2. When use becomes misuse

A Guide to Addiction Information and Referral for Settlement Services Professionals

On this page:

• Why people misuse
• Who uses drugs
  • Key facts about drug use
  • Ethnocultural and racial minority populations and drug use
  • Women and children in violent relationships
• How to tell if there is a problem
  • Indirect and direct signs of drug misuse
  • Teenagers and drugs
  • Older adults
  • Informal tests
  • Formal tests

When use becomes misuse

Misuse of drugs is defined as use that continues in spite of problems that it creates for the person or other people. Such misuse is sometimes sporadic but usually continuous.

Why people misuse

There are many theories and viewpoints about why people misuse drugs but there is not one explanation that applies to all cases of drug use. Different perspectives focus on different aspects of the problem: biological, psychological and sociological. The following are the most common perspectives in the field.

One perspective sees alcohol and drug abuse as a disease, which makes a person incapable of using alcohol and drugs in moderation. The primary symptom of the disease is that it is progressive. Use of alcohol or drugs leads to obsessive preoccupation with the substance(s), compulsion to use and inevitable loss of control. It is possible to control the disease and achieve recovery only through total abstinence. This perspective guides many alcohol and drug treatment programs and it is the foundation for Alcoholics Anonymous and numerous other mutual aid programs.

Another perspective is the idea of social learning. It focuses on the interaction between the individual and the environment and asserts that both are important in understanding and treating alcohol and drug problems. The social learning perspective suggests that problematic use occurs because consumption of alcohol or drugs is positively reinforced in society. Use of alcohol or drugs can become a strategy for coping with challenging situations or difficult emotional states such as anxiety, anger or guilt. Approaches to treatment focus on helping clients assume responsibility for their behaviour, with the expectation that they will gradually acquire the skills and attitudes needed for self-control. Both abstinence and controlled drinking are desirable outcomes. Interventions include behavioural skill training, so that the person does not rely on alcohol or drugs to cope; cognitive interventions, to change how the client thinks about alcohol or drugs; and lifestyle change processes. This perspective has become important in the area of relapse prevention.

The biopsychosocial perspective views a substance use disorder as a complex pattern with biological, psychological and sociocultural components. In this perspective, there is no single correct approach to treatment. A comprehensive biopsychosocial response to substance abuse makes a range of treatment options available. Treatment planning matches the needs, strengths and circumstances of each client.

Who use s drugs

We can’t generalize about who uses drugs but we can identify patterns of use and problems among specific groups.

Key facts about drug use

• Men and women differ in the types of drugs they use and in how much they use.
• Women are more likely to abstain from alcohol or drink less. More men are heavy drinkers.
• Women are more likely to use prescription drugs and they are three times more likely than men to use tranquillizers. Men are more likely to use illegal drugs such as cocaine and marijuana.
• Five out of 10 teenagers use alcohol. A smaller proportion use tobacco and marijuana, while very few ever use LSD, crack or cocaine, or other illegal drugs.
• The proportion of teenagers who have 15 or more drinks a week is similar to that of the general population.
• Cigarette smoking is equally common among boys and girls.
• Although overall drug use has declined dramatically since 1979, the past few years show the use of some drugs (including alcohol and marijuana) is beginning to climb.
• Seniors tend to use more tranquillizers, sleeping pills, stomach remedies, laxatives and insulin than the general population.
• The risk of compounding drinking problems by using alcohol while taking prescription drugs may be greater among seniors.
• Smoking is less common among seniors than in the general population, and seniors who smoke tend to smoke less.
• There is a significant relationship between physical limitations and the frequency of drinking and drinking problems.
• People reporting extensive physical limitations drink less often than those with moderate or no limitations. People with moderate physical limitations report the highest rate of alcohol problems.
• The use of sleeping pills or tranquillizers increases significantly with increased physical limitations.
• The proportion of smokers is higher among those at lower income levels whereas former smokers are more likely to have middle and upper level incomes.
• People with lower incomes are more likely to use prescription drugs. People with middle to upper level incomes are more likely to report using marijuana or hashish.
• Students, followed by retired people, are most likely never to have smoked. “Blue-collar workers” and housekeepers are most likely to be heavy smokers. Managers and professionals are the people least likely to smoke.

Ethnocultural and racial minority populations and drug use

Very little information is available about patterns of drug use in ethnocultural and racial communities. We do know that culture influences attitudes toward alcohol and drug use as well as definitions of problematic use. Cultural beliefs also determine how people respond to a drinker and how they define and deal with problems related to drinking. In examining the use and misuse of alcohol and other drugs among ethnocultural communities, it is important to note that such problems exist in all cultures.

Culture is not static; it is influenced by migration, settlement and integration, and changes in socioeconomic conditions. These factors may result in changes to the accepted behaviours and practices regarding consumption rates and the social acceptability of drugs and alcohol. For example, in certain cultures alcohol is not readily available and it is not an acceptable part of social interaction. People from these cultures may be unfamiliar with North American social drinking practices, and as newcomers it may be difficult to distinguish the limits between use and abuse.

Patterns of alcohol and other drug use often change after migration due to complex, interrelated problems confronted by newcomers. Resettlement affects a person on all levels: physical, social and cultural. The degree of change and stress may depend on the differences between the society of origin and the host country. A troubled economy in the host country, racism, socioeconomic status, and a person’s unrealistic expectations are also contributing factors.

It is easy to understand how and why newcomers experience problems with alcohol and other drugs. Often, they are a coping strategy; one adopted after or worsened by the migration and settlement process. In other cases, doctors may over-prescribe drugs such as tranquillizers, sedatives and painkillers to assist patients in coping with stress-induced conditions such as anxiety and depression.

Women and children in violent relationships

Recent studies show that many people who have suffered abuse depend on alcohol and drugs to cope with the physical and emotional pain. However, it is important to keep in mind that not everyone who is abused relies on alcohol or other drugs to cope. People use drugs for many reasons, which may be unrelated to violence.

The relationship between alcohol and drug use and violence against women and children is very complex. It manifests itself in the following three ways:

• In the coincidence of abuse in childhood and drug use in adulthood. People who have problems with alcohol or drugs are often people who were abused physically, emotionally and/or sexually as children.
• In the correlation of violence in an adult relationship and drug use. Women in an abusive relationship are more likely to use sedatives and/or to be dependent on alcohol.
• In the coexistence of drug use and abusive or violent behaviour in a relationship. Problem drinkers are more likely to abuse their partners; impaired abusers inflict more injuries - and the most severe injuries. The use of drugs or alcohol often precedes episodes of violence. Frequent drinking is also linked to the incidence of sexual and other forms of child abuse.

How to tell if there is a problem

Indirect and direct signs of drug misuse

Often, it is not the number of drinks that matters as much as the consequences of the drinking. Although we often associate drug use with health problems, medical complications usually become evident only after prolonged and heavy use. Yet other types of problems may become apparent at an earlier stage of use. Identifying and acting on these indicators may allow for intervention before drug use becomes problematic.

Family indicators

Drug use probably affects family life the most. Separation, sexual difficulties, verbal and/or physical abuse, and psychosomatic complaints from other family members may be signs of a drug problem.

Social indicators

Prolonged drug use often affects a person’s social life. As the importance of drugs increases, relationships with family and friends lose their significance. Changes in relationships (for example, associating only with those who use drugs) and in recreational activities (participating in activities that involve drugs) are common.

Employment indicators

Especially over time, drug use can result in apathy, loss of enthusiasm, poor motivation and even intellectual impairment. These effects may be reflected at work in deteriorating job performance, loss of a sense of job responsibility, tardiness and absenteeism (especially on fixed days, such as the day after payday) and an increasing number of accidents and mistakes.

Financial indicators

Drug use can be an expensive habit. Consequently, money that is normally spent on necessities such as food and clothing is used to buy drugs. Heavy debt, collection agency problems and degenerated living conditions can result.

Legal indicators

Legal problems can also indicate misuse. For users of illicit substances, examples of legal concerns include arrest for possession of drugs, arrest for crimes committed to obtain money to buy drugs and legal complications arising from bankruptcy or divorce. For users of licit drugs, illegal consumption often results in conflict; for example, drinking over the legal limit and driving. Two or more charges or convictions for impaired driving are considered a significant indicator of an alcohol problem.

Teenagers and drugs

Drug use by young people can result in the same kinds of problems discussed above, however, the indicators may manifest themselves differently. Possible signs of drug use by teenagers include:

• behaviour, appearance or attitude suddenly changes toward family members or others
• behaviour becomes more secretive or less helpful at home
• school grades drop
• money or valuable objects go missing at home
• a new group of friends or friends don’t visit at home anymore

While these signs may indicate drug use, there may be other explanations. It is important to remember that adolescence is a time of great change. It is also helpful to know that, while many young people experiment with drugs, few go on to become drug dependent.

Older adults

In older adults some of the warning signs of harmful drinking are often mistaken for signs of aging. Warning signs include:

• drinking greater amounts and drinking more often
• drinking kept secret or denying how much he or she consumes
• drinking early in the day
• gulping drinks
• spending large amounts of money on alcohol
• drinking to cope with loneliness or loss
• confusion; forgetfulness
• anxiety or depression; mood changes
• falling or having accidents
• sleeping problems
• eating poorly; weight loss and loss of appetite
• deteriorating health
• medication not working effectively
• neglecting oneself or one’s home
• conflict and withdrawal from family and friends
• problems with prescription drugs.

Informal tests

An informal way of identifying a problem is simply the quantity a person drinks or how often she or he uses illegal drugs. With alcohol, for example, researchers have been able to establish some clear levels associated with increased risk. The following guidelines are based on the best research evidence available:

• drinking more than 12 drinks per week
• drinking more than four drinks (men) or three drinks (women) daily
• drinking more than one drink per hour
• driving any motor vehicle after drinking
• drinking with the intention of becoming drunk
• drinking before or during work hours
• drinking while on prescription drugs
• drinking before or during sports activities
• drinking when feeling depressed, lonely or under stress
• drinking out of habit.

(A drink is defined as beer, wine or liquor. A beer contains roughly the same amount of alcohol as a mixed drink or a glass of wine.)

Formal tests

Formal testing tools include laboratory tests for physical changes that indicate drug consumption and surveys or interviews about drug use. Questionnaires about alcohol-related problems and consequences are another tool. One example is the CAGE test, which consists of four simple questions that reliably identify people who have drinking problems and rule out those who do not. The questions are:

• Have you ever felt you ought to cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad about or guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady your nerves and get rid of a hangover? (Eye opener)

Two or more positive responses suggest sufficient evidence of alcohol misuse to warrant further investigation.

The name CAGE is derived from the key word in each question: Cut down, Annoyed, Guilty, Eye opener. An advantage of the CAGE questionnaire is that it is short, making it easy to incorporate into a client interview. For this reason, it is especially valuable for health care professionals, however, it is still not clear how effective the CAGE test is at identifying people who are just beginning to experience problems with their drinking.

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