2. Concepts and definitions
Concepts and definitions are particularly important to the subject of drug use and drug
problems.(2) This subject often evokes emotional responses
because of our own ambivalence towards drug use. The literature on this subject also leads
to much confusion.
Many myths have been created and perpetuated about drug use and drug problems over the
last 30 years. A consensus is now being reached concerning the most valuable concepts, and
the way that different words should be used.
If drug users are to be helped to avoid problems and to minimise their disabilities, it
is important that simple terms should be understood and used uniformly.
This term refers to any chemical that changes the mental
state and that may be used repeatedly for that effect by a person. Some are likely to
adversely affect the health of the individual and the social surroundings.
'Drug' now includes alcohol, tobacco, psychoactive
pharmaceuticals, illicit drugs and substances such as petrol, some fluorocarbons and
anabolic steroids.
Experimental use: trying out the drug to experience its effect and to decide whether or
not to adopt an ongoing pattern of use.
Social and recreational use: using the drug as a means of enhancing social interaction
or the enjoyment of some leisure activity.
Symptomatic use: using the drug as a means of reducing unpleasant sensations or
experiences or to avoid challenging situations or responsibilities.
Dependent use: using the drug with a sense of compulsion, so that other
responsibilities are neglected and harm may result.
Such dependent use becomes habitual, stereotyped in pattern, and responsive to external
cues and pressures. This pattern is quickly reinstituted after a period of abstinence.
Abstinence may be associated with the onset of withdrawal symptoms and the discomfort of
withdrawal will become a motivator for renewed drug use.
Drug dependence syndrome describes the
pattern of behaviour shown by, and the physical changes experienced by, drug-dependent
users.
Psychological dependence describes the
behavioural aspects of drug dependence.
Physical dependence exists in a tissue or
intact organism when the presence of the drug is necessary for normal functioning. It
refers to the tolerance which develops to the effects of drug use and to the withdrawal
effects experienced when drug use is stopped.
Neuroadaptation describes the altered
sensitivity of cells, as well as the patterns of behavioural and auto-physiological
responses which develop with repeated drug use
Addiction, a term
which has been in use for thousands of years, means to give oneself to either a person or
a behaviour pattern. Addiction is a universal term and applies to those who give
themselves to a wide variety of behaviours often to the extent that their lives become
unmanageable. Addiction to alcohol and drugs is only an example of this pattern of
behaviour. However, once an addiction is established that behaviour tends to be relied
upon increasingly.
There are a number of
characteristics evident with an addiction:
- A strong desire or
sense of compulsion to engage in the particular behaviour (especially when the opportunity
to engage in such behaviour is not available);
- Impaired capacity to
control the behaviour (notably in terms of controlling its onset, staying off, or
controlling the level at which the behaviour occurs);
- Discomfort and distress
when the behaviour is prevented or stops; and
- Persisting with the
behaviour despite clear evidence that it is leading to problems
While not all of these
characteristics are present in every instance of addictive behaviour, a sense of
compulsion tends to be an essential element. Together these four features provide a good
picture of addictive behaviour with its sense of compulsion, the difficulty of maintaining
control over the behaviour, the distress associated with withdrawal, and the persistence
that such behaviours show once they have become established (Gossop, 1989).
People with an
addiction need to face the reality of the situation and to have some positive experiences
in order to regain self-esteem and hope. They must attempt to acquire a new set of values
or personal orientation in order to achieve successful control and cure.
This term refers to all the harm a
person may experience as a result of the use of drugs.
Such disabilities include a whole
range of adverse health and social consequences which may be experienced as either direct
or indirect consequence of drug use.
These include:
These include:
Drug-related disabilities may occur
in all types of drug users but are more likely to occur as the frequency and quantity of
drug use increases. Accordingly it is possible to categorise drug users in terms of the
risk of their experiencing harm. In practice this has been done only with alcohol, eg 'Low risk drinking'.
Intoxication may be defined as the intake of a
quantity of a substance which exceeds the individual's tolerance and produces behavioural
or physical abnormalities.
Overdose may be defined as the state that occurs
when a person has ingested a drug quantity higher than the recommended therapeutic dose
and that also exceeds his or her tolerance.
This term is now not recommended for use because
it can have many meanings and is used as a pejorative term implying a deliberate misuse of
drugs regardless of consequences. Alternative phrases may be used which are less explicit
and pejorative in nature.
This term describes the new approach being
taken to all drug-related problems. The aim of any intervention is not so much stopping
drug use but focusing on the reduction of specific drug-related harm.
Detoxification can be defined as the means by
which the drug-dependent person may withdraw from the effects of that drug in a supervised
way in order that withdrawal symptoms and the risks relating to withdrawal are minimised.
.i.detoxification;
Safe drinking or responsible drinking
Low risk drinking
Hazardous drinking
Clinical signs and symptoms of possible
hazardous alcohol use
Harmful drinking
Dysfunctional drinking
Binge drinking
Alcoholism, alcoholic, problem drinker
Standard drinks – grams of alcohol
A harmful dose of alcohol
Alcohol content
Indices of harm
Blood alcohol concentration
Harm and blood alcohol concentration
No specific level or pattern of drinking alcohol should be considered safe.
It has been agreed on the basis of available evidence that a range of drinking which
most people would consider low risk and drinking which is considered hazardous, dangerous
or dysfunctional, can be defined.
Female Male
Never more than Never more than
two standard drinks four standard drinks
in a day) in a day
(except for pregnancy)
(1 standard drink = 10 grams of alcohol)
Figure: one standard drink
Hazardous drinking refers to:
These include:
(Note: not in order of priority.)
Harmful drinking is defined as:
Dysfunctional drinking is defined
as:
Binge drinking has been described as the
consumption of alcohol to intoxication in a very short period of time. Generally there are
two forms of binge drinking:
- Drinking heavily on a single occasion, ie
the consumption of five or more drinks in one drinking session.
- Heavy and continuous drinking over a number
of days or weeks. This form of drinking may be characteristic of people who have high
levels of tolerance for alcohol or are susceptible to alcohol dependence.
Binge drinking is particularly evident
among young people, usually in the form of a number of bouts of drinking in the course of
a week. This form of drinking may affect an individual's cognition, distractability,
information-processing ability, and increase the risk of alcohol-related accidents (Pols
and Hawks, 1992).
These terms should be used with great caution in order to avoid misunderstanding.
Alcoholism can be used to cover the whole range of alcohol-related disabilities.
However, alcoholism has acquired a host of meanings by association with the disease
concept of alcoholism. This implies that it is a progressive and irreversible condition
that can be arrested but never cured, and involving a special sensitivity in the sufferer
who experiences craving for alcohol and loss of control of its use.
This disease concept of alcoholism can be useful but it also has many disadvantages. It
certainly can lead to unreasonable expectations and to the adoption of a passive role by
the drinker. It can promote a false sense of confidence in drinkers who believe that
alcoholics are a race apart. The idea of alcoholism as a disease can distract drinkers and
helpers from the fact that the central issue relates to the priorities and motivation of
the drinker and the drinker's capacity to control his habits or behaviour.
Alcoholic can be used as an adjective, ie alcoholic liver disease, which indicates the
problem is related to the use of alcohol. It may also be used as a noun ('he is an
alcoholic'). However, such usage is poor communication, with many emotional overtones. It
implies a simplicity of understanding which does not reflect the complexity of human
behaviour. Because of this, it is advised that the term not be used as a noun.
Problem drinker and drinking problem are loose terms that are better replaced by other
more specific terms, namely hazardous, harmful and dysfunctional drinking.
It is essential in taking a history of
alcohol consumption to determine the amount of absolute alcohol (100% ethanol) consumed by
the patient. To simplify this process it is customary to estimate the number of standard
drinks consumed per day and during a typical week.
A standard drink is defined as the amount
of any particular alcoholic beverage that contains approximately 10 grams (12.5 mL of
ethanol) which is generally equivalent to the usual drink served at a hotel or restaurant
(see figure showing range of standard drinks).
We need also to list the patient's intake as a number of standard drinks per day or per
week. Then by multiplying this number by ten we can calculate the number of grams of
alcohol consumed. This will allow us to determine whether the drinking is responsible,
hazardous or harmful. Recent research indicates that people have difficulty estimating
consumption of standard drinks using the information that is currently available on
alcoholic beverage containers.
Harmful dose is an amount of alcohol
likely to cause a harmful effect. In older terminology, it would cause an alcohol-related
problem.
Dose: alcohol consumption should be
expressed in grams – so many grams per drink consumed, so many grams on a single
drinking occasion, so many grams on an average daily basis over an extended period of
years.
The alcohol content of various beverages
is expressed in two ways:
Harm due to alcohol consumption is
manifested in a variety of ways:
Some problems are indirect effects. There
may be physical, social, psychological or behavioural problems which occur because of
hazardous or harmful alcohol use. For example:
This can be expressed as mg alcohol/100 mL
of blood eg 50 mg/100 mL = 0.05% or more commonly mg alcohol/100 mL of blood as grams per
cent eg 0.05 g%
The blood alcohol concentration (BAC) is
determined by two main factors:
Many drinkers, especially chronic
drinkers, do not start on a drinking session with a zero BAC.
One can only generalise in predicting the
likely BAC. In a male weighing 70 kilograms, 10 grams of alcohol usually raises the BAC by
0.02 grams per 100 mL of blood. The rate of elimination is about 8 grams per hour,
resulting in a fall in the BAC of about 0.015 grams per 100 mL per hour.
Driving skills begin to deteriorate at
0.03-0.04 grams per 100 mL.
Certain cognitive and other cerebral
functions are impaired: judgment, processing information, consciousness, vision.
Significant deterioration occurs at 0.05-0.08. A rapid decline in skills then occurs with
small increments in the BAC.
The same impaired cerebral functions
affect all forms of skilled performance at work, during leisure activities, etc.
Disinhibition is related to the BAC.
Disturbed behaviour often resulting in antisocial acts may become manifest between 0.06
and 0.10 g%.
Loss of control seems to be in part
related to the BAC, occurring at about 0.04-0.06 g%.
These effects can result from a single
drinking episode in any type of drinker.
In 1992 the National Health and Medical Research
Council published a series of recommendations regarding responsible drinking behaviour.
(Please refer to the chart on page 11 for further
details of the alcohol content of the usual Australian standard drinks.)
Guidelines for the safe consumption of
alcohol must be devised acknowledging that alcohol does much to enrich our social life. At
the same time the serious consequences of alcohol consumption for individuals and
societies cannot be overlooked.
Guidelines must be devised which
recognise the complexity of the effects of alcohol on different organs of the body, the
range of patterns of alcohol consumption, and the influence of other compounding factors
such as gender and nutrition.
The guidelines may need to be modified
according to the circumstances of the individual case including general health, presence
or absence of personal or family history of drug or alcohol dependence, occupation and
especially the context in which alcohol is to be consumed.
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