625 W. Washington Ave • Madison, WI 53703-2637

Vol 1, Issue 2 September, 2003

1. Have you ever felt you ought to cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

…CAGE Risk Assessment

This risk assessment is used by health professionals to screen for potential alcohol abuse or dependency. People who respond with more than one yes are at risk.

SUBSTANCE USE, ABUSE, DEPENDENCY
– Suzanne Moran, MS, CADCIII, RCS
Associate Manager, Alcohol/Drug Program

No single treatment approach is appropriate for all individuals. Finding the right treatment program involves consideration of such factors as cost, length of care, philosophical approach, setting, and needs of the individual.

Historically, the U.S. has gone through various stages of acceptance, denial, and criminalization of drug abuses. As a society, our attitudes towards individuals using alcohol and other drugs vary from belief in the moral inferiority of the drug user to belief in the individual's right to the medicinal properties of drug use.

In the substance abuse treatment field, alcohol and other drug abuse is recognized as a complex issue resulting from the interaction of biological, psychological, and social factors. Consistent with the complete range of beliefs in our society, each individual is recognized as having complex and unique experiences, beliefs, and perceptions that create their world view. The social mores connected to the individual's world view determine when his or her substance use has become abuse. The effects of the drugs on the person's body and behavior determine when the drug abuse has become drug dependence.

A helpful framework for understanding these differences is the, "use, abuse, and dependence" continuum. This continuum differentiates markers for drug use, drug abuse, psychological dependence, and physical dependence. Of note is that this continuum is one of many definitions that are used to determine the severity of substance use, and it is best used as a framework to begin understanding substance use assessment.

The Use, Abuse, and Dependence Continuum
ALCOHOL/DRUG USE
Substance users comprise the largest group of individuals in the U.S. and include those who use socially. Social use is defined as low to moderate, responsible use with no social, psychological, health, economic, legal, or familial consequences. However, this social use may become complicated by potential legal consequences if the use involves an illicit drug.

ABUSE
An individual who has experienced substance abuse has had consequences related to his or her substance use. The individual may have experienced a consequence such as a drunken driving offense, or a single episode of "blacking out" (being unable to remember portions of time during a period of alcohol abuse). The individual may have had a single incident of using more than he or she planned, and experienced a loss of control that resulted in a consequence in some (or several) area(s) of his or her life. This is considered an "incident of drug abuse." This incident of abuse generally triggers self concern in the individual.

When incidents of drug abuse continue indefinitely, without increasing consequences, this is identified as a pattern of abuse. The individual may experience the concerns of others about the amount, frequency or consequences of his or her use, and may engage in periods of abstinence to "prove" to oneself or to others that the use is not a problem. The individual experiences increasing loss of predictability with the amount, frequency, or consequences of his or her using.

PHYSICAL DEPENDENCE
When an individual moves from experiencing psychological dependence to the development of physical dependence, two markers are present: 1) increased tolerance for the drug, and 2) withdrawal symptoms when the drug is stopped. An individual who is physically dependent on a drug is unable to stop using the drug without experiencing these symptoms. This leads to maintenance using in which the individual uses constantly to avoid withdrawal, or to periods of heavy binge using followed by a clear withdrawal process. Depending on the drug of abuse, the withdrawal process may require medical monitoring, as with alcohol, or it may be physically taxing without requiring medical intervention, as with heroin. Tolerance for the drug is defined as needing increasing amounts of the drug in order to prevent withdrawal and/or reach a certain level of intoxication. The individual experiencing physical dependence is generally psychologically dependent as well. In the later stages of alcohol dependence, tolerance decreases as the liver is damaged and withdrawal symptoms become more severe and potentially life threatening.

Etiology
The use, abuse and dependence continuum provides a framework for assessing the severity of substance use. However, it does not address the etiology of substance abuse and dependence. As stated earlier, alcohol and other drug abuse is recognized as a complex issue resulting from the interaction of biological, psychological, and social factors. Biologically, twin studies have shown that certain patterns of alcohol abuse are genetically predisposed. As we continue to learn about the biology of emotional and thought process, we recognize that substances can directly affect emotional experience, memory, and perception.

For individuals who are substance dependent, research has shown that a large portion of these individuals have a significant history of traumatic experiences. Traumatic experiences, especially during childhood, have been shown to create changes in the structure of the brain, and functioning. Thus, the interaction of traumatic experiences and substance abuse further complicates the recovery process for individuals who have been traumatized through physical, sexual, or emotional abuse.

Additionally, the co-occurrence of substance abuse and anxiety disorders and mood disorders (such as depression) is well documented. There is a strong advocacy for a disease model, both in the medical and in the 12 step recovery community. The disease model is best summarized by the Narcotics Anonymous statement that addiction is "progressive, incurable, and fatal" leading to "jails, institutions, and death."

Understanding the role of substances in the individual's life provides the clues for intervention. Frequently another mental health problem has preceded the substance abuse, and the individual began the use of substances to cope with the original problem. The powerful influences of culture and family also affect the norms of the individual's substance use, and those with a family history of substance abuse are more at risk for development of a problem themselves.

For those who find themselves psychologically and/or physically dependent on a substance, there are two steps to recovery: 1) stopping the use of the substance, and 2) developing healthy coping skills, activities, and relationships that do not involve substance use. Like changes that we all struggle to make with our lifestyles, the changes needed to sustain recovery from substance abuse and dependence are very challenging as they involve change at the neurobiological level in the body. For this reason, there are numerous treatment choices and paths to recovery reflecting the importance of respecting the complexity and uniqueness of the individual.

CULTURAL INFLUENCES & PERSPECTIVES
Culture influences the way alcohol is introduced, the progression of consumption, family influence/control, the definition of "normal" drinking, and the recovery process.

– Vicky Quintanilla, MSSW
Chemical Abuse Specialist II

To understand cultural differences, it is important to note that Latino people come from 23 DIFFERENT countries, each with its own variation in the use, abuse, dependence of alcohol. Each of these countries (or regions within the countries) may differ from mainstream American culture in the way alcohol is introduced, the progression of consumption, family influence/control, and the definition of “normal” drinking.

In some Latino cultures, men are introduced to alcohol by the male figure in the family, often the father. This is seen as a way to help the boy “become a man” and a bonding between father and son. For women, the process might be somewhat similar, but because of role differences, women are less likely to be interested in the initiation of this event. In addition, underage drinking is acceptable as long as the drinking is done within the family, and in some countries of Latin America "underage drinking" as defined by mainstream American culture is not prohibited.

Just as consumption is likely to be introduced by the family, the family also becomes the gatekeeper of drinking norms. This happens because the vast majority of men and women live with their parents and/or other relatives beyond the age of 18 (which is considered perfectly normal in Latino culture).

A 25 year-old Latino male said, “Just thinking about the idea of coming home and being drunk would make me think about how much to drink when I was living with my family back in...” In my clinical experience, the progression of alcohol consumption is exacerbated for Latino immigrants when they move to the U.S. because of all the challenges they have to confront when arriving here: language barriers, legal status, feelings of loneliness, family distance, discrimination, etc. As one young Latino male said, “I need to ahogar las penas” which means “I need to drown the sadness.”

– Jacquelyn Hunt
Chemical Abuse Specialist II

In order to understand some of the specific cultural influences of substance use, abuse, dependence, and recovery among African Americans, one needs to understand the history of African American people. Unlike others coming to this country, African Americans were brought on slave ships and their culture was stolen from them.

In considering the history of oppression, economic disadvantages, broken families, etc., what has been the main source of strength of many African Americans is their spiritual beliefs. The deeply rooted belief that "God could bring us through anything," is still very relevant in the culture today.

From my perspective, when one looks back over the years of slavery, it was the singing of spiritual hymns that got the slaves through the long days in the fields. Historically as a people, their belief in God has brought them through the harshest times and this is much the same when it comes to looking at substance use, abuse, dependency, and recovery. Regardless of the problem, (alcoholism, physical illness, etc.), the belief is that "God can deliver you from the situation." From this perspective, the 'disease model of addiction' is not strongly accepted in the traditional African American community/family.

In addition, the African American family has a very strong bond. There are very few things that happen in a family that are not perceived to be the family's responsibility to help resolve. The African American family has not historically been receptive to assistance from formal systems and considers this to be an interference. Prayer, held at the request of elder family members, is a powerful form of intervention. Other family members follow this lead.

Gender
The uniqueness of the individual is reflected in the gender differences in the experience of alcohol and other drug abuse. As many women continue to be primary caregivers for children, there are generally more barriers for women to attend treatment services. Women are more likely to have physical illnesses related to substance abuse within five years of heavy use. As reported in our last MHC newsletter, "women are more likely to develop substance abuse disorders after they become depressed." Men and women enter drug treatment from different avenues, and men are more likely to enter treatment through the criminal justice system. A recent study found that women are more likely to enter treatment for drugs other than alcohol.

MYTHS / TRUTHS
"People who drink too much only hurt themselves."
Truth: Every person who drinks has a parent, sibling, grandparent, best friend, or partner who worries about them. What if the person gets behind the wheel of a car?

"Alcohol is a safer drug because people generally react the same."
Truth: There are dozens of factors that affect reactions to alcohol – body weight, time of day, how one feels mentally, body chemistry, expectations, etc.

"It's just a beer. It can't permanently damage you."
Truth: Beer can do major damage to your digestive system. It can hurt your heart, liver, stomach, and other critical organs. It can take away years from life.

"Marijuana doesn’t stay in your system very long."
Truth: Marijuana is fat soluble (alcohol is water soluble). THC, the active chemical in marijuana, can be detected in the urine 14 days after use. Even after a person has stopped smoking, the effects will linger.

"Switching between beer, wine, and liquor will make you more drunk than sticking to one type of alcohol."
Truth: Your blood alcohol concentration is what determines how drunk you are, not the flavors you selected. Alcohol is alcohol.

"Alcohol gives you energy."
Truth: It's a depressant. It slows down your ability to think, speak, move.

"Cocaine is not addictive unless you use it frequently."
Truth: Cocaine is both physically and psychologically addictive. The one time use of crack (a cooked form of cocaine) can be immediately addictive/ fatal.

"A cold shower or cup of coffee will sober someone up."
Truth: Nothing sobers you up but time. You may be clean and awake, but you're still drunk.

"Drugs are a bigger problem than alcohol."
Truth: Alcohol and tobacco kill more than 50 times the number of people killed by cocaine, heroin, and every other illegal drug combined. Ten million Americans are addicted to alcohol. It is a drug.

"A drink or two will not interfere with my driving."
Truth: Small amounts of alcohol can impair your judgment. Even one drink can cloud your thinking, dim your vision, and slow your reflexes.

Adapted from – Mothers Against Drunk Driving Myths/Truths

…In selecting a treatment program, consider:
1. What is the cost/payment structure?
2. Program run by state-accredited, licensed, and/or trained professionals?
3. Facility clean, organized, well-run?
4. Encompass the full range (medical, psychological, vocational, legal, etc)?
5. Address sexual orientation, physical disabilities and provide age, gender, culturally appropriate services?
6. Long-term aftercare support and/or guidance encouraged or provided?
7. Monitoring of possible relapse?
8. Ongoing assessment to ensure
treatment plan meets changing needs?
9. Employ strategies to engage individuals in longer-term treatment (if needed), increasing the likelihood of success?
10. Offer counseling (individual/group) and other behavioral therapies?
11. Offer medication as part of the treatment regimen, if appropriate?
12. Services/referrals offered to family members to ensure understanding of addiction and recovery process?

– U.S. Center for Substance Abuse Treatment

Useful Websites
• SAMHSA – Center for Substance Abuse Treatment
http://www.samhsa.gov/centers/csat2002/csat_frame.html

• WI Clearing House for Prevention
http://wch.uhs.wisc.edu/

• National Clearing House for AoDA Information
http://store.health.org/catalog/