What is Substance Use Disorder? Abuse versus Dependence

Read from a clinical point of view, the book Alcoholics Anonymous (the “Big Book”) is an excelled diagnostic reference manual for the identification and treatment of alcohol abuse and alcohol addiction.Published seventeen years before the American Medical Association’s (AMA) acknowledgement of alcoholism as a medical disease, Alcoholics Anonymous made the distinction between alcohol abuse and alcohol dependence or alcoholism. This distinction between abuse and dependence is used today for other substance abuse and dependence. (E.g. cocaine, opiates, methamphetamines, food etc.)

From Alcoholics Anonymous (pages 20-21)

“Now these are commonplace observation on drinkers which we hear all the time. Back of them is a world of ignorance and misunderstanding. We see that these expressions refer to people whose reactions are very different from ours.

Moderate drinkers have little trouble in giving up liquor entirely if they have good reason for it. They can take it or leave it alone.

Then we have a certain type of hard drinker. He may have the habit badly enough to gradually impair him physically and mentally. It may cause him to die a few years before his time. If a sufficiently strong reason—ill health, falling in love, change of environment, or the warning of a doctor—becomes operative, this man can also stop or moderate, although he may find it difficult and troublesome and may even need medical attention.

But what about the real alcoholic? He may start off as a moderate drinker; he may or may not become a continuous hard drinker; but at some stage of his drinking career he begins to lose all control of his liquor consumption, once he starts to drink.”

Once making this preliminary distinction between alcohol abuse and alcohol dependence, the Big Book goes on to refine the characteristic stages of an alcohol dependent. Its description is in the form of four different types of husbands.

From Alcoholics Anonymous (pages 108-111)

Husband One: Your husband may be only a heavy drinker. His drinking may be constant or it may be heavy only on certain occasions. Perhaps he spends too much money for his liquor. It may be slowing him up mentally and physically, but he does not see it. Sometime he is a source of embarrassment to you and his friends. He is positive he can handle his liquor, that it does him no harm, that drinking is necessary in his business. He would probably be insulted if he were called an alcoholic. This world is full of people like him. Some will moderate or stop altogether, and some will not. Of those who keep on, a good number will become true alcoholics after a while.

Husband Two: Your husband is showing lack of control, for he is unable to stay on the water wagon even when he wants to. He often gets entirely out of hand when drinking. He admits this is true, but is positive that he will do better. He has begun to try, with or without your cooperation, various means of moderating or staying dry. Maybe he is beginning to lose his friends. He business may suffer somewhat. He is worried at times, and is becoming aware that he cannot drink like other people. He sometimes drinks in the morning and through the day also, to hold his nervousness in check. He is remorseful after serious drinking and tells you he wants to stop. But when he gets over the spree, begins to think once more how he can drink moderately next time. These are the earmarks of a real alcoholic. Perhaps he can still tend to business fairly well. He has by no means ruined everything. As we say among ourselves. “He wants to want to stop“

Husband Three: This husband has gone much further than husband number two. Though once like number two he became worse. His friends have slipped away, his home is a near-wreck, and he cannot hold a position. Maybe the doctor has been called in, and the weary round of sanatoriums and hospitals has begun. He admits he cannot drink like other people, but does not see why. He clings to the notion that he will yet find a way to do so. He may have come to the point where he desperately wants to stop but cannot. His case presents additional questions, which we shall try to answer for you. You can be quite hopeful of a situation like this.

Husband Four: You may have a husband of who you completely despair. He has been placed in one institution after another. He is violent, or appears definitely insane when drunk. Sometimes he drinks on the way home from the hospital. Perhaps he has had delirium tremens. Doctors may shake their heads and advise you to have him committed. Maybe you have already been obliged to put him away. This picture may not be as dark as it looks. Many of our husbands were just as far gone. Yet, they got well.

Now in its 66th year of publication and Fourth Edition, the basic text of Alcoholics Anonymous and its definition of an alcoholic has not changed.

The American Psychiatric Association (APA) has also made similar if not identical definitions of alcoholic abuse and dependence. In its 1994 publication of Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, (DSM-IV), the APA set forth the Criteria for Substance Abuse and Substance Dependence, referred to as Substance [Alcohol] Use Disorder.

From DSM-IV (pages 175-191)

Criteria for Substance [Alcohol] Abuse.

(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:

(1) Recurrent substance use resulting in a failure to fulfil major role obligations at work, schools, 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 substance 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 spouse about consequences of intoxication, physical fights).

(B). The symptoms have never met the criteria for Substance Dependence for this class of substance.

Criteria for Substance [Alcohol] Dependence.

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1) Tolerance, as defined by either of the following:

(a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect.

(b) A 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 associated with the particular substance.

(b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. [“Hair of the dog that bit him”]

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

(4) There is a persistent desire or unsuccessful efforts to cut down or control substance use.

(5) A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or switching liquor stores on a daily basis), using the substance or recovering from its effects.

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

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