There has never been a culture which did not, in some way, use psychoactive drugs. This use has ranged from a pervasive use of a drug (e.g., alcohol in the U.S. in the twentieth century) to a very specific culturally defined use of a drug (e.g., the use of coca by Peruvian Indian chieftains). In the U.S., we have never had a period in history when drugs were not used (or abused). During the eighteenth century, abuse of alcohol in the U.S. was rampant. During the nineteenth century, opioids were imported from the Far East; cocaine was imported from South America; and nicotine (which had been adopted from the religious ceremonies of the American Indians) was recognized as an abused drug.
The twentieth century has been a time of exponential change in the culture of the United States, and this holds true for drug use as well. Opioids and cocaine were popular during the early part of the century and were legal until the passage of the Harrison Narcotic Act of 1914. Although this act clearly altered the availability of these drugs, it is not clear how it affected their use. The eighteenth amendment (i.e., the Volstead Amendment) outlawed the manufacture, sale, and consumption of alcoholic beverages. Doomed from the outset, the amendment drove the manufacture, sale, and consumption of alcohol underground, resulting in numerous complications, including lead poisoning from the unsafe and unmonitored distillation of alcohol. The amendment was repealed by the twenty-first amendment.
After the resumption of legal use of alcohol, the U.S. experienced an increase in the use of nicotine. In the 1960's, there was a "cultural revolution" which included the pervasive use of numerous drugs-including, for the first time, psychotomimetic drugs, such as lysergic acid diethylamide (LSD). This pervasive drug use has continued into the 1990's, but the types of drugs used have changed somewhat. There has been a decline in the use of hallucinogens, an increase in the use of marijuana, and a renewed increase in the use of cocaine.
It is difficult to know how use patterns of drugs have changed over time- either quantitatively or qualitatively. It is only during the past twenty years that efforts have been made to examine systematically and scientifically the use of drugs in our culture. The use of drugs does not have a negative or pathologic connotation. However, the words abuse, addiction, and dependence do have a negative or pathologic connotation. Despite efforts to precisely define these words, there has been little agreement to date. An effort was made by the American Medical Association in 1986; however, it resulted in imprecise and inconsistent definitions. The definitions that have been most widely agreed upon are those of the American Psychiatric Association in the Diagnostic and Statistical Manual III-R, and these definitions are limited in scope.
In order to continue the development of a science of addictionology or addictive disorders, a precise nomenclature must be developed. The following definitions further define those provided by the American Psychiatric Association.
DRUG ABUSE: The self-administration of a drug in a culturally
disapproved fashion which results in (or has great potential
to result in) adverse consequences.
DRUG ADDICTION: A behavioral pattern of drug abuse characterized by the
compulsive use of a drug, an overwhelming involvement with
the securing of a supply of that drug, and a high tendency
for relapse.
DRUG DEPENDENCE: A state of neuroadaptation created by the repeated
administration of a drug such that, if the drug is
discontinued, a withdrawal or abstinence syndrome will result.
Implicit in these definitions are a number of issues. One is that drug abuse is culturally defined. This is clearly true. Even within our own culture in the U.S., we have a number of sub-cultures which have different criteria for drug abuse. Alcohol use is common in the United States, with at least 65% of the population using the drug in a culturally approved way. However, in Utah, the Mormon sub-culture is much less approving of alcohol and its use; in that sub- culture, use may be defined as abuse.
Also implicit is that drug abuse is a behavior, and there are many causes of that behavior. For example, approximately 35% of college students are frequent, heavy users of alcohol. This is a transient phenomenon which seems to be related to the developmental stage of college students. By the time they graduate from college, that behavior has become much less prevalent. The transient nature of this behavior is clearly inconsistent with the traditional behavior and is clearly inconsistent with the traditional definition of alcoholism (i.e., a progressive disease).
In addition, these definitions allow for the abuse of a substance to be a secondary phenomenon. In the course of treatment of a primary illness, clinicians have recognized substance abuse which has not been treated or been inadequately treated. An example of this is the patient with an undiagnosed and untreated anxiety disorder who abuses alcohol in an effort to treat him/herself. Although the disorder is not the primary reason for alcohol abuse, this is clearly one of the reasons.
According to these definitions, one of the possible causes of drug abuse is addiction. Addiction is a behavioral pattern of drug abuse. It is consistent with the primary disease concept of alcoholism or other drug addiction and is defined in phenomenologic terms. The definition does not include (nor does it exclude) a tolerance or dependence phenomenon. Therefore, it easily includes the chronic abuse of drugs such as LSD (for which dependence may be difficult to define); chronic abuse before dependence is observed; and episodic patterns (i.e., "binge alcoholism").
The definition of dependence is precise and explains a neurophysiologic alteration brought on by the repeated administration of a drug. It implies a change in drug receptor sensitivity and/or associated neurochemistry. The definition does not include (nor does it exclude) abuse and addiction, so it could also include the dependence phenomenon which may result from "iatrogenic" tolerance and withdrawal which is unrelated to addiction and abuse. Clearly, most people can be made dependent upon a number of drugs-both addicts and non- addicts. The dependence may be the same regardless of whether the cause is addiction or iatrogenic.