Comparison of the perceived harm for various psychoactive drugs from a poll among medical psychiatrists specialized in addiction treatment.
|Classification and external resources|
|Patient UK||Substance abuse|
Substance abuse, also known as drug abuse, is a patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others, and is a form of substance-related disorder. Widely differing definitions of drug abuse are used in public health, medical and criminal justice contexts.
The exact cause of substance abuse is not clear, with theories including: a genetic disposition; learned from others - or a habit which if addiction develops, manifests as a chronic debilitating disease.
Drugs most often associated with this term include: alcohol, substituted amphetamines, barbiturates, benzodiazepines (particularly alprazolam, lorazepam, diazepam and clonazepam), cocaine, methaqualone, cannabis and opioids.
In some cases criminal or anti-social behavior occurs when the person is under the influence of a drug, and long term personality changes in individuals may occur as well. In addition to possible physical, social, and psychological harm, use of some drugs may also lead to criminal penalties, although these vary widely depending on the local jurisdiction.
Substance abuse is widespread with an estimated 120 million users of hard drugs such as cocaine, heroin, and other synthetic drugs. In 2013 drug use disorders resulted in 127,000 deaths up from 53,000 in 1990. The highest number of deaths are from opioid use disorders at 51,000. Cocaine use disorder resulted in 4,300 deaths and amphetamine use disorder resulted in 3,800 deaths. Alcohol use disorders resulted in an additional 139,000 deaths.
- 1 Classification
- 2 Signs and symptoms
- 3 Treatment
- 4 Epidemiology
- 5 History
- 6 Society and culture
- 7 Special populations
- 8 See also
- 9 References
- 10 Further reading
- 11 External links
Public health definitions
Public health practitioners have attempted to look at substance use from a broader perspective than the individual, emphasizing the role of society, culture, and availability. Some health professionals choose to avoid the terms alcohol or drug "abuse" in favor of language they consider more objective, such as "substance and alcohol type problems" or "harmful/problematic use" of drugs.
The Health Officers Council of British Columbia — in their 2005 policy discussion paper, A Public Health Approach to Drug Control in Canada — has adopted a public health model of psychoactive substance use that challenges the simplistic black-and-white construction of the binary (or complementary) antonyms "use" vs. "abuse". This model explicitly recognizes a spectrum of use, ranging from beneficial use to chronic dependence
'Drug abuse' is no longer a current medical diagnosis in either of the most used diagnostic tools in the world, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), and the World Health Organization's International Statistical Classification of Diseases and ICRIS Medical organization Related Health Problems (ICD)
Substance abuse has been adopted by the DSM as a blanket term to include drug abuse and other things, while the ICD uses the term Harmful use to cover physical or psychological harm to the user from use.
Physical dependence, abuse of, and withdrawal from drugs and other miscellaneous substances is outlined in the DSM a:
When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped.
Drug misuse is a term used commonly when prescription medication with sedative, anxiolytic, analgesic, or stimulant properties are used for mood alteration or intoxication ignoring the fact that overdose of such medicines have serious adverse effects. Prescription misuse has been defined differently and rather inconsistently based on status of drug prescription, the uses without a prescription, intentional use to achieve intoxicating effects, route of administration, co-ingestion with alcohol, and the presence or absence of dependence symptoms. Chronic use leads to a change in the central nervous system which means the patient has developed tolerance to the medicine that more of the substance is needed in order to produce desired effects.When this happens, any effort to stop or reduce the use of this substance would cause withdrawal symptoms to occur.
The rate of prescription drug abuse is fast overtaking illegal drug abuse in the United States. According to the National Institute of Drug Abuse, 7 million people were taking prescription drugs for nonmedical use in 2010. Among 12th graders, prescription drug misuse is now second only to cannabis. "Nearly 1 in 12 high school seniors reported nonmedical use of Vicodin; 1 in 20 reported abuse of OxyContin." Both of these drugs contain opioids.
Avenues of obtaining prescription drugs for misuse are varied: sharing between family and friends, illegally buying medications at school or work, and often "doctor shopping" to find multiple physicians to prescribe the same medication, without knowledge of other prescribers.
Increasingly, law enforcement is holding physicians responsible for prescribing controlled substances without fully establishing patient controls, such as a patient "drug contract." Concerned physicians are educating themselves on how to identify medication-seeking behavior in their patients, and are becoming familiar with "red flags" that would alert them to potential prescription drug abuse.
As a value judgment
Philip Jenkins claims that there are two issues with the term "drug abuse". First, what constitutes a "drug" is debatable. For instance, GHB, a naturally occurring substance in the central nervous system is considered a drug, and is illegal in many countries, while nicotine is not officially considered a drug in most countries. Second, the word "abuse" implies a recognized standard of use for any substance. Drinking an occasional glass of wine is considered acceptable in most Western countries, while drinking several bottles is seen as an abuse. Strict temperance advocates, who may or may not be religiously motivated, would see drinking even one glass as an abuse. Some groups even condemn caffeine use in any quantity. Similarly, adopting the view that any (recreational) use of cannabis or substituted amphetamines constitutes drug abuse implies a decision made that the substance is harmful, even in minute quantities. In the U.S., drugs have been legally classified into five categories, schedule I, II, III, IV, or V in the Controlled Substances Act. The drugs are classified on their deemed potential for abuse.
Signs and symptoms
Depending on the actual compound, drug abuse including alcohol may lead to health problems, social problems, morbidity, injuries, unprotected sex, violence, deaths, motor vehicle accidents, homicides, suicides, physical dependence or psychological addiction.
There is a high rate of suicide in alcoholics and other drug abusers. The reasons believed to cause the increased risk of suicide include the long-term abuse of alcohol and other drugs causing physiological distortion of brain chemistry as well as the social isolation. Another factor is the acute intoxicating effects of the drugs may make suicide more likely to occur. Suicide is also very common in adolescent alcohol abusers, with 1 in 4 suicides in adolescents being related to alcohol abuse. In the USA approximately 30 percent of suicides are related to alcohol abuse. Alcohol abuse is also associated with increased risks of committing criminal offences including child abuse, domestic violence, rapes, burglaries and assaults.
Drug abuse, including alcohol and prescription drugs, can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and also during the withdrawal state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. A protracted withdrawal syndrome can also occur with symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use. Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use and cannabis may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate alcohol sustained use may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence.
Drug abuse makes central nervous system (CNS) effects, which produce changes in mood, levels of awareness or perceptions and sensations. Most of these drugs also alter systems other than the CNS. Some of these are often thought of as being abused. Some drugs appear to be more likely to lead to uncontrolled use than others.
Impulsivity is characterized by actions based on sudden desires, whims, or inclinations rather than careful thought. Individuals with substance abuse have higher levels of impulsivity, and individuals who use multiple drugs tend to be more impulsive. A number of studies using the Iowa gambling task as a measure for impulsive behavior found that drug using populations made more risky choices compared to healthy controls. There is a hypothesis that the loss of impulse control may be due to impaired inhibitory control resulting from drug induced changes that take place in the frontal cortex. The neurodevelopmental and hormonal changes that happen during adolescence may modulate impulse control that could possibly lead to the experimentation with drugs and may lead to the road of addiction.
Screening and assessment
From the applied behavior analysis literature, behavioral psychology, and from randomized clinical trials, several evidenced based interventions have emerged: behavioral marital therapy, motivational Interviewing, community reinforcement approach, exposure therapy, contingency management
They help suppress cravings and mental anxiety, improve focus on treatment and new learning behavioral skills, ease withdrawal symptoms and reduce the chances of relapse.
In children and adolescents, cognitive behavioral therapy (CBT) and family therapy currently has the most research evidence for the treatment of substance abuse problems. Well-established studies also include ecological family-based treatment and group CBT. These treatments can be administered in a variety of different formats, each of which has varying levels of research support A few integrated treatment models, which combines parts from various types of treatment, have also been seen as both well-established or probably effective.
Social skills are significantly impaired in people suffering from alcoholism due to the neurotoxic effects of alcohol on the brain, especially the prefrontal cortex area of the brain. It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious, including managing the social environment.
Pharmacological therapy - A number of medications have been approved for the treatment of substance abuse. These include replacement therapies such as buprenorphine and methadone as well as antagonist medications like disulfiram and naltrexone in either short acting, or the newer long acting form. Several other medications, often ones originally used in other contexts, have also been shown to be effective including bupropion and modafinil.
Antipsychotic medications have not been found to be useful.
The initiation of drug and alcohol use is most likely to occur during adolescence, and some experimentation with substances by older adolescents is common. For example, results from 2010 Monitoring the Future survey, a nationwide study on rates of substance use in the United States, show that 48.2% of 12th graders report having used an illicit drug at some point in their lives. In the 30 days prior to the survey, 41.2% of 12th graders had consumed alcohol and 19.2% of 12th graders had smoked tobacco cigarettes. In 2009 in the United States about 21% of high school students have taken prescription drugs without a prescription. And earlier in 2002, the World Health Organization estimated that around 140 million people were alcohol dependent and another 400 million with alcohol-related problems.
Studies have shown that the large majority of adolescents will phase out of drug use before it becomes problematic. Thus, although rates of overall use are high, the percentage of adolescents who meet criteria for substance abuse is significantly lower (close to 5%). According to BBC, "Worldwide, the UN estimates there are more than 50 million regular users of morphine diacetate (heroin), cocaine and synthetic drugs."
APA, AMA, and NCDA
In 1932, the American Psychiatric Association created a definition that used legality, social acceptability, and cultural familiarity as qualifying factors:
…as a general rule, we reserve the term drug abuse to apply to the illegal, nonmedical use of a limited number of substances, most of them drugs, which have properties of altering the mental state in ways that are considered by social norms and defined by statute to be inappropriate, undesirable, harmful, threatening, or, at minimum, culture-alien."
In 1966, the American Medical Association's Committee on Alcoholism and Addiction defined abuse of stimulants (amphetamines, primarily) in terms of 'medical supervision':
…'use' refers to the proper place of stimulants in medical practice; 'misuse' applies to the physician's role in initiating a potentially dangerous course of therapy; and 'abuse' refers to self-administration of these drugs without medical supervision and particularly in large doses that may lead to psychological dependency, tolerance and abnormal behavior.
In 1973, the National Commission on Marijuana and Drug Abuse stated:
...drug abuse may refer to any type of drug or chemical without regard to its pharmacologic actions. It is an eclectic concept having only one uniform connotation: societal disapproval. ... The Commission believes that the term drug abuse must be deleted from official pronouncements and public policy dialogue. The term has no functional utility and has become no more than an arbitrary codeword for that drug use which is presently considered wrong.
The first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (published in 1952) grouped alcohol and drug abuse under Sociopathic Personality Disturbances, which were thought to be symptoms of deeper psychological disorders or moral weakness.
The third edition, published in 1980, was the first to recognize substance abuse (including drug abuse) and substance dependence as conditions separate from substance abuse alone, bringing in social and cultural factors. The definition of dependence emphasised tolerance to drugs, and withdrawal from them as key components to diagnosis, whereas abuse was defined as "problematic use with social or occupational impairment" but without withdrawal or tolerance.
In 1987, the DSM-IIIR category "psychoactive substance abuse," which includes former concepts of drug abuse is defined as "a maladaptive pattern of use indicated by...continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the use (or by) recurrent use in situations in which it is physically hazardous." It is a residual category, with dependence taking precedence when applicable. It was the first definition to give equal weight to behavioural and physiological factors in diagnosis.
By 1988, the DSM-IV defines substance dependence as "a syndrome involving compulsive use, with or without tolerance and withdrawal"; whereas substance abuse is "problematic use without compulsive use, significant tolerance, or withdrawal." Substance abuse can be harmful to your health and may even be deadly in certain scenarios
By 1994, The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association, the DSM-IV-TR, defines substance dependence as "when an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed." followed by criteria for the diagnose
DSM-IV-TR defines substance abuse as:
- A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
- Recurrent substance use resulting in a failure to fulfill major role 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)
- Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
- Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
- 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 spouse about consequences of intoxication, physical fights)
- B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
The fifth edition of the DSM (DSM-5), planned for release in 2013, is likely to have this terminology revisited yet again. Under consideration is a transition from the abuse/dependence terminology. At the moment, abuse is seen as an early form or less hazardous form of the disease characterized with the dependence criteria. However, the APA's 'dependence' term, as noted above, does not mean that physiologic dependence is present but rather means that a disease state is present, one that most would likely refer to as an addicted state. Many involved recognize that the terminology has often led to confusion, both within the medical community and with the general public. The American Psychiatric Association requests input as to how the terminology of this illness should be altered as it moves forward with DSM-5 discussion.
Society and culture
- Related articles: Drug control law, Prohibition (drugs), Arguments for and against drug prohibition, Harm reduction model
Most governments have designed legislation to criminalize certain types of drug use. These drugs are often called "illegal drugs" but generally what is illegal is their unlicensed production, distribution, and possession. These drugs are also called "controlled substances". Even for simple possession, legal punishment can be quite severe (including the death penalty in some countries). Laws vary across countries, and even within them, and have fluctuated widely throughout history.
Attempts by government-sponsored drug control policy to interdict drug supply and eliminate drug abuse have been largely unsuccessful. In spite of the huge efforts by the U.S., drug supply and purity has reached an all-time high, with the vast majority of resources spent on interdiction and law enforcement instead of public health. In the United States, the number of nonviolent drug offenders in prison exceeds by 100,000 the total incarcerated population in the EU, despite the fact that the EU has 100 million more citizens.
Despite drug legislation (or perhaps because of it), large, organized criminal drug cartels operate worldwide. Advocates of decriminalization argue that drug prohibition makes drug dealing a lucrative business, leading to much of the associated criminal activity.
Policymakers try to understand the relative costs of drug-related interventions. An appropriate drug policy relies on the assessment of drug-related public expenditure based on a classification system where costs are properly identified.
Labelled drug-related expenditures are defined as the direct planned spending that reflects the voluntary engagement of the state in the field of illicit drugs. Direct public expenditures explicitly labeled as drug-related can be easily traced back by exhaustively reviewing official accountancy documents such as national budgets and year-end reports. Unlabelled expenditure refers to unplanned spending and is estimated through modeling techniques, based on a top-down budgetary procedure. Starting from overall aggregated expenditures, this procedure estimates the proportion causally attributable to substance abuse (Unlabelled Drug-related Expenditure = Overall Expenditure × Attributable Proportion). For example, to estimate the prison drug-related expenditures in a given country, two elements would be necessary: the overall prison expenditures in the country for a given period, and the attributable proportion of inmates due to drug-related issues. The product of the two will give a rough estimate that can be compared across different countries.
As part of the reporting exercise corresponding to 2005, the European Monitoring Centre for Drugs and Drug Addiction's network of national focal points set up in the 27 European Union (EU) Member States, Norway, and the candidates countries to the EU, were requested to identify labeled drug-related public expenditure, at the country level.
This was reported by 10 countries categorized according to the functions of government, amounting to a total of EUR 2.17 billion. Overall, the highest proportion of this total came within the government functions of Health (66%) (e.g. medical services), and Public Order and Safety (POS) (20%) (e.g. police services, law courts, prisons). By country, the average share of GDP was 0.023% for Health, and 0.013% for POS. However, these shares varied considerably across countries, ranging from 0.00033% in Slovakia, up to 0.053% of GDP in Ireland in the case of Health, and from 0.003% in Portugal, to 0.02% in the UK, in the case of POS; almost a 161-fold difference between the highest and the lowest countries for Health, and a 6-fold difference for POS. Why do Ireland and the UK spend so much in Health and POS, or Slovakia and Portugal so little, in GDP terms?
To respond to this question and to make a comprehensive assessment of drug-related public expenditure across countries, this study compared Health and POS spending and GDP in the 10 reporting countries. Results found suggest GDP to be a major determinant of the Health and POS drug-related public expenditures of a country. Labelled drug-related public expenditure showed a positive association with the GDP across the countries considered: r = 0.81 in the case of Health, and r = 0.91 for POS. The percentage change in Health and POS expenditures due to a one percent increase in GDP (the income elasticity of demand) was estimated to be 1.78% and 1.23% respectively.
Being highly income elastic, Health and POS expenditures can be considered luxury goods; as a nation becomes wealthier it openly spends proportionately more on drug-related health and public order and safety interventions.
The UK Home Office estimated that the social and economic cost of drug abuse to the UK economy in terms of crime, absenteeism and sickness is in excess of £20 billion a year. However, the UK Home Office does not estimate what portion of those crimes are unintended consequences of drug prohibition (crimes to sustain expensive drug consumption, risky production and dangerous distribution), nor what is the cost of enforcement. Those aspects are necessary for a full analysis of the economics of prohibition.
(billions of dollars)
These figures represent overall economic costs, which can be divided in three major components: health costs, productivity losses and non-health direct expenditures.
- Health-related costs were projected to total $16 billion in 2002.
- Productivity losses were estimated at $128.6 billion. In contrast to the other costs of drug abuse (which involve direct expenditures for goods and services), this value reflects a loss of potential resources: work in the labor market and in household production that was never performed, but could reasonably be expected to have been performed absent the impact of drug abuse.
- Included are estimated productivity losses due to premature death ($24.6 billion), drug abuse-related illness ($33.4 billion), incarceration ($39.0 billion), crime careers ($27.6 billion) and productivity losses of victims of crime ($1.8 billion).
- The non-health direct expenditures primarily concern costs associated with the criminal justice system and crime victim costs, but also include a modest level of expenses for administration of the social welfare system. The total for 2002 was estimated at $36.4 billion. The largest detailed component of these costs is for state and federal corrections at $14.2 billion, which is primarily for the operation of prisons. Another $9.8 billion was spent on state and local police protection, followed by $6.2 billion for federal supply reduction initiatives.
According to a report from the Agency for Healthcare Research and Quality (AHRQ), Medicaid was billed for a significantly higher number of hospitals stays for Opioid drug overuse than Medicare or private insurance in 1993. By 2012, the differences were diminished. Over the same time, Medicare had the most rapid growth in number of hospital stays.
Immigrants and refugees
Immigrant and refugees have often been under great stress, physical trauma and depression and anxiety due to separation from loved ones often characterize the pre-migration and transit phases, followed by "cultural dissonance," language barriers, racism, discrimination, economic adversity, overcrowding, social isolation, and loss of status and difficulty obtaining work and fears of deportation are common. Refugees frequently experience concerns about the health and safety of loved ones left behind and uncertainty regarding the possibility of returning to their country of origin. For some, substance abuse functions as a coping mechanism to attempt to deal with these stressors.
Immigrants and refugees may bring the substance use and abuse patterns and behaviors of their country of origin, or adopt the attitudes, behaviors, and norms regarding substance use and abuse that exist within the dominant culture into which they are entering.
Street children in many developing countries are a high risk group for substance misuse, in particular solvent abuse. Drawing on research in Kenya, Cottrell-Boyce argues that "drug use amongst street children is primarily functional – dulling the senses against the hardships of life on the street – but can also provide a link to the support structure of the ‘street family’ peer group as a potent symbol of shared experience."
In order to maintain high-quality performance, some musicians take chemical substances. As a group they have a higher rate of substance abuse. The most common chemical substance which is abused by pop musicians is cocaine, because of its neurological effects. Stimulants like cocaine increase alertness and cause feelings of euphoria, and can therefore make the performer feel as though they in some ways ‘own the stage’.
Another way in which substance abuse is harmful for a performer (musicians especially) is if the substance being abused is aspirated. The lungs are an important organ used by singers, and addiction to cigarettes may seriously harm the quality of their performance. Smoking causes harm to alveoli, which are responsible for absorbing oxygen.
- Addictive personality
- Combined drug intoxication
- Controlled Substances Act
- Drug addiction
- Drug overdose
- List of controlled drugs in the United Kingdom
- List of drug-related deaths
- Harm reduction
- Low-threshold treatment programs
- Needle-exchange programme
- Poly drug use
- Polysubstance abuse
- Risk factors in pregnancy
- Substance use disorder
- Nutt, D.; King, L. A.; Saulsbury, W.; Blakemore, C. (2007). "Development of a rational scale to assess the harm of drugs of potential misuse". The Lancet. 369 (9566): 1047–1053. doi:10.1016/S0140-6736(07)60464-4. PMID 17382831.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- "Addiction is a Chronic Disease". http://archives.drugabuse.gov/about/welcome/aboutdrugabuse/chronicdisease. External link in
|website=(help); Missing or empty
- Ksir, Oakley Ray; Charles (2002). Drugs, society, and human behavior (9th ed.). Boston [u.a.]: McGraw-Hill. ISBN 0072319631.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- (2002). Mosby's Medical, Nursing & Allied Health Dictionary. Sixth Edition. Drug abuse definition, p. 552. Nursing diagnoses, p. 2109. ISBN 0-323-01430-5.
- GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet. 385: 117–71. doi:10.1016/S0140-6736(14)61682-2. PMC 4340604. PMID 25530442.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- DSM-IV & DSM-IV-TR:Substance Dependence
- Barrett SP, Meisner JR, Stewart SH (November 2008). "What constitutes prescription drug misuse? Problems and pitfalls of current conceptualizations" (PDF). Curr Drug Abuse Rev. 1 (3): 255–62. doi:10.2174/1874473710801030255. PMID 19630724.CS1 maint: multiple names: authors list (link)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- McCabe SE, Boyd CJ, Teter CJ (June 2009). "Subtypes of nonmedical prescription drug misuse". Drug Alcohol Depend. 102 (1–3): 63–70. doi:10.1016/j.drugalcdep.2009.01.007. PMC 2975029. PMID 19278795.CS1 maint: multiple names: authors list (link)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Antai-Otong, D. 2008. Psychiatric Nursing: Biological and Behavioral Concepts. 2nd edition. Canada: Thompson Delmar Learning
- PDMP Center of Excellence: The Prescription Drug Abuse Epidemic. © 2010-2012 
- "Topics in Brief: Prescription Drug Abuse" NIDA, December 2011.
- "Combating Prescription Drug Abuse in Your Practice" Aubrey Westgate, Physicians Practice, June 2012.
- Philip Jenkins, Synthetic panics: the symbolic politics of designer drugs, NYU Press, 1999, ISBN 0-8147-4244-0, pp. ix-x
- Burke PJ, O'Sullivan J, Vaughan BL (November 2005). "Adolescent substance use: brief interventions by emergency care providers". Pediatr Emerg Care. 21 (11): 770–6. doi:10.1097/01.pec.0000186435.66838.b3. PMID 16280955.CS1 maint: multiple names: authors list (link)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- O'Connor, Rory; Sheehy, Noel (29 January 2000). Understanding suicidal behaviour. Leicester: BPS Books. pp. 33–36. ISBN 978-1-85433-290-5.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Isralowitz, Richard (2004). Drug use: a reference handbook. Santa Barbara, Calif.: ABC-CLIO. pp. 122–123. ISBN 978-1-57607-708-5.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- University of Miami: Substance Abuse, Substance Abuse and Health Risks
- Evans, Katie; Sullivan, Michael J. (1 March 2001). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser (2nd ed.). Guilford Press. pp. 75–76. ISBN 978-1-57230-446-8.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Jaffe, J.H. (1975). Drug addiction and drug abuse. In L.S. Goodman & A. Gilman (Eds.) The pharmacological basis of therapeutics (5th ed.). New York: MacMillan. pp. 284–324.
- Gerard Moeller M.D., Barratt Ernest S., Ph , Dougherty Donald M., Ph , Schmitz Joy M., Ph , Swann Alan C. "Psychiatric Aspects of Impulsivity". The American Journal of Psychiatry. 158 (11): 2001. doi:10.1176/appi.ajp.158.11.1783.CS1 maint: multiple names: authors list (link)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152830/"Similar Processes despite Divergent Behavior in Two Commonly Used Measures of Risky Decision Making.
- Genetic influences on impulsivity, risk taking, stress responsivity and vulnerability to drug abuse and addiction
- R. Andrew Chambers, M.D., Jane R. Taylor, Ph.D., Marc N. Potenza, M.D., Ph.D.US National Library of Medicine National Institutes of Health:Developmental Neurocircuitry of Motivation in Adolescence: A Critical Period of Addiction Vulnerability. 
- O'Donohue, W; K.E. Ferguson (2006). "Evidence-Based Practice in Psychology and Behavior Analysis" (accessdate = 2008-03-24). The Behavior Analyst Today. Joseph D. Cautilli. 7 (3): 335–350. doi:10.1037/h0100155. Missing pipe in:
- Chambless, D.L.; et al. (1998). "An update on empirically validated therapies" (PDF). Clinical Psychology. American Psychological Association. 49: 5–14. Retrieved 2008-03-24.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- "NIH Senior Health "Build With You in Mind": Survey". nihseniorhealth.gov. Retrieved 29 July 2015.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- "Association for Behavioral and Cognitive Therapies - What is CBT?".<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- "Association for Behavioral and Cognitive Therapies - What is Family Therapy?".<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Hogue, A; Henderson, CE; Ozechowski, TJ; Robbins, MS (2014). "Evidence base on outpatient behavioral treatments for adolescent substance use: updates and recommendations 2007-2013". Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53. 43 (5): 695–720. doi:10.1080/15374416.2014.915550. PMID 24926870.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- "Association for Behavioral and Cognitive Therapies - Treatment for Substance Use Disorders".<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- "Self-Help Groups Article". Retrieved May 27, 2015.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Uekermann J, Daum I (May 2008). "Social cognition in alcoholism: a link to prefrontal cortex dysfunction?". Addiction. 103 (5): 726–35. doi:10.1111/j.1360-0443.2008.02157.x. PMID 18412750.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Purvis G., MacInnis D. M. (2009). "Implementation of the Community Reinforcement Approach (CRA) in a Long-Standing Addictions Outpatient Clinic" (PDF). Journal of Behavior Analysis of Sports, Health, Fitness and Behavioral Medicine. 2: 133–44.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- The California Evidence-Based Clearinghouse: Current Pharmacological Treatment Available for Alchhol Abuse. Copyright 2006-2013.
- James W. Kalat Biological psychology 11th edition pg.78
- Maglione, M; Maher, AR; Hu, J; Wang, Z; Shanman, R; Shekelle, PG; Roth, B; Hilton, L; Suttorp, MJ; Ewing, BA; Motala, A; Perry, T (September 2011). "Off-Label Use of Atypical Antipsychotics: An Update [Internet]". Agency for Healthcare Research and Quality (US); 2011 Sep. Report No.: 11-EHC087-EF. PMID 22132426.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Global Status Report on Alcohol 2004
- Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2011). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2010. Ann Arbor: Institute for Social Research, The University of Michigan.
- "CDC Newsroom Press Release June 3, 2010".<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Barker, P. ed. 2003. Psychiatric and mental health nursing: the craft and caring. London: Arnold. pp297
- Effective Child Therapy: Substance Abuse and Dependence. Copyright 2012
- "Drug Trade". BBC News.
- Glasscote, R.M., Sussex, J.N., Jaffe, J.H., Ball, J., Brill, L. (1932). The Treatment of Drug Abuse for people like you...: Programs, Problems, Prospects. Washington, D.C.: Joint Information Service of the American Psychiatric Association and the National Association for Mental Health.
- Second Report of the National Commission on Marihuana and Drug Abuse; Drug Use In America: Problem In Perspective (March 1973), p.13
- Transformations: Substance Drug Abuse
- American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC.
- Copeman M (April 2003). "Drug supply and drug abuse". CMAJ. 168 (9): 1113, author reply 1113. PMC 153673. PMID 12719309.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Wood E, Tyndall MW, Spittal PM, et al. (January 2003). "Impact of supply-side policies for control of illicit drugs in the face of the AIDS and overdose epidemics: investigation of a massive heroin seizure". CMAJ. 168 (2): 165–9. PMC 140425. PMID 12538544.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Bewley-Taylor,Dave, Hallam, Chris, Allen Rob. The Beckley Foundation Drug Policy Programme: The Incarceration of Drug Offenders: An Overview. March 2009. 
- Prieto L (2010). "Labelled drug-related public expenditure in relation to gross domestic product (gdp) in Europe: A luxury good?". Substance Abuse Treatment, Prevention, and Policy. 5: 9. doi:10.1186/1747-597x-5-9.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- "NHS and Drug Abuse". National Health Service (NHS). March 22, 2010. Retrieved March 22, 2010.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Thornton, Mark. "The Economics of Prohibition".<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- The economic costs of drug abuse in the United States
- Owens PL, Barrett ML, Weiss AJ, Washington RE, Kronick R (August 2014). "Hospital Inpatient Utilization Related to Opioid Overuse Among Adults, 1993-2012". HCUP Statistical Brief #177. Rockville, MD: Agency for Healthcare Research and Quality.CS1 maint: multiple names: authors list (link)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Drachman, D. (1992). "A stage-of-migration framework for service to immigrant populations". Social Work. 37 (1): 68–72. doi:10.1093/sw/37.1.68.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Pumariega A. J., Rothe E., Pumariega J. B. (2005). "Mental health of immigrants and refugees". Community Mental Health Journal, 41:. 5: 581–597. doi:10.1007/s10597-005-6363-1.CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- National Institute on Alcohol Abuse and Alcoholism. (2005). Module 10F: Immigrants, refugees, and alcohol. In NIAAA: Social work education for the prevention and treatment of alcohol use disorders (NIH publication). Washington, D.C.
- Caetano R., Clark C. L., Tam T. (1998). "Alcohol consumption among racial/ethnic minorities: Theory and research". Journal of Alcohol, Health, and Research. 22 (4): 233–241.CS1 maint: multiple names: authors list (link)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- UNODC. "Understanding Substance Use Among Street Children" (PDF). Retrieved 30 January 2014.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Cottrell-Boyce, Joe (2010). "THE ROLE OF SOLVENTS IN THE LIVES OF STREET CHILDREN" (PDF). African Journal of Drug & Alcohol Studies. 9 (2): 93–102. doi:10.4314/ajdas.v9i2.64142. Retrieved 28 January 2014.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Breitenfeld D., Thaller V., Perić B., Jagetic N., Hadžić D., Breitenfeld T. (2008). "Substance abuse in performing musicians". Alcoholism: Journal on Alcoholism and Related Addictions. 44 (1): 37–42.CS1 maint: multiple names: authors list (link)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Lowinson, Joyce H; Ruiz, Pedro; Millman, Robert B; Langrod, John G (eds) (2005). Substance Abuse: A Comprehensive Textbook (4th ed.). Philadelphia: Lippincott Williams & Wilkins. ISBN 0-7817-3474-6. Retrieved 2 December 2010CS1 maint: extra text: authors list (link)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
- Walker, Evelyn, and Perry Deane Young (1986). A Killing Cure. New York: H. Holt and Co. xiv, 338 p. N.B.: Explanatory subtitle on book's dust cover: One Woman's True Account of Sexual and Drug Abuse and Near Death at the Hands of Her Psychiatrist. Without ISBN
- Alexander GC, Kruszewski SP, Webster DW. Rethinking Opioid Prescribing to Protect Patient Safety and Public Health" JAMA 2012;308:1865-1866.