16:  Substance Abuse

Chapter 16 Overview

There is little doubt that the presence of drug and alcohol abuse has a phenomenal impact on the stability of the family.  Substance abuse alone contributes to at least one-third of all child abuse reported.  This chapter will examine substance abuse and its effect on individuals.

The use of drugs and alcohol, combined with the normal living stresses, creates distorted thinking which makes relationships more complex; uncontrollable emotions and unreasonable judgement complicate the family that may already bear various levels of dysfunctioning.

Nine classes of psychoactive substance are associated with both abuse and dependence:

• Alcohol;
• Amphetamine (also known as "speed") or similarly acting drugs;
• Cannabis (also known as marijuana and hashish);
• Cocaine (and its derivative "crack");
• Hallucinogens;
• Inhalants;
• Opioids;
• Phencyclidine (also known as PCP or "angel dust"); and
• Sedatives.

Distinction is made here between dependency and abuse.

Psychoactive Substance Dependence

The essential feature of this disorder is a cluster of cognitive, behavioral, and physiological symptoms that indicate that the person has impaired control of psychoactive substance use.  The person continues use of the substance despite adverse consequences.  Symptoms of the dependence syndrome include, but are not limited to, the physiologic symptoms of tolerance and withdrawal.

The symptoms of the dependence syndrome are the same across all categories of psychoactive substances, but for some classes some of the symptoms are less salient, and in a few instances do not apply (i.e., withdrawal symptoms do not occur in hallucinogen dependence).

Symptoms of Dependence

The following are the characteristic symptoms of substance dependence.  It should be noted that not all nine symptoms must be present for the diagnosis of dependence, and for some classes of psychoactive substances, certain of these symptoms do not apply.

At least three of the nine characteristic symptoms of dependence are necessary to make the diagnosis.  In addition, the diagnosis of the dependence syndrome requires that some symptoms of the disturbance have persisted for at least one month, or have occurred repeatedly over a longer period of time, as in binge drinking:

1. The person finds that when he or she actually takes the psychoactive substance, it is often in larger amounts or over a longer period than originally intended.  For example, the person may decide to take only one drink of alcohol, but after taking this first drink, continues to drink until severely intoxicated.
2. The person recognizes that the substance use is excessive, and has attempted to reduce or control it, but has been unable to do so as long as the substance is available.  In other instances the person may want to reduce or control his or her substance use, but has never actually made an effort to do so.
3. A great deal of time is spent in activities necessary to procure the substance (including theft), taking it, or recovering from its effects.  In mild cases the person may spend several hours a day taking the substance, but continue to be involved in other activities.  In severe cases, virtually all of the user's daily activities revolve around obtaining, using, and recuperating from the effects of the substance.
4. The person may suffer intoxication or withdrawal symptoms when he or she is expected to fulfill major role obligations (work, school, homemaking).  For example, the person may be intoxicated when working outside the home or when expected to take care of his or her children.  In addition, the person may be intoxicated or have withdrawal symptoms in situations in which substance use is physically hazardous, such as driving a car or operating machinery.
5. Important social, occupational, or recreational activities are given up or reduced because of substance use.  The person may withdraw from family activities and hobbies in order to spend more time with substance-using friends, or use the substance in private.
6. With heavy and prolonged substance use, a variety of social, psychological, and physical problems occur, and are exacerbated by continued use of the substance.  Despite having one or more of these problems (and recognizing that use of the substance causes or exacerbates them), the person continues to use the substance.
7. Significant tolerance, a markedly diminished effect with continued use of the same amount of the substance, occurs.  The person will then take greatly increased amounts of the substance in order to achieve intoxication or the desired effect.  This is distinguished from the marked personal differences in initial sensitivity to the effects of a particular substance.

The degree to which tolerance develops varies greatly across classes of substances.  Many heavy users of cannabis are not aware of tolerance to it, although tolerance has been demonstrated in some people.  Whether there is tolerance to phencyclidine (PCP) and related substances is unclear.  Heavy users of alcohol at the peak of their tolerance can consume only about 50% more than they originally needed in order to experience the effects of intoxication.  In contrast, heavy users of opioids often increase the amount of opioids consumed to tenfold the amount they originally used, an amount that would be lethal to a nonuser.  When the psychoactive substance used is illegal and perhaps mixed with other substances, tolerance may be difficult to determine.

NOTE:  The following items may not apply to cannabis, hallucinogens, or phencyclidine (PCP).

8. With continued use characteristic withdrawal symptoms develop when the person stops or reduces intake of the substance.  The withdrawal symptoms vary greatly across classes of substances.  Marked and generally easily measured physiologic signs of withdrawal are common with alcohol, opioids and sedatives.  Such signs are less obvious with amphetamines, cocaine, nicotine, and cannabis, but intense subjective symptoms can occur upon withdrawal from heavy use of these substances.  No significant withdrawal is seen even after repeated use of hallucinogens; withdrawal from PCP and related substance has not yet been described in humans, although it has been demonstrated in animals.
9. After developing unpleasant withdrawal symptoms the person begins taking the substance in order to relieve or avoid those symptoms.  This typically involves using the substance throughout the day beginning soon after awaking.  This symptom is generally not present with cannabis, hallucinogens, and PCP.

Criteria for Severity of Psychoactive Substance Dependence

Dependence, as defined here, is conceptualized as having different degrees of severity, and guidelines for mild, moderate, and severe dependence and dependence in partial or full remission are provided:

• Mild:  Few, if any, symptoms in excess of those required to make the diagnosis, and the symptoms result in no more than mild impairment in occupational functioning or in usual social activities or relationships with others.
• Moderate:  Symptoms or functional impairment between "mild" and "severe."

• Severe:  Many symptoms in excess of those required to make the diagnosis, and the symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.
• In Partial Remission:  During the past six months some use of the substance and some symptoms of dependence.
• In Full Remission:  During the past six months either no use of substance, or use of the substance but no symptoms of dependence.

Psychoactive Substance Abuse

Psychoactive substance abuse is a residual category for noting maladaptive patterns of psychoactive substance use that have never met the criteria for dependence for that particular class of substance.

The maladaptive pattern of use is indicated by either:

1. The continued use of the psychoactive substance despite knowledge of having a persistent or recurrent social, occupation, psychological, or physical problem that is caused or exacerbated by use of the substance, or
2. The recurrent use of the substance in situations when use is physically hazardous (i.e., driving while intoxicated).

The diagnosis is made only if some symptoms of the disturbance have persisted for at least one month or have occurred repeatedly over a longer period of time.

The person must have never met the criteria for dependence for this substance.

This diagnosis is most likely to be applicable to people who have only recently started taking psychoactive substances and to involve substances, such as cannabis, octane, and hallucinogens, that are less likely to be associated with marked physiologic signs of withdrawal and the need to take the substance to relieve or avoid withdrawal symptoms.

Examples of situations in which this category would be appropriate are as follows:

• A college student binges on cocaine every few weekends.  These periods are followed by a day or two of missing school because of "crashing."  There are no other symptoms;
• A middle-aged man repeatedly drives his car when intoxicated with alcohol.  There are no other symptoms;
• A woman keeps drinking alcohol even though her physician has told her that it is responsible for exacerbating the symptoms of a duodenal ulcer.  There are no other symptoms.

More on Alcoholism

The alcoholic is an individual who compulsively uses alcohol even though it is destroying his/her life and who displays other symptoms, such as withdrawal, blackouts, and changing tolerance.

Alcoholism is a chronic, progressive disease, the same way that tuberculosis and diabetes are chronic progressive diseases.  The disease is manifested by the compulsion to use even as the using destroys life.  One can't become an alcoholic overnight anymore than one can contract any of the other progressive diseases overnight.

Effects of Alcohol/Chemical Dependency Upon the Family

Alcoholism (and drug addiction) usually manifests itself in a way that begins to affect the individual's life.  It begins to affect his/her family.  It is a family disease.  The following information, while describing alcoholism, is also applicable to families experiencing addiction to other drugs.

Children who grow up in alcoholic families, spouses living with an alcoholic and parents with alcoholic children are all affected by a common thread with common symptoms.  One of the most common is role reversal or taking on each other's functions or responsibilities.  The entire family becomes negatively emotionally involved with the alcoholic.  The alcoholic's addiction is with the bottle.  The family, in their distorted roles, is addicted to the alcoholic.  Thus, both have a disease.

None of the family members are primarily concerned with their own feelings or needs.  Rather they live in perpetual dread of the alcoholic's behavior.  All of their highs and lows are reactions to the behavior of the alcoholic.  The longer the family lives in the condition, the more distorted their own emotions and general reasoning becomes.  Distorted emotions and reasoning are common symptoms among members of a family where the disease of alcoholism is present.  Several "categories" can apply, and as always one must allow for the fact that all are individuals.

Listed below are the most frequent categories and roles present in these families:

• Chemical Dependent:  Goes through progression of guilt, shame, and a growing fear.  They deny the problem by hiding it behind a wall of defense and remaining basically an adolescent in terms of emotional growth.  This false front does give others in the family the illusion that they (the alcoholic) are "OK."

It is said that it takes at least two to have an alcoholic.  Examples of co-dependency include:

• The Chief Enabler:  Person closest to, and most depended on by the alcoholic for their self worth.  They are inevitably affected by the mood swings of the alcoholic.  To keep a facade of normalcy, the enabler becomes more and more responsible for perpetuating the facade.
• The Family Hero:  Usually, but not always, the oldest child.  They see and hear more of what is happening in the family unit.  They begin to feel responsible for the pain and turmoil in the family.  They work hard to make things better, with a diligence to improve the situation.  They often excel in academics, sports, or social organizations and bring favorable recognition to themselves and the family.  They may appear quite mature, responsible, and healthy.  However, hidden beneath the surface is loneliness, guilt, fear, and anger.
• The Scapegoat:  Usually identified by the family as "The Problem."  Usually the second child, he/she is quite often deprived of positive attention which is given to the hero and deprived of the immense energy which the parent with substance dependency may require.  Quite often cute, humorous, and fragile, sometimes loud and precocious, the scapegoat gets attention in negative ways through disruptive and acting out behavior.  Few see the fear and insecurity within the child.  Scapegoats are often blamed for many of the family problems which are not their fault.  "You would drink too, if you had a child like that," is often heard about the scapegoat.  They come to act in a manner which will justify the accusations and often develop substance abuse problems themselves.
• The Lost Child:  Tends to be withdrawn and a loner whose most valuable contribution is that he/she does not disrupt or demand attention.  Because the family's attention is focused elsewhere, there is little attention available anyway.  The lost child suffers loneliness even though loneliness is the most comfortable for them.  As the family turmoil increases, the child often finds validation in fantasy.  Without help it is almost impossible to find this validation in themselves, resulting in low self-esteem.  They stand a good chance of becoming depressed and addicted to alcohol or drugs or becoming adults who are involved in co-dependency situations.
• The Mascot:  Usually the family clown, the one who will do virtually anything to make the other members feel better.  The mascot takes on the job of relieving tension and lessening crisis.  They are very sensitive to the moods and needs of others.  When mascots reach adulthood, they have trouble recognizing and meeting their own needs and have trouble dealing with stress.

It is important to remember that these roles are uncomfortable and confusing to anyone in them.  The symptoms of one family member, while different from those of others, are all symptoms of a dysfunctional family.  It is possible for children to switch roles or for one person to assume more than one role at a time.  For example, if the hero moves away, the family may respond by promoting another member as its hero.

Another trait of alcoholic or dysfunctional families is the presence of certain rules which prohibit a healthy family life and tend to perpetuate the dysfunction.  These rules, while not stated, are none the less understood and enforced by all family members.  These rules can be summarized as "Don't talk, don't trust, don't feel."

• "Don't talk" refers to the pattern of internalizing everything and not expressing feelings or thoughts to anyone.  The family member understands that he or she should not disclose to anyone what is going on in the household - financial difficulties, drunkenness, physical/sexual abuse, or threats of divorce.  If this rule is carried into adulthood, it makes honestly discussing virtually anything, of a personal nature, very difficult.
• "Don't trust" refers to the family member's learning that the only safe way to exist in an alcohol/substance distressed household is to not trust anyone.  Others will prove to be unreliable.  If this rule is carried into adulthood, it makes forming any sort of partnership with another person very difficult.
• "Don't feel" refers to the family member learning to deny and avoid his/her emotions.  This rule is one way to avoid the emotional roller coaster of extreme highs and lows in an alcoholic household.  Again, if this rule is carried as a coping skill into adulthood, it makes the individual poorly equipped to deal with life's emotional challenges.  The adult child of an alcoholic is more likely to have inappropriate responses to events.  For example, the person may have a rather cool or indifferent response to a personal or family tragedy but over respond to a book, television program or movie.

Why do families tolerate these conditions?  It is because the conditions develop slowly, inch by inch, brick by brick.  Role changes happen gradually and defenses are built slowly over a period of time.

The family's best defense against the emotional impact of alcoholism is gaining knowledge and achieving the emotional maturity and courage needed to put it into effect.

Recovery Resources

Successful recovery often requires a formal treatment program.  The type of treatment program depends on the extent of the alcohol problem and the degree of impairment that has resulted.  The two basic types of treatment programs are residential programs, which typically include detoxification services as needed, and outpatient programs:

• Residential programs provide extensive, short-term, 24-hour support to develop sobriety and encourage new patterns of social relationships, self-awareness, and personal development.  Most residential programs have a length of stay of approximately 30 days.  Alcoholism is characterized by chromaticity and tendency toward relapse.  Consequently, most treatment programs in an attempt to counteract those two characteristics, offer a period of extended association with the facility called aftercare.  Aftercare usually consists of regular, scheduled return visits to the facility for group and/or individual counseling sessions.  Aftercare normally lasts from three months to one year or longer.  The longer a person remains abstinent, the better are his chances to continue to do so.
• Outpatient programs provide individual and/or group counseling to individuals who do not require, or who no longer require a residential program.  The advantages of outpatient to residential treatment are obvious; the person is able to continue with his/her job and home life with little interruption.  Outpatient is usually far cheaper than residential treatment.

Two very different types of outpatient treatments are "intensive" and "supportive."  In the intensive programs, the client usually attends classes, lectures, group therapy, and individual therapy sessions several times a week.  Clients live and sleep at home and continue to work and maintain other responsibilities.  Treatment sessions are usually in the evening.  The length of the intensive outpatient program is usually longer than that of a residential program.  Most programs are six to eight weeks.  In a supportive outpatient program, the client attends the treatment facility on a regular basis; usually once a week for individual or group therapy sessions.

It is possible for a client to be transferred from one type of treatment program to another as his progress or lack of it determines.  A person may need a combination of these types of treatment in succession or may only need outpatient services.

Although Alcoholics Anonymous (AA) is not a formal treatment program, it is often recommended to supplement professional treatment, and for some it may be the only recovery resource needed.  AA provides ongoing fellowship and support for sobriety.  AA was among the first methods to be successful in assisting large numbers of alcoholics to recovery.  Part of its success is attributable to the premise that every member is a resource for every other member.  In fact, the founding members discovered that helping each other remain sober was one of the best ways they had to remain abstinent themselves.

Al-Anon and Alateen are recovery programs for the spouse, friends and relatives of alcoholics (co-dependents).  Al-Anon members say that those who love a practicing alcoholic become as sick as the drinker.  The main purpose of participation in Al-Anon is not to help sober up the friend, lover, parent, child or spouse, but to free the co-dependent from their own destructive behaviors.  Although it shares some of the same principles of recovery as AA, Al-Anon is a separate entity and is not affiliated with AA.  While not necessarily a goal of Al-Anon, those in the program feel that if they become healthier and change how they behave, they can help the alcoholic to a new awareness of their behavior and possibly into recovery.  They maintain that continued participation in the dysfunctional roles is destructive to families and the alcoholic.

Group medical insurance in Missouri is required to include coverage for treatment of alcoholism just like any other type of medical treatment.  Group insurers are required to offer drug abuse coverage as an option.  However, not everyone has "group" medical insurance.  Those who have medical insurance could also have what are called "self-insured" policies or "individual" policies.  Treatment is available even if one does not have group medical insurance.  State funded programs provide services and charge on a sliding scale based upon family income and size.  Often there is no charge or a very low charge.

Information regarding treatment resources and support groups can usually be found in local phone directories, through community health centers, and local ministerial alliances.

Check List for Symptoms of Alcoholism

Does the person...

• Need a drink the "morning after"?
• Like to drink alone?
• Lose time from work due to drinking?
• Need a drink at a definite time daily?
• Have a loss of memory while or after drinking?
• Find himself/herself (or others) harder to get along with?
• Find his/her efficiency and ambition decreasing?
• Drink to relieve shyness, fear, inadequacy?
• Find his/her drinking is harming or worrying the family?
• Find himself/herself more moody, jealous, or irritable after drinking?

Parent Questionnaire

The following is a questionnaire the Children’s Service Worker can share with the parents if their child is suspected of abusing drugs or alcohol.  Symptoms vary, but there are common signs the parent can watch for:

1. A dramatic change in personality.  Does your youngster seem giddy, depressed, irritable, hostile without reason?
2. Do his or her moods change suddenly and without provocation?
3. Is your youngster less responsible about doing chores, getting home on time or following household rules and instructions?
4. Has he or she lost interest in school, extracurricular activities, especially sports?  Are grades dropping?  Have there been complaints of sleeping or being inattentive in class?  Problems at school are common warning signs.
5. Has there been a change in friends toward a drinking or drug taking group?  A youngster having problems with alcohol or drugs will abandon old friends and seek out those with similar attitudes and behavior.
6. Are you missing money or objects that are easily convertible into cash?
7. Does your youngster "turn off" to talk about alcohol or other drugs or strongly defend his or her right to use either or both?  Abusers would rather not hear anything which might interfere with their behavior.  People defend that which is most important to them.
8. Does the youngster stay alone in his or her bedroom most of the time?  Does he or she resent questions about activities and destinations?  Some secrecy and aloofness by teenagers is normal, but when carried to extremes, these may signal problems other than just growing up.
9. Has the youngster's relationships with other family members gotten worse?  Does he or she avoid family gatherings which once were enjoyed?  The primary family relationships are affected first.
10. Does your son or daughter lie to you or others?  Lying about one's drinking/drugging is almost an infallible sign of a problem.

If the parent sees real evidence, such as the aforementioned signs, that his/her son or daughter is having a problem, don't hesitate; the parent should take some action; the worst thing to do, is nothing.  It's easy for the parent to deny there is a problem, just as it is easy for the youngster to deny he or she is having a problem or even drinking or using other drugs.  The Children’s Service Worker should assist the parents in recognizing the problem and locating professional assistance.

Refusal Skills

One reason that many young people (and some adults) use alcohol and drugs is that they have difficulty refusing an offer if it is presented.  Many people feel pressured to use substances.  Pressure occurs when someone encourages or tries to force them to do something.  The following is presented to assist Children’s Service Workers and parents in their prevention efforts with young people.

There are at least five types of pressures used when trying to persuade someone to use substances:

1. Pressure to try substances includes the simple offer.

The simple offer involves someone offering a drink, a pill, a snort, or any other substance as they might offer a soda, a stick of chewing gum, or a piece of candy.  For example, "Would you like a beer?"

2. Pressure to try substances includes the dare offer.

The dare usually involves a challenge of the youth's courage or sense of daring with statements like "Go ahead, I dare you" or "What's the matter, are you scared to?"

3. Pressure to try substances includes the threat offer.

The threat implies that the youth will lose something of value if he/she does not use the substance.  The loss could be anything of value, such as friendship or even the threat of harm.  For example, "I won't be your friend if you don't try this."

4. Pressure to try substances includes the indirect offer.

The indirect offer does not directly threaten the youth, but it implies a loss of stature if he/she doesn't participate.  For example, "We're having a keg party.  Be there or be square."

5. Pressure to try substances includes the internal offer.

The internal offer appeals to the youth's internal needs rather than external or social needs.  For example, "Oh, you're feeling down today.  I have some pills that will take care of that."  This offer implies that substances will take care of your feelings and problems in living.

Sometimes the pressure will be a simple offer and will progress to a dare, threat, etc.

There are good reasons for a young person refusing offers of alcohol or drugs.  Here's a review of some of the basic ones:

1. For adolescents, all alcohol or drug use is illegal except for the use of medications as prescribed by a physician.
2. Substance abuse interferes with natural development physically, emotionally and mentally.  The interference involves both short-term effects and long-term effects.
3. Substance abuse is destructive to family relationships.  Substance abuse by one family member negatively effects all family members.
4. Substance use can become a preoccupation and interfere with other interests and your ability to function.

Once the young person has begun using substances it is not easy to just stop and start saying "no".  Even if they know in their mind that alcohol and drugs are a negative influence on their lives and their future, it is not easy to change their behavior.  However, there are certain skills and knowledge that can help them.

There are many different ways to refuse drug offers.  Some of these techniques are:

Related Subject: Division of Alcohol and Drug Abuse Service Provider Directory http://www.dmh.missouri.gov/ada/ProviderDirectory10-07.pdf 

Acknowledgments:  Jim Schlueter, Program Specialist, and other staff at the Missouri Department of Mental Health, Division of Alcohol and Drug Abuse, reviewed this chapter and submitted contributions.

Sources:
Missouri Department of Mental Health, Division of Alcohol and Drug Abuse, Curriculum Guide for Alcohol and Drug Education Programs (ADEP), 1988

Missouri Department of Mental Health, Division of Alcohol and Drug Abuse, Curriculum Guide for Alcohol Related Traffic Offenders Program (ARTOP), 1988

The Koala Center, P.O. Box 90, Lonedell, Missouri 63060, “Parent Questionnaire”