Dependence on psychoactive substances
With dependence on psychoactive substances is referred to a group of health problems due to repeated ingestion of various psychotropic substances . A strong, periodic or permanent desire for substance is considered typical . It can lead to neglect of other obligations or activities - possibly even progressive. A possible loss of control with compulsive substance use cannot be ruled out.
Depending on the substance, there may be an increase in tolerance and an increase in dose and - if not ingested - withdrawal symptoms may occur. If psychoactive substances are taken within a social context , the dependence must be viewed in the context of complex interactions between social and biological processes.
According to the definitions of the World Health Organization (WHO) - see box above right: Classification according to ICD-10 - addiction typically consists of a strong desire to ingest a substance, difficulties in controlling its use, and continued use despite harmful consequences.
For the frequency of the individual addiction syndromes, see the respective main article on psychotropic substances.
On the basis of scientific studies, the number of people manifestly dependent on medication in Germany is estimated at around 1.4–1.9 million. In about 80% of the cases, this is a dependence on benzodiazepines , which have a high potential for dependence.
Psychotropic substances , i.e. substances that influence thinking and feelings, can, with different potentials, induce a person to unconditionally re- use , i.e. lead to dependence. This property is called dependency potential or addictive potential .
According to a theory by Hollister (1978), the potential for dependence on substances with a very short or very long half-life should be lower. It is assumed that substances with a rapid influx of substances have the highest potential for dependence.
According to a British study from 2007, the substances with the highest addiction potential (in descending order according to addiction potential, scale values in brackets after) are:
- The opioid heroin (3.00),
- the stimulant cocaine (2.39),
- Tobacco (2.21),
- the opioid methadone (2.08),
- and sleeping pills from the group of barbiturates (2.01).
Substances with medium dependency potential:
- Alcohol (1.93),
- Benzodiazepines ( anti-anxiety substances , sleeping pills ) (1.83),
- the stimulant amphetamine (1.67),
- the opioid buprenorphine (1.64),
- Ketamine (1.54),
- and cannabis (see also: marijuana , hashish , hashish oil ) (1.51).
Substances with low addiction potential:
- 4-MTA (ecstasy-like, drug scene name Flatliners) (1.30),
- Methylphenidate (known as Ritalin) (1.25),
- LSD (1.23),
- GHB (1.19),
- Ecstasy (1.13),
- Khat (1.04),
- and inhalants (1.01).
Substances without pronounced dependence potential:
Study from 2017
In 2017, the World Commission on Drug Policy published a partly different order .
11.6% of those who use drugs become addicted on average:
- 32% for tobacco
- 23% for heroin
- 17% for cocaine
- 15% for alcohol
- 9% for cannabis.
More about individual substances
- Although alcoholic beverages are legal in many countries, ethanol has a dependency potential comparable to opiates, barbiturates and cocaine. Alcohol dependence develops after long-term increased alcohol consumption and leads to alcohol sickness . Delirium tremens can occur when the substance is discontinued . The number of alcohol addicts is high because alcohol is a cheap and easily obtainable drug that is also socially recognized, e.g. B. the consumption at social occasions.
- Amphetamines (speed)
- Amphetamines can trigger a strong psychological dependency, as the effect promises increased performance, improved concentration and euphoria as a party drug. The risk of addiction depends on the genetic disposition and the psychological situation of the person. In animal experiments, some individuals were able to regulate their consumption for the rest of their lives, while 50% developed psychological dependency after some time with strong tolerance development.
- The likelihood of becoming dependent on cannabis use is increased by a number of psychosocial factors. The development of an addiction syndrome has been assigned to an experimentally observed underfunction of the reward system in the human brain.
- The hallucinogens are in different categories divided . Psychedelics such as LSD , mescaline and hallucinogenic mushrooms usually do not cause addiction. Hallucinogens from the group of dissociatives , such as ketamine , on the other hand, cause addiction.
- Heroin and other opiates / opioids
- Heroin is one of the substances with the highest potential for addiction. Due to the euphoric effect, a psychological dependency quickly develops, as the consumer forgets negative thoughts and worries while intoxicated. The risk of addiction is therefore determined according to the psychosocial situation of the consumer. After frequent use, opiates become dependent, with withdrawal being experienced as extremely unpleasant and therefore offering the person affected a (negative) motivation to continue consuming in order to avoid or reduce the withdrawal symptoms.
- Cocaine and crack
- The potential for addiction to cocaine is also considered to be very high. Until 1980 the prevailing view was that cocaine did not cause addiction in the sense of withdrawal symptoms. A few years later this view turned into its opposite, among other things after corresponding changes in the brain became known. Mental withdrawal syndromes due to cocaine use have been scientifically established since the 1990s and are increasingly being researched on a biochemical level. The drug crack , made from cocaine , also causes addiction.
- About 4 to 5% of drugs have a potential for abuse or dependence. This applies in particular to hypnotics , sedatives and tranquillants, as well as psychostimulants , and also to opioid-containing analgesics . Patients usually expect a positive effect from drugs, so it may be difficult to correctly assess the potential risk of abuse or addiction when taking them.
- MDMA (ecstasy)
- The addiction rate of common MDMA users according to the criteria of DSM IV was estimated in a systematic review from 2011 to be around 15%. On the other hand, long-term damage (longer than 2 years) to nerve endings that work with dopamine or serotonin is also a general phenomenon in humans, which affects all consumers.
- Tobacco smoke
- For the dependence of tobacco smoke is nicotine responsible. Comparisons of animal studies and studies of human drug use show that pure nicotine has little potential for addiction, but tobacco cigarette smoke has a very high potential for addiction. In combination with other substances in tobacco smoke, nicotine has an extremely high potential for dependence and can very quickly lead to dependent behavior . According to a paper published in 2007 by D. Nutt et al. a. the addiction potential of tobacco smoke lies somewhere between alcohol and cocaine. More precisely, the physical addiction potential is that of alcohol or barbiturates and the psychological addiction potential that of cocaine. A comparison with addiction to opiates such as heroin is not indicated because this is much more difficult to treat and the withdrawal symptoms are more severe. A few cigarettes or a few days with little cigarette consumption are enough to become dependent. The potential for dependence on orally ingested nicotine is significantly lower, and patches have almost no potential for dependence.
- Above all, it is important that nicotine, in conjunction with other substances in tobacco smoke, subliminally creates the desire for a tobacco product and that the increasingly shorter habit-related stimulus-response interval creates an increasingly pronounced dependency in the form of increased tobacco consumption.
- Today we know that after three weeks of abstinence there is no longer any measurable change in the acetylcholine receptors - that is, they have returned to normal. During this time there can be restlessness and irritability up to aggressiveness and depression. At this point in time, the nicotine itself is no longer detectable in the brain (up to a maximum of three days after the end of nicotine consumption).
- As a result, one can establish a potential for dependency, which is rather unconscious, i.e. H. in unreflected everyday life, finds its greatest expression. In withdrawal phases it becomes apparent that these unconscious parts are now consciously processed by the withdrawing person.
- As a result, it can be stated that during withdrawal the dependence on the effects produced by the tobacco smoke is less important, as shown by many failed therapies with nicotine substitutes, but rather the learning process induced by the nicotinic stimulation of the nucleus accumbens . In a suitable way, this learning process can only be influenced or reversed by strong self-motivation or professional behavioral therapies. Nicotine replacement or medication can help with withdrawal.
- The likelihood of relapse among smokers who quit tobacco without aids is 97% within six months of quitting. Until 2012, it was assumed that nicotine replacement preparations with the correct dosage and further professional guidance could increase the chances of success by 3%. A recent study from 2012 found that relapse rates among those who used nicotine replacement supplements to quit were just as high as those who quit without aids.
- The psychological dependence due to imprinted behavior patterns that develop in the course of a “smoking career” can still be present years after withdrawal.
Multiple substance use
According to ICD-10 (F19.-), there is a disorder due to multiple substance use if the substance intake is chaotic and indiscriminate, or if components of different substances are inseparably mixed.
Theories on the development of addiction syndrome
Dependency is the result of a multi-causal process in which biological and social factors interact.
The likelihood of an addiction disease is also influenced by certain variants in the genetic make-up. However, to this day (2018) there is still a large gap between the very small individual effects of genetic deviations in this regard and the known extent of actual hereditary influence. Nevertheless, there are already very concrete results in the areas of nicotine, opioids , alcohol, cannabis and cocaine. Investigation methods in this area are family studies, adoption studies, twin studies , candidate gene discovery, genome-wide association studies and the analysis of copy number variants (CNV) in certain chromosome sections.
Neurobiological mechanisms of action
The emergence of a dependency is seen neurobiological an abnormal ( pathological ) form of an actually useful, biological learning process, the sensitization is called. A psychoactive substance causes changes on the surfaces and inside of nerve cells that increase the future desire to use this substance again. This sensitization of desire usually lasts long after withdrawal and therefore increases the risk of relapse. In contrast to the desire, the desired feeling ( euphoria ) is not increased, but rather weakens (development of tolerance ).
At the cellular and molecular level, sensitization is caused by changes in neurochemistry , neurophysiology , neuroanatomy, and gene expression . A single use of a substance can lead to long-lasting changes in the signal transmission of nerve cells. The most far-reaching changes happen during the developmental phases of the brain, most extreme during prenatal ( prenatal ) development.
In two reviews from 2016, dependence is described as a connection between three disease complexes, each of which is assigned to certain changes in certain networks of the brain. These are the complexes (1) pathological desire (addiction), (2) pathological withdrawal symptoms and (3) pathological expectations. In a subsequent review from 2018 it was described that this model - with small deviations - is also applicable to the abuse of cannabis .
Cross-sensitization of substances
Many studies have shown that repeated use of a substance can not only increase sensitivity to this substance ( sensitization ), but also sensitivity to other psychoactive substances. This process is known as cross-sensitization .
Compared to clinical studies , it is relatively easy to determine in animal experiments whether the consumption of one drug increases the later attractiveness of another drug. For example, cannabis use in animals increased self-administration of heroin, morphine and nicotine in follow-up experiments. Direct evidence has also been found that the mechanism of imprinting is an ongoing change in the brain's reward system. The importance of these results for the reward system in the human brain in relation to susceptibility to other drugs has been highlighted in several reviews .
Denise Kandel , professor of sociomedical sciences in psychiatry at Columbia University and director of the epidemiology of substance abuse at the New York State Psychiatric Institute, and colleagues have published the results of several studies on the timing of initial drug use since 1975. It has been observed that the order of initial use of various drugs is not random, but rather shows trends. The established technique of longitudinal studies made it possible to precisely describe these trends by specifying probabilities .
"There is strong empirical evidence [emphasis in original] that e-cigarette use increases the risk of adolescents and young adults ever using flammable tobacco cigarettes."
Among other things, the authors put this into connection with the fact that the well-known sensitization of the brain by the nicotine of e-cigarettes - especially in adolescents - leads to an increased probability of further nicotine consumption.
Willful control of substance desires
Dependency includes impairment of perception, risk assessment and control of one's own behavior. The likelihood of automatic behavior related to substance use is increased. The possibility to choose between different decisions is thus often difficult, but by no means completely lost.
Concomitant illnesses and consequences
In addition to the addiction syndrome, there are a number of comorbidities .
Mental disorders can precede a dependency syndrome and are to be treated as concomitant diseases. Possible concomitant diseases can be B. anxiety disorders , depression , ADHD , adjustment disorders , personality disorders or psychoses . The mental disorders mentioned can also be the result of an addiction syndrome; in the case of psychosis, the term drug psychosis is common. Also, social isolation may be preceded by a dependency syndrome or consequence.
Consequences of the addiction syndrome
The consequences of the addiction syndrome depend largely on the psychotropic substance to which the addiction exists. See therefore the main article on the respective substance.
Orientation towards addiction is becoming more and more important in the life of those affected. The consumer's attention is increasingly shifted to the consumption and procurement of the psychoactive substance and the subsequent lingering in a state of intoxication. Other activities, interests and obligations are often neglected. Personality, or personal development, can be significantly impaired. In addition, there is a risk of procurement crime .
Prevention and therapy
Newer approaches to drug prevention rely less on deterrence; H. the emphasis on often organism damaging properties, but increasingly on education. Deterrence was often not taken seriously by the target groups. Education is used as an alternative to repression-oriented drug policies, in which drug use is viewed as intolerable.
The aim of this prevention concept is to impart knowledge about the effects of a substance. This concerns both the expected pleasant effects or undesirable side effects, as well as the possible social and health damage. This knowledge should then enable you to make your own decision. Since it is not assumed that this decision will always be against consumption, the aim is to encourage safe handling, such as avoiding mixed consumption. The aim of prevention should be to work towards strengthening the personality and showing alternatives to substance use. Potential users must be able to experience these alternatives - for example, the experience that after two hours of “exhausting” one feels at least as “relaxed” as when consuming cannabis.
Prevention and substance-specific information should begin as early as possible, as the first contact with drugs often takes place in adolescence .
- Withdrawal from the addictive substance
- Substitution by a substance with little or no harmful effect
- Psychotherapeutic treatment (short-term interventions, especially long-term weaning) in a specialist clinic , whereby these focus on possible deficits in the personality development of the patient and are strongly oriented towards individual possibilities
- physical therapy
- Participation in self-help group
- Treatment of relatives / caregivers; see also: codependency
In the treatment of opiate addicts, the (sometimes permanent) administration of a substitute as part of a substitution therapy can lead to a significant harm reduction . The requirement for abstinence as the sole treatment goal is abandoned or decided in each individual case (and possibly again and again). The effectiveness of permanent substitution has been convincingly proven and is also recognized by the legislature. Drugs are also being developed that are not to be regarded as substitutions, but are intended to specifically combat the symptoms of dependence, e.g. B. Clofenciclan .
The treatment of addictions has developed into a specialty of medicine, which today is increasingly based on the knowledge of neurobiology and can offer a whole spectrum of therapeutic methods. Educational measures can also be part of a therapy, especially for young people.
The term “psychological dependence” originates from the observation that dependence syndrome is sometimes primarily experienced through negative feelings ( emotions ) such as depression or anxiety . In this context, one spoke of “physical dependency” when additional vegetative disorders such as restlessness or circulatory disorders occurred . However, the boundaries between the two terms were always fluid, as emotional and vegetative effects always influence each other.
Since the increasing description of changes in the brain in connection with addiction syndromes, the differences between so-called psychological and physical effects have become superfluous since the 1990s . The observed changes in the brain affect both types of effects equally. In science, the distinction has since almost died out. The last PubMed- listed review article by western authors with "psychological dependence" in the title appeared in 1990.
Other forms of addiction that are not characterized by the use of psychotropic substances are summarized in the article Addiction (Medicine) . If the use of psychoactive substances leads to a violation of the law, dependence or substance use is defined as criminal. Questions of this kind then usually touch the fields of toxicology in forensic medicine .
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