Paul Devenyi Revised by Ralph Myerson

Medical and Behavioral Toxicity Overview Alcohol and other drugs of abuse have caused and continue to cause considerable adverse health effects to both the individual and to society. Both legal and illegal drugs (substances) of abuse are taken to modify mood, feeling, thinking, and perception. As with most drugs (medications), both acute and chronic toxicities occur. In general, the term acute refers to the short period of time when the drug is present in the body, exerting its main effects. The term chronic refers to a longer term, usually years.

Acute toxicity results in the impairment of behavior leading to other complications (e.g., trauma) and, in the case of some drugs, high doses can decrease breathing (respiratory depression) or change the rhythm of the heart, leading to accidental or intentional death. Chronic use can result in organ damage, which may lead to chronic illness or death (as with alcoholic cirrhosis of the liver). Persistent use of many classes of drugs also leads to TOLERANCE (an increased amount is required to produce the same effects) and physiologic (physical) dependence, so that a WITHDRAWAL syndrome is associated with sudden cessation of drug use. Drug users who employ hypodermic needles and syringes (injecting drug users [IDUs]) are at risk for blood-borne diseases associated with the use of unsterile equipment, such as hepatitis and human immunodeficiency virus (HIV 1 and 2—the viruses responsible for AIDS; see ACQUIRED IMMUNODEFICIENCY Syndrome).

This article focuses on ALCOHOL as the representative drug, but other drugs of abuse will be referred to where appropriate. In North America, diagnosis of alcohol and other psychoactive substance abuse/dependence is usually made according to the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA). The fourth edition, called DSM-IV, defines psychoactive substance dependence as at least three of the following (occurring in the same 12-month period):

1. tolerance, as defined by either of the following:

a. need for markedly increased amounts of the substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the same amount of the substance

2. withdrawal, as manifested by either of the following:

a. the characteristic withdrawal syndrome for the substance b. the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms

3. the substance is often taken in larger amounts or over a longer period than was intended

4. a persistent desire for or unsuccessful efforts in cutting down or controlling substance use

5. a great deal of time is spent in activities necessary in obtaining the substance (e.g., visiting multiple doctors or driving long distances), using the substance (e.g., chainsmoking), or recovering from its effects

6. important social, occupational, or recreational activities are given up or reduced because of substance use

7. continued substance use despite knowledge of having had a persistent or recurrent physical or psychological problem that was likely to have been caused or exacerbated by the substance (e.g., recurrent cocaine use despite recognition of cocaine-induced depression; continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

The diagnosis of alcohol and other substance abuse (as opposed to dependence) relies on:

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following occurring at any time during the same twelve-month period: 1. recurrent substance use resulting in a failure to fullfill major obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

2. recurrent use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

3. recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

4. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with family members about consequences of intoxication; physical fights)

B. Has never met criteria for Substance Dependence for this class of substance.

These criteria continue to evolve and are likely to be somewhat changed in the future. Clearly the lack of one of the above diagnoses does not preclude a given person from being at risk for complications of alcohol or drug use (e.g., trauma as a result of intoxication).

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