Editor’s note: Following is the first article in a tree-part series of opinion pieces on myths about drugs of abuse, written by Des Colohan.
PART 2: Difficult to distinguish drug use from drug abuse and drug abuse from drug addiction
PART 3: A deadly love affair
Recently, I had an opportunity to make a presentation to the standing committee of the P.E.I. legislature on Health, Social Development and Seniors on the issue of prescription drug addiction. It became very apparent as the result of our discussions that there are many misconceptions about drug abuse and addiction and I am going to try to clear up some of those misunderstandings. In the first place, many people confuse the terms drug abuse and drug addiction and use the term addiction way too loosely.
There is a distinct difference between substance abuse, defined as the intentional or deliberate overuse or misuse of a drug due to poor judgment, self-medication, over-celebration or in situations where drug use might be illegal or harmful; and drug addiction, which is a chronic disease of brain reward, motivation, memory and related circuitry. Addiction is characterized by an inability to consistently abstain, impairment in behavioural control, severe craving, diminished recognition of significant problems with one’s behaviours and relationships, and a dysfunctional emotional response. It is caused by dysregulation of one or more of the brain’s neurotransmitter systems.
There are many misunderstandings about drug abuse and addiction. Here are some of the more common myths.
1. Therapeutic pain killers like morphine, codeine, oxycodone and hydromorphone have a high rate of addiction. It depends on what you consider a high rate of addiction. 80-90 per cent of people who use potentially addictive drugs never become addicted.The drug most likely to be associated with addiction is nicotine at 32 per cent of regular users. Heroin will hook about 23 per cent, cocaine about 17 per cent, alcohol about 15 per cent, amphetamines about 11 per cent and marijuana about 9 per cent. What’s the addiction potential of prescription opiates? Honestly, we don’t know, but experience shows that opiates can be used safely to treat severe chronic pain as long as patients selected are low risk to develop addictions, dosing is kept as low as possible, and there is frequent reassessment, including urine drug testing.
2. There is a high rate of addiction when stimulants are used to treat Attention Deficit Hyperactivity Disorder (ADHD). In fact, according to Dr. David Wong, an Island paediatrician, children with ADHD are being under-diagnosed and under-treated. They have a very low risk of addiction. Untreated children with ADHD are more likely to self-medicate later in life with more dangerous drugs like alcohol, nicotine and cocaine.
3. Withdrawal symptoms equal addiction. All psychoactive prescription drugs will cause physical dependence if used regularly for more than a couple of weeks because they bind to receptors in the brain, hijacking an essential part of the brain’s communication system. If the drug is stopped abruptly, the nervous system reacts by sending messages to the person’s consciousness that something is wrong. This results in the symptoms of withdrawal. Not all drugs cause withdrawal and some drug withdrawals are more severe and more dangerous than others. In general, drugs which sedate or depress brain function cause worse withdrawal than stimulants.
4. Marijuana is not addicting. Actually, about nine per cent of chronic marijuana users meet the DSM-V criteria for substance use disorder. Heavy use may create an a motivational syndrome, characterized by apathy, dullness, impairment of judgment, concentration and memory, along with loss of interest in pursuit of conventional goals.
5. Sugar and caffeine are addicting. Neither of these meets DSM-V criteria for substance use disorder. Both can cause physical dependence and withdrawal, but neither has been shown to cause malfunctioning of the brain’s reward system, the mesolimbic dopamine system, a phenomenon common to the addictive drugs.
6. Crack cocaine is more addictive than powder cocaine. Patently not true. Chemically, these are the same drug and their effects on the brain are the same. However, because crack cocaine is smoked, it gets to the brain faster than powder cocaine, which cannot be smoked, consequently producing a more intense rush or high.
7. Club drugs are new, not very dangerous and affect everyone the same way. Club drugs include ecstasy, rohypnol, methamphetamine, GHB, ketamine, LSD, spice, salvia and bath salts. Some of these drugs can be extremely dangerous and affect different people differently.
8. Ecstasy is highly addicting. There is no current evidence that ecstasy, a hallucinogenic amphetamine, is addicting. As we study this drug more closely, we may well find that it can in fact cause addiction.
9. All psychoactive drugs have equal addiction potential. We know that this isn’t true. Nicotine is more likely to cause addiction than heroin, which is more addictive than cocaine, which is more addictive than alcohol, which is more addictive than marijuana, and so on. Addiction risk depends on genetics (40-70 per cent of the risk), substance exposure, history of mental illness, abuse as a child and other psychosocial factors.
10. Everyone who uses cocaine or heroin is an addict. Here we need to keep in mind the difference between drug use (most people who consume alcohol never abuse or become addicted to alcohol), drug abuse and drug addiction. Unfortunately, the drugs are not the primary problem but they get a lot of the blame. The small percentage of the population who have the right stuff to become addicted, as well as the 10 per cent of the population who misuse drugs, are the real problem. Strategies to curb drug abuse and addiction need to focus on prevention and, in the case of addiction, effective and ongoing treatment.
In my next piece, I will discuss other misconceptions about addiction and drug abuse and make some suggestions for addressing this major societal issue.
By Des Colohan
Desmond Colohan is a P.E.I. physician with a keen interest in chronic pain, addictions and responsible public policy.