are in a unique position to be involved in the early recognition and treatment of drug abuse, which can positively impact not only the addiction process but also the course of other mental disorders.

Address correspondence and reprint requests to Dr. Volkow, Director, National Institute on Drug Abuse, 6001 Executive Blvd., Room 5274, Bethesda, MD 20892; [email protected] (e-mail).

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An Overview of Substance Use

Buddy T is a writer and founding member of the Online Al-Anon Outreach Committee with decades of experience writing about alcoholism. Because he is a member of a support group that stresses the importance of anonymity at the public level, he does not use his photograph or his real name on this website.

Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.

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Illegal Substance Use

Prescription substance misuse, other commonly abused substances.

• Identifying Substance Misuse

Substance abuse is typically defined as a pattern of harmful use of any substance for mood-altering purposes. Substances can include alcohol, prescription and over-the-counter drugs, illegal drugs, inhalants and solvents, nicotine, and even coffee.

"Abuse" can result from using a substance in a way that is not intended or recommended, or from using more than prescribed. To be clear, someone can use substances and not be addicted or even have a substance use disorder, as defined in the " Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text-Revision" (DSM-5-TR) .

A Note on Language

While people commonly refer to problematic substance use as "substance abuse," the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) no longer uses this term. It is considered stigmatizing, so it is now preferred to use language such as "substance misuse" or "substance use disorder."

The National Institute on Drug Abuse (NIDA) says that "abuse" is no longer used because of its negative connotations and associations with punishment and judgment.

This article discusses what constitutes harmful substance use, illegal substance use, and prescription drug misuse. It also covers some of the substances that are more frequently misused as well as the risks of substance misuse.

What Is Substance Misuse?

Health officials consider substance use as crossing the line into substance misuse if that repeated use causes significant impairment, such as:

• Disabilities
• Failure to meet responsibilities
• Health issues
• Impaired control
• Social issues

In other words, if someone drinks enough to get frequent hangovers; uses enough drugs that they miss work or school; smokes enough marijuana that they have lost friends; or often drinks or uses more than they intended to use, their substance use is probably considered misuse or harmful use.

What Causes Substance Misuse?

Substance use is a complex problem that is influenced by a number of factors. There is no way to predict who will become addicted to drugs, but a combination of influences can increase a person's risk of developing an addiction.

Genes, other mental health conditions, developmental factors, and environmental influences all play a role.

"People who drink alcohol or use drugs often initially get started to enhance their sense of well-being, relationships, and social enjoyment. Unfortunately, the downsides to substance use can emerge relatively quickly, depending on which substance and how much and how often it is used," says Paul Linde, MD , the medical director for psychiatry and collaborative care at Ria Health.

Dr. Linde notes that family history often plays a significant role, which can include both biological factors and learned behaviors. A person's susceptibility to substance misuse has a partial genetic basis, but environmental factors play an important role as well. 

Growing up in families in which drinking or using drugs is common or normalized also places one at a greater risk for developing a substance use disorder.

Generally, when people talk about 'substance abuse,' they are referring to the use of illegal drugs. Drugs of misuse do more than alter mood. They can cloud judgment, distort perceptions, and alter reaction times, increasing the risk of accidents and injury.

These drugs were declared illegal in the first place because they are potentially addictive or can cause severe negative health effects. Some believe that any use of illegal substances is dangerous and, therefore, abusive.

In the United States, the most commonly used illegal drugs are:

• Methamphetamine
• Hallucinogens
• Ecstasy or molly

When people use the term substance abuse, they are usually referring to the use of illegal drugs such as cocaine, heroin, and methamphetamine. These substances are illegal because of their high risk for abuse and dangerous side effects.

Recreational Drug Use

Some people argue that casual, occasional use of some drugs is not harmful and is merely use, not abuse. The most vocal of the proponents of recreational drug use are those who smoke marijuana. They argue that marijuana is not addictive and has many beneficial qualities, unlike the "harder" drugs.

But recent research has shown that even marijuana may have more harmful physical, mental, and psychomotor effects than first believed. Research has found that marijuana can have serious short-term and long-term health risks.

In addition, the National Institute on Drug Abuse (NIDA) reports that people who use marijuana can become addicted. NIDA estimates that 30% of people who use marijuana will become dependent. This risk is four to seven times higher for those who began using the drug in their teens.

Prescription substance misuse has risen substantially over the last few decades. The National Institute on Drug Abuse estimates that between 8% to 12% of U.S. patients who are prescribed opioid pain relievers develop a substance use disorder.

According to the Centers for Disease Control and Prevention (CDC), the number of opioid-related deaths increased by 16% between 2019 and 2020, with an average of 44 people dying each day from prescription opioid overdoses in 2020.

In the U.S., three main classes of prescription drugs are commonly misused: Opioids, central nervous system depressants, and stimulants. These include:

• Amphetamines
• Barbiturates
• Benzodiazepines
• Fentanyl and analogs
• Methylphenidate
• Sleep medications

Substance use can also involve misusing prescription medications that have the potential for dependence.

Alcohol, prescription, and over-the-counter medications, inhalants and solvents, and even coffee and cigarettes can all be used to harmful excess. Many children have their first encounter with substance misuse by using inhalants, simply because they are found in many common household products and, therefore, readily available.

Alcohol is legal for adults over the age of 21 in the United States. However, it doesn't take much alcohol to reach a harmful level of drinking , and that is when alcohol use can turn into alcohol abuse.

Drinking five or more drinks for men (four for women) in any one sitting is considered binge drinking , which can be harmful to your physical and mental health in many different ways.

Nicotine is the single most abused substance in the world. Although smoking has declined in recent years, it is estimated that 28.3 million Americans still smoke cigarettes despite the well-publicized harmful effects.

Again, just because it is legal, doesn't mean it can't be abused. The fact that the negative health effects of nicotine take a long time to manifest probably plays a role in the widespread abuse of tobacco.

Whereas nicotine is the most abused drug, caffeine is the most commonly used mood-altering drug in the world. And yes, too much caffeine can be harmful to your health.

Studies have also found a link between caffeine use and several psychiatric syndromes, including caffeine-induced sleep disorder and caffeine-induced anxiety disorder.

People diagnosed with generalized anxiety disorder , panic disorder, primary insomnia, and gastroesophageal reflux are usually advised to reduce or eliminate regular caffeine use.

So-called "designer drugs" and synthetic drugs, such as bath salts and synthetic marijuana, can be abused and can possibly be more dangerous than other drugs.

Other designer drugs that are commonly misused include:

• Rohypnol (date rape drugs)

Anabolic Steroids

Anabolic steroids have no mood-altering or intoxicating properties, but they can still be misused. Using anabolic steroids to enhance performance or develop muscles and strength is abusive because of the negative side effects of steroid use.

These can range from merely annoying to life-threatening in some cases. If using a substance can cause you harm, it is substance abuse. Theoretically, almost any substance can be abused.

Substance misuse can involve substances including alcohol, nicotine, caffeine, synthetic drugs, and anabolic steroids. 

Risks of Substance Misuse

When society determine that using certain substances is harmful, it places legal prohibitions on their use. This is to protect individuals' well-being and shield society from the costs involved with related healthcare resources, lost productivity, the spread of diseases, crime, and an increased risk of becoming unhoused (although the impact of criminalization has been open to considerable controversy).

The line between use and abuse is unclear for many legal substances. Is having a couple of drinks every day after work to unwind use or misuse? Is drinking two pots of coffee in the morning to get your day started use or misuse? It also is not uncommon for people to not recognize the impact that their substance use has on their life.

If you are concerned about your substance use, Dr. Linde suggests it can be helpful to ask yourself questions about the negative medical, psychosocial, legal, and financial consequences of drinking and using drugs.

Examining the pros and cons of continuing to use substances, a technique known as motivational interviewing, is often used by addiction treatment professionals as part of the assessment process.

Understanding these risks may help you recognize the signs of a serious problem and improve your motivation to seek treatment.

• Physical health problems : Substance misuse can increase the risk of physical health issues, including heart disease, stroke, and cancer.
• Mental health problems : Substance use often co-occurs with mental health problems, but it can also worsen or contribute to the onset of some conditions as well.  
• Risky or dangerous behavior : Substance use can increase the risk of risky behaviors, such as driving while intoxicated and engaging in unprotected sex.
• Legal risks : Using illegal substances means an increased risk of legal consequences, including arrest and incarceration.

Substance use poses both individual and societal risks. For individuals, it can lead to health problems, mental health issues, risky behavior, and legal problems. For societies, substance use can increase the costs associated with health problems and lost productivity. It can also contribute to social problems such as crime.

How to Identify Substance Misuse

Has your substance use become harmful? If you think this may be true for you, you are certainly not alone. According to the latest statistics, 21.9% of Americans over the age of 12 have used illicit drugs in the past year, and 9.2 million people over the age of 12 have misused opioids.

Symptoms of a substance use disorder include:

• Developing a tolerance to the substance so that you need to take more to achieve the same effects
• Being unable to control your substance use
• Needing to use the substance daily
• Spending a great deal of time obtaining, using, and recovering from substance use
• Taking substances in risky settings
• Missing school or work due to substance use or performing poorly
• Skipping social or recreational activities due to substance use
• Continuing to take a substance despite the negative consequences
• Experiencing withdrawal symptoms when you stop taking a substance
• Changes in sleep, appetite, and hygiene
• Attempting to hide your substance use from others

Substance Use Disorders

The DSM-5 recognizes substance-related disorders resulting from the use of 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, and other hallucinogens, such as LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (including amphetamine-type substances, cocaine, and other stimulants); tobacco; and other or unknown substances.

Treatment for Substance Use Problems

Are you hesitant to seek help for your substance use? Again, you are not alone. In 2021, an estimated 46.3 million people needed substance use treatment, but only around 6% received any treatment.

If you have tried to quit or cut back on your own and found you could not do so, you may want to try other options and learn more about treatment for substance use .

Treatment for substance use disorders may involve behavioral therapies, medications, or a combination of different approaches. Cognitive behavioral therapy (CBT) , contingency management, and motivational enhancement therapy are a few types of therapy that may be used. Medications can also help people with opioid, nicotine, or alcohol addiction.

How to Prevent Substance Use

Family history, peer pressure, and recreational drug use are all risk factors for substance use. Being aware of these risks can help you take steps to avoid using substances in the first place. Seeking treatment for mental health conditions can also play a role in prevention.

If you use substances for recreational purposes, misuse prescription medications, or take substances for the purposes of becoming intoxicated, talk to your doctor about your treatment options.

If you or a loved one are struggling with substance use or addiction, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.

For more mental health resources, see our National Helpline Database .

McLellan AT. Substance misuse and substance use disorders: Why do they matter in healthcare? .  Trans Am Clin Climatol Assoc . 2017;128:112–130.

National Institute on Drug Abuse.  Terms to use and avoid when talking about addiction .

National Institute on Drug Abuse. Understanding drug use and addiction .

Csete J, Kamarulzaman A, Kazatchkine M, et al. Public health and international drug policy .  Lancet . 2016;387(10026):1427–1480. doi:10.1016/S0140-6736(16)00619-X

National Institute on Drug Abuse. Cannabis (marijuana) DrugFacts .

National Institute on Drug Abuse. Marijuana research report: Is marijuana addictive? .

Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN.  Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis .  Pain . 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1

Centers for Disease Control and Prevention. Prescription opioid overdose death maps .

National Institute on Drug Abuse. Misuse of prescription drugs research report: Overview .

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Lachenmeier DW, Rehm J. Comparative risk assessment of alcohol, tobacco, cannabis and other illicit drugs using the margin of exposure approach .  Sci Rep . 2015;5:8126. doi:10.1038/srep08126

Centers for Disease Control and Prevention. Current cigarette smoking among adults in the United States .

Jee HJ, Lee SG, Bormate KJ, Jung YS. Effect of caffeine consumption on the risk for neurological and psychiatric disorders: Sex differences in human .  Nutrients . 2020;12(10):3080. doi:10.3390/nu12103080

National Institute on Drug Abuse. What are anabolic steroids? .

National Institute on Drug Abuse. What are the other health consequences of drug addiction ?

Substance Abuse and Mental Health Services Administration. 2021 National Survey of Drug Use and Health (NSDUH) releases .

American Psychiatric Association (APA).  Diagnostic and Statistical Manual of Mental Disorders . 5th ed, text revision. Washington, D.C.; 2022.

By Buddy T Buddy T is a writer and founding member of the Online Al-Anon Outreach Committee with decades of experience writing about alcoholism. Because he is a member of a support group that stresses the importance of anonymity at the public level, he does not use his photograph or his real name on this website.

Essay on Drug Awareness

Students are often asked to write an essay on Drug Awareness in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Drug Awareness

Understanding drugs.

Drugs are substances that can change how your body and mind work. They can be legal, like medicine prescribed by a doctor, or illegal.

Effects of Drugs

Drugs can make you feel different. Some might make you feel happy for a short time, but they can also harm your body and brain.

The Risk of Addiction

Some people may start using drugs out of curiosity or to feel good, but it can lead to addiction. Addiction is when you can’t stop taking the drug, even if it’s causing harm.

Staying Safe

It’s important to say no to illegal drugs and only take medicines as directed by a doctor.

250 Words Essay on Drug Awareness

Introduction.

Drugs are substances that alter the body’s physiological processes. While some drugs are beneficial and used for medicinal purposes, others can be harmful, leading to addiction, health issues, and societal problems. Drug awareness is a crucial topic, especially for college students, as it is the foundation for understanding and preventing drug misuse.

The Importance of Drug Awareness

Drug awareness is essential to equip individuals with knowledge about the potential risks and consequences of drug use. It helps in understanding the difference between use and misuse, the signs of addiction, and the effects of drugs on physical and mental health. This knowledge can be a powerful tool in preventing drug misuse and addiction.

The Role of Education

Education plays a significant role in drug awareness. It is not only about imparting knowledge but also about fostering a healthy attitude towards drug use. Educational institutions, particularly colleges, hold a responsibility to provide students with accurate information, enabling them to make informed decisions.

In conclusion, drug awareness is a vital aspect of health education. It empowers individuals, especially college students, to make informed decisions about drug use, thus preventing potential misuse and addiction. The role of education in promoting drug awareness cannot be overstated, as it equips students with necessary knowledge and fosters a responsible attitude towards drug use.

500 Words Essay on Drug Awareness

The issue of drug abuse and addiction has become a global concern, with implications that transcend cultural, economic, and social boundaries. Drug awareness is a critical aspect in curbing this menace, as it equips individuals with the knowledge and skills to resist drug use, and encourages a healthier, safer society.

The Prevalence of Drug Abuse

The prevalence of drug abuse is alarming, with the World Health Organization estimating that nearly 5.5% of the world’s population aged 15-64 years have used drugs at least once in their lifetime. This statistic underscores the urgency for effective drug awareness programs. It is essential to understand the factors contributing to drug abuse, which include peer pressure, curiosity, stress, and the desire for escapism. These factors, coupled with the easy accessibility of drugs, create a potent recipe for addiction.

Drug awareness plays a crucial role in preventing drug abuse and addiction. Through education, individuals gain a better understanding of the dangers and implications of drug use. They learn about the harmful effects of drugs on physical health, mental health, and social relationships. Moreover, drug awareness programs can debunk myths surrounding drug use, such as the misconception that drug use is a victimless crime or that all drug users are morally weak.

Components of Effective Drug Awareness Programs

Effective drug awareness programs should be comprehensive, targeting various aspects of the drug abuse issue. Firstly, they should provide factual information about drugs, their effects, and the risks associated with their use. Secondly, they must equip individuals with the skills to resist peer pressure and make informed decisions. Lastly, these programs should provide support and resources for those struggling with addiction, emphasizing that recovery is possible and that help is available.

The Role of Society in Drug Awareness

Society plays a significant role in promoting drug awareness. Schools, workplaces, and communities can host awareness campaigns, workshops, and seminars. The media can also play an influential role in disseminating accurate information about drugs and addiction. Moreover, government policies can support drug awareness initiatives, providing funding and resources for these programs.

In conclusion, drug awareness is a crucial tool in the fight against drug abuse and addiction. By educating individuals about the realities of drug use and equipping them with the skills to resist it, we can foster a society that is healthier, safer, and more informed. It is a collective responsibility that requires the participation of all sectors of society, from the individual to the government. Through a concerted effort, we can make significant strides in addressing this global issue.

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Home — Essay Samples — Nursing & Health — Drugs — Drugs: Effects and Solutions Explored in Research

Drugs: Effects and Solutions Explored in Research

• Categories: Drug Addiction Drugs

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Published: Dec 3, 2020

Words: 1959 | Pages: 4 | 10 min read

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Introduction, drugs in general, drugs and society, drug abuse solutions.

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Chapter 7: Alcohol and Other Drugs

7.4 explaining drug use, learning objectives.

• Understand the possible biological origins of drug addiction.
• Explain why longitudinal research on personality traits and drug use is important.
• Outline the aspects of the social environment that may influence drug use.

To know how to reduce drug use, we must first know what explains it. The major explanations for drug use come from the fields of biology, psychology, and sociology.

Biological Explanations

In looking at drug use, the field of biology focuses on two related major questions. First, how and why do drugs affect a person’s behavior, mood, perception, and other qualities? Second, what biological factors explain why some people are more likely than others to use drugs?

Regarding the first question, the field of biology has an excellent understanding of how drugs work. The details of this understanding are beyond the scope of this chapter, but they involve how drugs affect areas in the brain and the neurotransmitters that cause a particular drug’s effects. For example, cocaine produces euphoria and other positive emotions in part because it first produces an accumulation of dopamine, a neurotransmitter linked to feelings of pleasure and enjoyment.

Research on identical twins suggests that alcoholism has a genetic basis.

Regarding the second question, biological research is more speculative, but it assumes that some people are particularly vulnerable to the effects of drugs. These people are more likely to experience very intense effects and to become physiologically and/or psychologically addicted to a particular drug. To the extent this process occurs, the people in question are assumed to have a biological predisposition for drug addiction that is thought to be a genetic predisposition.

Most research on genetic predisposition has focused on alcohol and alcoholism (Hanson et al., 2012). Studies of twins find that identical twins are more likely than fraternal twins (who are not genetically identical) to both have alcohol problems or not to have them. In addition, studies of children of alcoholic parents who are adopted by nonalcoholic parents find that these children are more likely than those born to nonalcoholic parents to develop alcohol problems themselves. Although a genetic predisposition for alcoholism might exist for reasons not yet well understood, there is not enough similar research on other types of drug addiction to assume that a genetic predisposition exists for these types. Many nonbiological factors also explain the use of, and addiction to, alcohol and other drugs. We now turn to these factors.

Psychological Explanations

Psychological explanations join biological explanations in focusing on why certain individuals are more likely than others to use drugs and to be addicted to drugs (Hanson et al., 2012). Some popular psychological explanations center on personality differences between drug users and nonusers. These explanations assume that users have personality traits that predispose them to drug use. These traits include low self-esteem and low self-confidence, low trust in others, and a need for thrills and stimulation. In effect, drug users have inadequate personalities, or personality defects, that make them prone to drug use, and once they start using drugs, their personality problems multiply.

One problem with research on personality explanations is methodological: If we find personality differences between drug users and nonusers, should we conclude that personality problems cause drug use, or is it possible that drug use causes personality problems? Most of the research on personality and drug use cannot answer this question adequately, since it studies drug users and nonusers at one point in time ( cross-sectional research ). To answer this question adequately, longitudinal research , which examines the same people over time, is necessary. Among initial drug abstainers at Time 1, if those with the personality traits mentioned earlier turn out to be more likely than those without the traits to be using drugs at Time 2, then we can infer that personality problems affect drug use rather than the reverse. Longitudinal research on personality and drug use that studies adolescents and college students does indeed find this causal sequence (Sher, Bartholow, & Wood, 2000). However, some scholars still question the importance of personality factors for drug use and addiction (Goode, 2012). They say these factors have only a small effect, if that, and they cite research questioning whether personality differences between users and nonusers in fact exist (Feldman, Boyer, Kumar, & Prout, 2011).

Other psychological explanations are based on the classic concept from behavioral psychology of operant conditioning —the idea that people and animals are more likely to engage in a behavior when they are rewarded, or reinforced, for it. These explanations assume that people use drugs because drugs are positive reinforcers in two respects. First, drugs provide pleasurable effects themselves and thus provide direct reinforcement . Second, drug use often is communal: People frequently use drugs (alcohol is certainly a prime example, but so are many other drugs) with other people, and they enjoy this type of social activity. In this manner, drug use provides indirect reinforcement .

Sociological Explanations

Sociological explanations emphasize the importance of certain aspects of the social environment—social structure, social bonds to family and school, social interaction, and culture—or drug use, depending on the type of drug. For drugs like heroin and crack that tend to be used mostly in large urban areas, the social structure, or, to be more precise, social inequality, certainly seems to matter. As sociologist Elliott Currie (1994, p. 3) has observed, the use of these drugs by urban residents, most of them poor and of color, reflects the impact of poverty and racial inequality: “Serious drug use is not evenly distributed: it runs ‘along the fault lines of our society.’ It is concentrated among some groups and not others, and has been for at least half a century.” This fact helps explain why heroin use grew in the inner cities during the 1960s, as these areas remained poor even as the US economy was growing. Inner-city youths were attracted to heroin because its physiological effects helped them forget about their situation and also because the heroin subculture—using an illegal drug with friends, buying the drug from dealers, and so forth—was an exciting alternative to the bleakness of their daily lives. Crack became popular in inner cities during the 1980s for the same reasons.

Social bonds to families and schools also make a difference. Adolescents with weak bonds to their families and schools, as measured by such factors as the closeness they feel to their parents and teachers, are more likely to use drugs of various types than adolescents with stronger bonds to their families and schools. Their weaker bonds prompt them to be less likely to accept conventional norms and more likely to use drugs and engage in other delinquent behavior.

Regarding social interaction, sociologists emphasize that peer influences greatly influence one’s likelihood of using alcohol, tobacco, and a host of other drugs (Hanson et al., 2012). Much and probably most drug use begins during adolescence, when peer influences are especially important. When our friends during this stage of life are drinking, smoking, or using other drugs, many of us want to fit in with the crowd and thus use one of these drugs ourselves. In a related explanation, sociologists also emphasize that society’s “drug culture” matters for drug use. For example, because we have a culture that so favors alcohol, many people drink alcohol. And because we have a drug culture in general, it is no surprise, sociologically speaking, that drug use of many types is so common.

To the extent that social inequality, social interaction, and a drug culture matter for drug use, sociologists say, it is a mistake to view most drug use as stemming from an individual’s biological or psychological problems. Although these problems do play a role for some individuals’ use of some drugs, drug use as a whole stems to a large degree from the social environment and must be understood as a social problem, and not just as an individual problem.

Beyond these general explanations of why people use drugs, sociological discussions of drug use reflect the three sociological perspectives introduced in Chapter 1 “Understanding Social Problems” —functionalism, conflict theory, and symbolic interactionism—as we shall now discuss. Table 7.6 “Theory Snapshot” summarizes this discussion.

Table 7.6 Theory Snapshot

Functionalism

Recall that functionalist theory emphasizes the need for social stability, the functions that different aspects of society serve for society’s well-being, and the threats (or dysfunctions) to society’s well-being posed by certain aspects of society. In line with this theory, sociologists emphasize that drug use may actually be functional for several members of society. For the people who use legal or illegal drugs, drug use is functional because it provides them the various positive physiological effects that drugs have. For the people who sell legal or illegal drugs, drug use is functional because it provides them a major source of income. Illegal drug use is even functional for the criminal justice system, as it helps provide jobs for the police, court officials, and prison workers who deal with illegal drugs. Legal and illegal drugs also provide jobs for the social service agencies and other organizations and individuals whose work focuses on helping people addicted to a drug. At the same time, drugs, whether legal or illegal, have the many dysfunctions for society that this chapter discussed earlier, and this fact must not be forgotten as we acknowledge the functions of drugs.

Conflict Theory

Conflict theory stresses the negative effects of social inequality and the efforts of the elites at the top of society’s hierarchy to maintain their position. This theory helps us understand drugs and drug use in at least three respects. First, and as noted just earlier, much drug use in poor urban areas results from the poverty, racial inequality, and other conditions affecting people in these locations. They turn to illegal drugs partly to feel better about their situation, and partly because the illegal drug market is a potentially great source of income that does not require even a high school degree.

Second, conflict theory emphasizes that racial and ethnic prejudice and inequality help determine why some drugs are illegal as well as the criminal penalties for these drugs. For example, the penalties for crack are much harsher, gram for gram, than those for powder cocaine, even though the two drugs are pharmacologically identical. Crack users are primarily poor African Americans in urban areas, while powder cocaine users are primarily whites, many of them at least fairly wealthy. These facts prompt many observers to say that the harsher penalties for crack are racially biased (Tonry, 2011). Other evidence for this argument of conflict theory is seen in the history of the illegality of opium, cocaine, and marijuana. As we discussed earlier, racial and ethnic prejudice played an important role in why these common drugs in the nineteenth century became illegal: prejudice against Chinese immigrants for opium, prejudice against African Americans for cocaine, and prejudice against Mexican Americans for marijuana.

Third, conflict theory emphasizes the huge influence that multinational corporations have in the marketing and sale of the legal drugs—alcohol, tobacco, and many prescription drugs—that often have harmful individual and societal consequences. To maximize their profits, these companies do their best, as noted earlier, to convince Americans and people in other nations to use their products. They also spend billions of dollars to lobby Congress. As also mentioned earlier, the tobacco industry hid for years evidence of the deadly effects of its products. All these efforts illustrate conflict theory’s critical view of the role that corporations play in today’s society.

Symbolic Interactionism

Symbolic interactionism focuses on the interaction of individuals and on how they interpret their interaction. Given this focus, symbolic interactionism views social problems as arising from the interaction of individuals. As such, it understands drug use as a behavior arising from an individual’s interaction with people who engage in drug use. From this type of social interaction, an individual learns how to use a drug and also learns various attitudes that justify drug use and define the effects of a drug as effects that are enjoyable.

A study of drug use that reflects this approach is Howard S. Becker’s (1953) classic article, “Becoming a Marihuana User.” Becker wrote that someone usually begins smoking marijuana in the presence of friends who are experienced marijuana users. This social interaction, he argued, is critical for new users to wish to continue using marijuana. To want to do so, they must learn three behaviors or perceptions from the experienced users who are “turning them on” to marijuana use. First, new users must learn how to smoke a joint (marijuana cigarette) by deeply inhaling marijuana smoke and holding in the smoke before exhaling. Second, they must perceive that the effects they feel after smoking enough marijuana (spatial distortion, hunger pangs, short-term memory loss) signify that they are stoned (under the influence of marijuana); their friends typically tell them that if they are feeling these effects, they are indeed stoned. Third, they must learn to define these effects as pleasurable; if people suddenly experience spatial distortion, intense hunger, and memory loss, they might very well worry they are having huge problems! To prevent this from happening, their friends say things to them such as, “Doesn’t that feel great!” This and similar comments help reassure the new users that the potentially worrisome effects they are experiencing are not only bad ones but in fact very enjoyable ones.

Key Takeaways

• Biological theories assume that some people are especially vulnerable to drug addiction for genetic reasons.
• A popular set of psychological theories assumes that drug addiction results from certain personality traits and problems.
• Sociological theories attribute drug use to various aspects of the social environment, including peer influences, weak social bonds, and the larger drug culture.

For Your Review

• When you think about the reasons for drug use and addiction, do you think biological factors, psychological factors, or the social environment play the most important role? Explain you answer.
• Write a brief essay in which you discuss a time when your friends influenced you, or someone else you know, to use a legal or illegal drug.

Becker, H. S. (1953). Becoming a Marihuana User. American Journal of Sociology, 59 , 235–242.

Currie, E. (1994). Reckoning: Drugs, the cities, and the American future . New York, NY: Hill and Wang.

Feldman, M., Boyer, B., Kumar, V. K., & Prout, M. (2011). Personality, drug preference, drug use, and drug availability. Journal of Drug Education, 41 (1), 45–63.

Goode, E. (2012). Drugs in American society (8th ed.). New York, NY: McGraw-Hill.

Hanson, G. R., Venturelli, P. J., & Fleckenstein, A. E. (2012). Drugs and society (11th ed.). Burlington, MA: Jones & Bartlett.

Sher, K. J., Bartholow, B. D., & Wood, M. D. (2000). Personality and substance use disorders: A prospective study. Journal of Consulting and Clinical Psychology, 68 , 818–829.

Tonry, M. (2011). Punishing race: A continuing American dilemma . New York, NY: Oxford University Press.

• Social Problems: Continuity and Change. Provided by : Social Problems: Continuity and Change is adapted from a work produced and distributed under a Creative Commons license (CC BY-NC-SA) in 2010 by a publisher who has requested that they and the original author not receive attribution. This adapted edition is produced by the University of Minnesota Libraries Publishing through the eLearning Support Initiative.. Located at : http://open.lib.umn.edu/socialproblems/ . License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike
• Identical Twins Jedward. Authored by : Michael Dorausch. Provided by : Flickr. Located at : https://www.flickr.com/photos/chiropractic/6849052778/ . License : CC BY-SA: Attribution-ShareAlike

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Drug addiction.

Dimy Fluyau ; Muhammad F. Hashmi ; Thomas E. Charlton .

Affiliations

Last Update: January 10, 2024 .

• Continuing Education Activity

The definition of addiction among the general population is a fact or condition of being addicted to a particular substance, thing, or activity. Medically, there are 2 categories: substance and nonsubstance addiction, and many risk factors predispose individuals to both. In particular, a history of risk-taking behavior, genetic predisposition, and propensity for stress play a role. Over time, addiction changes parts of the brain, specifically the dopaminergic system, responsible for perceiving rewards.

Addiction is a chronic, relapsing brain disease that leads to medical, psychological, and social complications. This activity outlines the importance of the interprofessional team in treating patients with addiction to ensure the best long-term outcomes. Participating clinicians review the importance of considering a holistic approach to the care of their patients.

• Determine the relationship between genetics and addictive behaviors.
• Evaluate the presentation of a patient with the most common types of addiction.
• Interpret the toxicokinetics of alcohol intoxication as the most common intoxication.
• Explain the importance of care coordination among the interprofessional team to deliver optimal care for patients with addiction.
• Introduction

The definition of addiction among the general population is "the condition of being addicted to a particular substance, thing, or activity." Medically, it may be defined as "a chronic, relapsing condition characterized by a compulsive drug-seeking behavior, continued use despite harmful consequence, and long-lasting changes in the brain." This current Oxford English dictionary definition is traced back to Roman law in which addiction was a "formal giving over by sentence of the court." [1]  The concept relates to the relinquishment of control by the "addicted" person, identical to how drug-dependent patients succumb to the cravings for their drug of choice.

Two main concepts of addiction involve substance addiction (drug addiction), a neuropsychiatric disorder characterized by a repeated desire to take a drug continuously despite the drug's harmful consequences. Nonsubstance addiction (behavioral addiction) does not involve a drug. Still, it includes similar behaviors as when one uses a drug, such as pathological gambling, food addiction, internet addiction, gaming, sex addiction, and mobile phone addiction. [2]

A complex interplay of neurobiology, genetics, and the environment accounts for the development of addiction, alcohol, and other drug use disorders. Reward activity is a piece of available evidence that supports the neurobiological underpinnings of addiction. However, observations implicating the dopamine reward system may downplay the potential contribution of learning and memory in the hippocampus and emotional regulation in the amygdala as possible etiologies in developing and maintaining an addiction. [3] [4] [5]

The implication of genetics across addictive behaviors was suggested via the transcription factor Delta-FosB. Delta-FosB is among the mechanisms by which the abuse of drugs can produce changes in the brain and contribute to the addiction phenotype. Delta-FosB, a member of the Fos family of transcription factors, accumulates within a subset of neurons of the nucleus accumbens and dorsal striatum after multiple administrations of illicit drugs. Studies also found a similar accumulation of Delta-FosB in the brain after compulsive running, suggesting that Delta-FosB may accrue in many types of compulsive behaviors. [6] [7]

Furthermore, how individuals handle stress psychologically, physically, and biochemically plays a significant role in the context of parental use, psychological or cognitive deficits, and levels of stress. [1]

Preclinical research has shown that stress exposures, especially in early life with child maltreatment and regular adversity, enhance drug self-administration and precipitate many relapses in individuals with addiction. Specifically, there are notable changes in the corticotropin-releasing factor, the hypothalamic-pituitary-adrenal axis (CRF/HPA), and autonomic arousal. [8] In essence, stress refers to processes that involve perception, appraisal, and response to harmful, threatening, or challenging events or stimuli. [8] Stress can be helpful, and persevering through stress results in feelings of mastery and accomplishment. However, any 'stress' that is prolonged or chronic can become unpredictable and uncontrollable, resulting in a loss of sense of accomplishment or adaptability and the development of homeostatic dysregulation. This homeostatic dysregulation creates the potential for drug-seeking behaviors and possibly addiction.

Studies in Latin American laboratories highlight the association between single nucleotide polymorphisms (SNPs) in stress-related genes and addiction. SNPs may interact with stress hormones, transcription factors, and cytokines. This interaction may be a pathway to identify reliable biomarkers of vulnerability to drug abuse and relapse. Other studies also suggest that CRF receptors in the lateral septum and the ventral tegmental area (VTA), specifically the CRF2-alpha-R isoform, are a potential therapeutic target for drug addiction. The Wnt family of secreted glycolipoproteins and their interplay could explain the interaction between stress and addictive behavior. Researchers also studied the cannabinoid system as a promising target for stress-induced relapse on drugs. [9]

In summary, addiction consistently finds roots in stressful contexts, particularly when prolonged throughout early childhood. Environmental risk factors such as impulsivity, inadequate parental supervision, and delinquency are common across chemical and behavioral expressions of addiction. Studies suggest that individuals who engage in one problem behavior are likely to engage in another problem behavior. Sociodemographic risk factors related to poverty, geography, family, and peer groups also influence the onset and course of substance and non-substance addiction.

• Epidemiology

A study in 2005, reflecting on the 2001 National Household Survey of Drug Abuse, found that out of 55561 subjects, 33576 reported alcohol use within the past year. Ultimately, the study found a slightly higher prevalence of abuse-to-dependence in males and females with (2.1 to 1) and (1.6 to 1). [10]  Per a research study in 2014, 7% of the American population meets the criteria for the diagnosis of alcohol misuse or alcoholism. [10] In 2010, the World Health Organization (WHO) estimated about 208 million people worldwide have alcohol use disorder. In 2016, globally, alcohol dependence was the most prevalent substance use disorder, but the most common drug use disorders in 2016 were cannabis and opioids. Amphetamine and cocaine use was less frequent. [11]

Designer drugs are illicitly produced chemical analogs to preexisting psychoactive or analgesic molecules. These drugs are more potent than known controlled or uncontrolled substances. There is a growing international concern that designer drugs are manufactured and distributed to circumvent drug laws and evade interdiction. [12] Designer drugs keep changing depending on the location. Among them are the following:

• Synthetic stimulants like bath salts, a synthetic cathinone
• A synthetic version of tetrahydrocannabinol (THC) called k2 or spice
• A norepinephrine-dopamine reuptake inhibitor and a member of the cathinone and pyrovalerone classes called flakka
• Synthetic designer hallucinogens called N-bomb and solaris [12]
• Synthetic opioid-non-fentanyl derived ones, such as U-47700, called "U4," "pink," or "pinky, U-49900, AH-7921, or MT-45 [13]
• Methylenedioxy-derivatives of amphetamine and methamphetamine

The most used chemical is 3,4-methylenedioxymethamphetamine (MDMA-ecstasy). [14]  The use of designer drugs is mostly encountered among young males who are 15 to 25 years old and who frequent clubs, raves, and house parties. In 1993, the National Institute on Drug Abuse survey reported an estimate of 2% of all American college students admitted to using MDMA in the previous 12 months. [12]  Several studies estimated that 6% to 17% of American college students had used synthetic cannabinoid drugs at least once. [15] Around 1% of young Europeans between the ages of 14 and 18 used synthetic cannabinoid drugs at least once in their lifetime. [16]

Deaths by overdose were increased by adulterants in products sold as heroin or as counterfeit painkillers in North America and Canada. In a city like Miami, there was an increase of 600% in fentanyl-related deaths reported from 2014 to 2015. Fatalities from these novel synthetic opioids were also reported in North America, Latin America, Canada, Asia, Europe, and Africa. [17] [18]

Abuse of prescription medicines involves:

• Central nervous depressants (benzodiazepines, non-benzodiazepines, and barbiturates).
• Prescription opioids (hydrocodone, oxycodone, fentanyl, and codeine).
• Prescription stimulants (dextroamphetamine, dextroamphetamine or amphetamine combination product, and methylphenidate).

Deaths from prescription opioid overdose were 5 times higher in 2016 than in 1999. In 2012, the National Center for Health Statistics reported that pain relievers (opioids) were involved in more "drug poisoning deaths" than heroin and cocaine. [19]

Around 9.7% of students in grades 7 to 12 reported using dextromethorphan recreationally in 2013, compared with 6.9% in 2011, based on the Ontario Student Drug Use and Health Survey. Most of the calls to poison control were related to dextromethorphan, which involved adolescent males. [19]  Acetylsalicylic acid (ASA) or acetaminophen use of more than 4 g per day for an extended time is considered misuse. [20]

Extracts of many leaves have been found to possess a powerfully addictive substance. One such example is an extract from the  Mitragyna speciosa (kratom) tree. Kratom is the subject of attention worldwide .  Reports suggest that calls to poison centers related to kratom use, by year, increased from 2010 to 2015. Kratom ( M speciosa ) misuse appears to be rising in the Western world at an alarming rate, with reported deaths. [21]

• Pathophysiology

The pathophysiology of addiction revolves around the concepts of synaptic plasticity, specifically long-term potentiation (LTP) and long-term depression (LTD). Long-term potentiation is the phenomenon of strengthened neural connections over time and with increased stimuli. Long-term depression is the decrease in the responsiveness of a neural signal with stimulation. These are the same processes involved in learning and habit formation. The biochemical proof in drug addiction is founded in the same molecules undergoing upregulation in both cases—extracellular signal-regulated protein kinase (ERK), cyclic AMP response element-binding (CREB), ELK-1, and Fos. [22]  Rats treated to suppress ERK stopped preferring the caged area with cocaine over the caged area with normal saline. [22]  Eventually, CREB, ELK-1, and Fos decreased, each known to be involved with LTP and drug misuse. [22]

Biochemical studies have shown the involvement of a dynorphin A (DYN) and K-opioid receptor (KOPr) system. [23] This system is found throughout the brain and spinal cord. Specifically, KOPr is found within brain circuits that regulate mood and motivation through dopaminergic and glutamatergic neurotransmitters. Studies have shown that dysregulation in this system has led to not only the anhedonia and depressive symptomatology of withdrawal but also drug-craving and drug-seeking behaviors. [23]  These 2 systems are involved in addiction development. Further research continues to study the process of addiction.

Furthermore, research indicates that dopamine is a critical player in terms of neurological changes in the brain of an individual with addiction. A quick and significant rise is associated with the onset and maintenance of an addiction. [24]  As the habit becomes chronic, dopamine decreases and eventually changes the prefrontal region of the brain, specifically the orbitofrontal cortex and cingulate gyrus. [24]

• Toxicokinetics

Being the most common and costly intoxication, it is essential to review the toxicokinetics of alcohol intoxication. Upon intake, alcohol begins metabolism with extensive first-pass metabolism catalyzed by the enzyme alcohol dehydrogenase (ADH). [25] While all the cells in our body can metabolize alcohol, most occur in the liver with ADH and CYP2E1 (though CYP450 enzymes are inactive until reaching chronic abuse or ingesting substantial amounts). Ethanol is metabolized initially to acetaldehyde, which gets further metabolized in mitochondria to acetate via acetaldehyde dehydrogenase. While acetate enters the peripheral circulation for utilization in various reactions as the key intermediate acetyl CoA, acetaldehyde forms in addicts, causing injury by activating immune processes.

This reaction finds particular relevance in alcoholic liver disease as ADH and ALDH1 reduce all stores of NAD+ to NADH. The eventual damage is the result of reactive oxygen species (ROS). Typically, glutathione (GSH) stores neutralize ROS, but alcohol depletes GSH stores, leaving ROS unchecked. For example, ROS interacts with lipids to undergo lipid peroxidation, resulting in malondialdehyde (MDA) and 4-hydroxy-2-nonenal (HNE), which can form protein adducts. [25] Thus, alcohol metabolism, specifically through the generation of ROS and depletion of reducing agents such as GSH, causes damage to multiple organs in the body, such as the liver, lungs, muscles, and brain. [25]

For reference, the average rate of alcohol metabolism is 7 g/h or roughly one drink/h.

• History and Physical

History and physical examination of individuals with addiction vary depending on the type of addiction, substance ingested, time since ingestion, and route. For example, most forms of alcohol intoxication present with slurred speech, ataxia, and impaired judgment. Depending on the dose and time frame of ingestion, this process can quickly spiral toward CNS depression, coma, and multiorgan failure. This progression applies to ethanol, methanol, isopropanol, and ethylene glycol.

Regarding cocaine and other stimulants, expect an acute patient with anxiety, potential psychosis, and sympathetically-driven vital signs (tachycardia, tachypnea, high blood pressure, etc). [26] Management begins with decreasing stress, stabilizing vitals, and preparing rapid response teams for deteriorating patients.

Also, significant variations are based on the stage of addiction and addictive substances.

The 5 stages of addiction are as follows:

• First Use:  These are naïve patients because they have not yet felt the effects of their substance. It could be a new pain medication prescription or peer-pressure-imposed experimentation.
• Continued Use:  Individuals begin to return to a medication they no longer “need” but want as they notice the post-high sensation does not clear as quickly.
• Tolerance:  Patients in this stage realize they need large doses of the drug to feel prior levels of high.
• Dependence:  Patients begin to show physical signs of withdrawal from discontinuing use. In addition, patients do not feel “normal” without their substance.
• Addiction:  These patients can be on one of 2 sides of the coin. They may be distressed by continued use but require it despite serious life problems that have resulted, or they may be in denial of the addiction and continue to spiral further.

The above descriptions of stages reveal the expected presentation of the addicted patient. History and physical examination will vary based on the stage of the condition. When presenting, a first-use patient is not in acute distress (barring active trauma or chronic pain) or has physical withdrawal signs. The tolerant patient will typically present with a story that necessitates increasing the dose of medication or an unexpected refill. The patient with full addiction can present in acute withdrawal with symptoms that vary based on the substance. Alcohol withdrawal will present with signs of autonomic dysregulation to the most worrisome, delirium tremens and seizures. [27]

Lab values (blood and urine), imaging, and specific tests vary depending on the cause of the addiction. If it is a psychoactive substance, there may be apparent derangements in the comprehensive metabolic panel (CMP) and complete blood count (CBC) values, as well as in the psychoanalysis and behavioral screening. The following is an abbreviated list of commonly used substances:

• CBC – Chronic use can cause an elevated mean corpuscular volume (MCV) with megaloblastic anemia from folate deficiency. [28]
• The anion gap is elevated in acute intoxication with a decreased CO 2 and decreased bicarbonate, reflecting an acidotic state.
• Methanol is the same with an addition of ophthalmologic issues. [29] It requires regular and serial eye examinations in the emergency department.
• Ethylene glycol leads to renal failure, necessitating serial BUN/Cr levels and GFR to monitor renal function; oxalic acid kidney stones commonly result in bloody urine on urinalysis (UA).
• Cocaine: An apparent sympathetic drive is expressed through elevated vitals. Patients are typically tachycardic and tachypneic. In addition, patients may present with acute psychosis. Intoxications may necessitate serial troponins, cardiac stress tests, and cardiac catheterization. [30] Due to the vasoconstriction of coronary vessels, troponins are regularly elevated.
• Opioids: Opposite to stimulants like cocaine, opioids present with parasympathetic symptoms such as bradycardia, hypotension, miosis, hypothermia, and sedation. The worrisome factor is sedation, leading to respiratory depression.

Please refer to the clinical pearls section for detailed screening criteria, such as CAGE, AUDIT, and the CIWA criteria.

An evaluation commonly used for addiction screening is the Addiction Severity Index (ASI). The screening evaluates 7 domains:

• Medical status
• Employment and support
• Alcohol use
• Legal status
• Family/social status
• Psychiatric status

The screening does not cover all special populations, such as the homeless; it is extensively cross-reviewed to show significant reliability and validity as the foundation of treatment plans for patients with addiction. [31]

Although not routine in clinical practice, imaging may be integrated into the evaluation panel of addiction. Researchers found that reduced dopamine (DA D2) receptors correlated with decreased activity in the anterior cingulate gyrus and orbitofrontal cortex in detoxified cocaine abusers. [32]

Liquid Chromatography, Mass Spectrometry, and Ion Mobility Spectrometry

Some substances, such as kratom and bath salts, are unidentifiable on a regular urine drug screen or blood work. Techniques such as liquid chromatography, mass spectrometry, and ion mobility spectrometry (IMS) are helpful. [21]

• Treatment / Management

Intoxications go hand-in-hand with addictions as they can either be the subject of the addiction or the propelling factor toward behavioral disruptions and suicidal tendencies. Further management involves monitoring and maintaining the patient's vital signs. This is dependent on the stage of presentation of the patient and the subject of the addiction. Multiple pharmacological treatments are available for the 2 most common substance addictions (tobacco and alcohol), such as group meetings and psychological and social support.

Pharmacologically, alcohol dependence is treatable with disulfiram, naltrexone, and acamprosate. [33]  Each has its place in alcohol dependence and addiction. Disulfiram is effective in managing a patient who recently quit and needs help maintaining abstinence, as any consumed alcohol causes relatively quick hangover-type symptoms to deter further drinking. Naltrexone removes the sensation of reward or pleasure with drinking, and acamprosate minimizes the initial withdrawal symptoms. Alcohol intoxication during episodes of relapse is treatable with long-acting benzodiazepines such as chlordiazepoxide or diazepam. [34]

For tobacco dependence, there is currently bupropion and varenicline. Off-label uses exist for drugs like clonidine, an alpha-2 agonist for managing high blood pressure. Also, there is nortriptyline, a member of the TCA class of antidepressants. Both of the latter drugs are effective if started before quitting. As for bupropion, the pill cuts down the craving for tobacco. [35] Varenicline helps curb the craving for nicotine as well as decrease withdrawal symptoms. [35] Along with these options are nicotine patches, gums, sprays, and lozenges.

Ultimately, however, these pharmacological interventions are combined with non-pharmacological methods for optimal efficacy and to limit and prevent substance use from developing into misuse to dependence. For example, regarding nicotine dependence, pharmacological treatments employed with the clinician's advice and empathy result in approximately double the long-term abstinence. [35]

Of interest, more people have overcome their addiction than those enrolled in a program (eg, 12-step, CBT). [36] For these reasons, consideration is necessary to treat an individual with addiction or not. If one plans to initiate treatment, a joint plan involving the patient's input yields better results.

• Differential Diagnosis

In terms of addictions, the differential should include ruling out the root causes of the addiction. Potential root causes are as follows:

Bipolar disorder – more than half of patients with substance abuse disorder have bipolar disorder, and significant mood fluctuations can present in the patient. [37]

Post-traumatic stress disorder (PTSD) – common concurrence among alcohol abusers. PTSD should be screened in all addicts. While the 2 are different conditions with separate signs and symptoms, treating the cause of PTSD can mitigate or eliminate the underlying addiction.

Since most cases of intoxication involve episodes of altered mental status, a helpful mnemonic for the emergency department physician is the following:

• A - alcohol
• E – encephalopathy (hypertensive, hepatic), electrolytes, endocrine, environmental
• I – insulin
• O – opiates, oxygen
• U – uremia
• T – trauma, toxins
• I – infection, increased intracranial pressure
• P – psychosis, poisoning, porphyria
• S – stroke, shock, seizure

Stages of addiction: refer above to the history and physical discussion to review the steps of addiction.

Stages of recovery and change from addiction include:

• Precontemplation: the patient still has yet to acknowledge the problem
• Contemplation: the patient has recognized the problem but not yet dealing with it
• Preparation: the patient makes an appointment to discuss receiving help
• Action: the patient begins treatment to reach and maintain abstinence
• Maintenance: the patient has become abstinent and is maintaining positive coping strategies
• Relapse: during the maintenance phase, patients may fall into the relapse stage from time to time and restart the recovery process  [38]

The evidence is quite clear on the long-term effects of drug dependence, with those diagnosed dying 22.5 years earlier than those without the diagnosis. This lifespan is related to the toxic effects of substances on multiple systems, including, but not limited to, the cardiac, respiratory, and neurological systems. Also, a 5-year study on alcohol and drug rehabilitation treatment found that older adults have favorable long-term outcomes versus young adults, especially older women, who had 52% 30-day abstinence rates versus a 40% younger adult rate. [39] [40] Factors such as social networks and gender play a role alongside age in these numbers.

Based on the current research on addiction, practitioners need to shift the management of patients from an acute paradigm to a chronic disease paradigm. [39] Furthermore, we must bolster the condition's screening, intervention, and overall management. Urgency is necessary for this shift as 6.9 million, or 2.8% of the US population, have the mortality risk associated with illicit drug use. [39] However, before any change gains traction, current research must bolster the evidence of decreased mortality with decreases in the prevalence and incidence of addiction.

Currently, there is a clear relationship between the changes in mortality risk and when patients begin treatment. [39] The prognosis depends on these factors.

• Complications

Regarding chronic alcohol use, Wernicke encephalopathy and Korsakoff syndrome are expected complications. The Wernicke encephalopathy consists of the triad of confusion, ophthalmoplegia, and ataxia (though usually, only one is present 20% of the time). [41]  Classic findings on CT and MRI scanning include atrophy of the bilateral mammillary bodies and hippocampal areas. [41]

Hepatic steatosis is a common complication of chronic alcohol use that results from cholesterol esters, phospholipids, and triglycerides formed ultimately from alcohol-induced ROS formation, altering lipid metabolism. Chronic heavy alcohol consumption is the most critical risk factor for chronic pancreatitis. The process begins with acute heavy consumption, which, through the toxic effects of alcohol metabolism, induces inflammatory and fibrotic changes in the pancreas over time. Specifically, the pancreatic stellate cells are activated, resulting in the expected fibrotic changes.

Cardiomyopathy is another documented complication expected due to chronic alcohol use resulting from oxidative stress, disruptions in proper calcium handling, and mitochondrial dysfunction. [42]  Cocaine addiction and intoxication lead to myocardial ischemia, psychosis, and fatal arrhythmias that require acute management to mitigate effects. [43]  From a behavioral perspective, addiction leads to multiple episodes of withdrawal and relapses.

• Postoperative and Rehabilitation Care

Rehabilitation treatment is the cornerstone of managing a patient with addiction, from sobering to maintaining their remission. Since the 1960s, various public and private modalities have been founded, such as methadone clinics, free outpatient treatment programs, and residential community treatment sites. [44]

Among the most common and effective programs are the 12-step programs, including Alcoholics Anonymous (AA), Narcotics Anonymous, and Cocaine Anonymous. These peer support groups are commonplace in addiction management with the dual benefit of aiding drug addiction reform and co-occurring mental health problems. Some of the positive outcomes of these programs include increased self-confidence, self-efficacy, and healthy coping strategies for addicts to maintain their abstinence. Overall, rehabilitation care for addiction management includes fail-safes that prevent relapse through pharmacological deterrents and peer-support groups. [45]

• Consultations

Psychiatry consults are necessary as addiction stems from underlying behavioral or psychological issues. However, due to the many medical or surgical complications associated with addiction, medical, surgical, or trauma consults are necessary. In addition, these consultations are required to address impending death due to complications, such as myocardial infarction, acute kidney failure, rhabdomyolysis, etc associated with stimulants like cocaine and amphetamine.

• Deterrence and Patient Education

Deterrence depends on proper screening criteria for early signs of potential addiction and early childhood education. School programs like DARE represent a positive effort to curb drug use and experimentation. However, while education is most effective before the development of health problems, patient education has a place at any stage of addiction. Patients are more likely to reach and maintain abstinence and institute positive lifestyle changes if clinicians and other healthcare professionals engage in consistent and positive patient encouragement.

• Pearls and Other Issues

Moderate alcohol consumption is defined as one drink per day for women and up to 2 drinks per day for men. Studies have revealed that this low to moderate alcohol use has been demonstrated to lower the risk of coronary artery disease.

The average rate of alcohol metabolism is approximately 7 grams per hour, equal to 1 drink per hour.

The CAGE questionnaire for alcoholism screening is as follows:

• Have you ever felt the need to cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt guilty drinking?
• Have you ever felt you needed a drink first thing in the morning (eyeopener) to steady your nerves or to get rid of a hangover? [46]

Each yes gets a +1, and each no gets a 0 for a total of 4. However, CAGE falls short in lower-severity situations. For these (if provided with ample time for interviewing), refer to the alcohol use disorders identification test (AUDIT):

• How often have you had a drink containing alcohol this past year?
• How many drinks of alcohol did you have on a typical day you were drinking this past year?
• How often did you have 6 or more drinks on one occasion this past year? [47]

Each question has 4 potential categories for responses, allowing each category a maximum of 4 and a low of 0. Scores less than 3 are consistent with normal alcohol consumption.

CIWA Criteria

• Nausea or vomiting 0-7
• Paroxysmal sweats 0-7
• Anxiety 0-7
• Agitation 0-7
• Tactile disturbances 0-7
• Auditory disturbances 0-7
• Visual disturbances 0-7
• Headache or fullness in the head 0-7
• Orientation or clouding of sensorium 0-4

Patients less than or equal to a score of 8 do not require medical treatment, whereas those above do.

While patients addicted to opioids may develop a tolerance for all other side effects, constipation, and miosis remain constant after the dosage. Therefore, providers should screen patients with these side effects before signs and symptoms of respiratory depression.

Although variable among the states, typical BAC levels that define alcohol intoxication are 80 mg/dL to 100 mg/dL (.08% to 0.1% BAC). For the chronic user, these levels take more time. In addition, one should avoid bupropion in patients with a current or past history of eating disorders, as this lowers the threshold for seizure side effects.

• Enhancing Healthcare Team Outcomes

Addiction is a very complex condition with multiple episodes of reaching abstinence and falling into relapse; this is why an interprofessional team is vital in treatment. Treatment begins with the clinician's risk factor identification and diagnosis but quickly grows to involve interprofessional teams to help the patient maintain abstinence. Through thorough evaluation, primary care clinicians can screen patients using the abovementioned criteria. These patients should have regular follow-up care. At the same time, social and familial support can be called upon to prevent the progression of addiction.

Once diagnosed, the swift involvement of a psychiatrist and dietician is essential. The psychiatrist can help uncover the root causes of the addiction, while the dietician can help maintain the patient's overall health. 

During relapses, nurses play pivotal roles. They can help track patient vitals, and proper medication and fluids are provided promptly to manage acute intoxications and aid the patient towards abstinence. Pharmacists are also essential members of the interprofessional team. They may be the first to notice addictive behaviors if the addiction involves prescription drugs. They are also good resources for detoxification, assisting clinicians in treatment and rehab centers, verifying dosing, and checking for drug interactions.

Also discussed above, 12-step programs, such as Alcoholics Anonymous, involving peer support, are integral to developing and maintaining abstinence. [48] Primary care clinicians, emergency department clinicians, nurses, 12-step programs, dieticians, and psychiatrists have well-researched roles in diagnosing and managing addiction patients. The interprofessional team of clinicians, nurses, specialists, psychological professionals, pharmacists, dieticians, and social workers must all coordinate their actions to achieve the best patient outcomes for addiction disorders. 

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Disclosure: Dimy Fluyau declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Thomas Charlton declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Fluyau D, Hashmi MF, Charlton TE. Drug Addiction. [Updated 2024 Jan 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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