For years the United States has been spending tens of billions of dollars a year in an attempt to control the trafficking and use of illicit drugs. Most of those dollars have been used to support stricter enforcement. When calculating the actual cost of addiction on society, there are many factors to consider. Increased chronic illnesses that jeopardize public health and resources include, but are not limited to, related cases of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), hepatitis, asthma, diabetes, cancer, and mental illnesses. The most recent cost analysis by the Department of Justice’s National Drug Intelligence Center (NDIC) included health care, crime, and the associated loss of productivity for drug abuse which were estimated at $193 billion in 2007 (NDIC, 2011).

A further complexity is the realization that approximately 25% of individuals with an SUD are also diagnosed with a concurrent mental health diagnoses (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007). Substance use significantly affects not only the user but also his or her immediate and extended family as well as the health and safety of that person’s community. The full impact of substance use is evident when assessing teenage pregnancy rates, HIV/AIDS, sexually transmitted infections (STIs), domestic violence, child abuse, motor vehicle accidents, aggression, crime, homicide and suicide (SAMHSA, 2006).

Understanding these far-reaching negative consequences is the key for health care professionals in educating and developing solutions to move forward. This chapter presents a broad overview of substance use and addiction. Theories of addiction, interventions, and community resources addressing problems relevant to community/public health nursing are discussed.

physically hazardous (such as driving while intoxicated), have multiple legal problems, or have recurrent social or interpersonal problems because of their substance use (APA, 2000).

Substance dependence refers to a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues to use a substance despite significant substance-related problems. Unlike substance abuse, substance dependence also includes symptoms of tolerance, withdrawal, and a pattern of compulsive use. Dependence includes symptoms of taking larger amounts of drugs than intended. There is often marked difficulty in being able to decrease drug intake. A majority of a person’s time revolves around the activities to obtain and maintain their drug use. Finally, despite acknowledgement that the drug use is a danger to their individual health, relationships, employment, and social well-being, they continue to use (APA, 2000).

The APA is in the process of developing a national consensus updating the DSM-V. The new DSM-V will refer to “addictions and related disorders,” and will eliminate the category of dependence to better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some experience when using prescribed medications.

Addiction, is defined by the National Institute on Drug Abuse (NIDA, 2010) as a chronic, relapsing brain disease characterized by compulsive drug seeking despite negative consequences. The definition of a brain disease acknowledges that the brain undergoes significant changes in its structure and function because of illicit substances. Some of these neurochemical and molecular changes may be permanent. As defined by the American Society of Addiction Medicine (ASAM), addiction also encompasses the genetic, psychosocial, and environmental influences in the development of substance use, abuse, and dependence (West, 2001). This definition conceptualizes addiction as a chronic disease similar to hypertension or diabetes. As with all chronic diseases, addiction is a pathological condition that has a clearly measurable, characteristic physiology and neurobiology. This definition of addiction is consistent with research that has identified genetic factors as well as environmental factors that precipitate relapse.

Another important distinction in addiction is pseudoaddiction, which includes the characteristics of drug-seeking compulsive behaviors that are consistent with addiction. The behaviors are the same but the underlying cause is different. Pseudoaddiction occurs in people experiencing inadequate medication management for pain relief. Once the pain is adequately treated, the person no longer abuses the medication. This is a very important concept for all health care practitioners to understand as ineffective pain management directly affects the person’s ability to heal (Savage, 2003).

The biopsychosocial model of addiction that best fits community/public health nursing is that of the public health model (Figure 25-1). The public health model of addiction stresses that biological, psychological, pharmacological, and social factors constantly interact and influence the problem of addiction in any person or group of people. As described by Mosher (1996), in the public health model, the host is the person who has the addiction; the agent is the alcohol or other drug sufficient in quantity to cause harm to the host; and the environment includes the social, economic, physical, political, and cultural settings in which the host and agent interact. The environment also includes the meanings, values, and norms assigned to a drug by its culture, community, and society.

Many of the repetitive behaviors associated with addictions involve multiple brain reward regions and neurotransmitters that regulate normal consumptive behaviors necessary for survival, for example, eating and drinking (Guardia et al., 2000; NIDA, 1994). Scientists are involved in a widely publicized search for genes that predispose persons to alcoholism and other addictions by regulating brain function. Changes in the brain are a major cause of alcohol and other drug addictions. Prescott and colleagues (1999) and other researchers have conducted twin studies that demonstrate a genetic vulnerability to alcoholism. Identical twins of alcoholic parents have more than a 60% chance and fraternal twins a 30% chance of becoming alcoholics.

Numerous environmental conditions such as physical and emotional trauma also play a part in the expression of addictions (Sansone et al., 2009). Other environmental risk factors include economic and social deprivation, low neighborhood attachment, community norms that facilitate drug use and abuse, and availability of alcohol and other drugs (Trigoboff & Wilson, 2004).

Genetic vulnerability and environmental factors interact to produce addiction; however, addiction can apparently be induced without genetic vulnerability through the impact of the environment alone. Mosher (1996, p. 244) stated, “Environmental factors—the forces that bring the agent into injurious contact with the host—are critical in the public health model of addiction. A high-risk environment creates a myriad of opportunities for public health harm.” High-risk environments can be found in the family, workplace, school, community, and war zones (Table 25-1).

Behavioral indicators in the second stage can include a decline in school or work performance, mood swings, personality changes, lying and conning, change in friendships, decrease in extracurricular activities, adoption of a drug culture appearance, conflicts with family members, and preoccupation with procuring and using alcohol and other drugs. As continued and increased use progresses, dependency develops. Alcohol and drugs may be used daily or continuously to avoid negative emotions. Use becomes unmanageable as the individual attempts to achieve homeostasis and feel normal. Behavioral indicators of dependence include physical deterioration, cognitive changes, lack of concern over being discovered, and absence from home, job, or other places of responsibility (SAMHSA, 1994).

Addiction is a disease of the brain. Abused substances activate the same brain circuits as do behaviors of basic survival such as eating and sex. During repeated drug use, the brain registers the increased pleasure, which corresponds with increases in a neurotransmitter called dopamine. Dopamine is one of many neurotransmitters, and it is responsible for feelings of pleasure and euphoria. The route it travels in the brain is called the pleasure pathway. Once this system is activated, the brain wants to keep the dopamine levels high to enhance the feelings of intense pleasure. The user is then placed in a chronic “cycle of distress” to keep the drug available. Once the pleasure has diminished, the need to decrease the anticipated distress of not having the drug is activated. Drugs that are abused provide very large amounts of dopamine to the brain. In response to the increased dopamine, the brain regulates itself by decreasing the normal production of dopamine. Over time, dopamine regulation becomes altered, and the user is unable to experience pleasure even from the drugs they crave. The abilities to control decision making and judgment and to manage desires and emotion are all negatively impacted.

Researchers now believe that the drug-seeking behavior is a primitive response that occurs prior to conscious awareness. The limbic system, specifically the nucleus accumbens, is the area of the brain that starts the drug-seeking addictive behavior in motion. This knowledge questions the thinking that addiction is related to willpower and free choice (Burns & Bechara, 2007).

Researchers can now visualize and compare brain changes using brain imaging. Studies show that the brains of heavy chronic drinkers shrink, specifically the frontal lobe, which is responsible for decision making and judgment. The cerebellum that governs gait and balance also shrinks. Withdrawal symptoms occur because the body and the brain have been trying to create a balance with the continual use of a drug. When the drug is no longer available, the systems of the body become overcompensated and unbalanced.

In 2009, an estimated 22.5 million persons (8.9% of the population aged 12 years or older) were classified with substance dependence or abuse in the past year based on DSM-IV-TR criteria (Figure 25-2). Of these, 3.2 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.9 million were dependent on or abused illicit drugs but not alcohol, and 15.4 million were dependent on or abused alcohol but not illicit drugs (SAMHSA, 2010).

Of nearly 4.6 million drug-related emergency department (ED) visits, half were attributed to adverse reactions to pharmaceuticals, and almost one-half (45.1%, or 2.1 million) were attributed to drug misuse or abuse. ED visits involving misuse or abuse of pharmaceuticals increased by 98.4% between 2004 and 2009, from 627,291 visits in 2004 to1,244,679 visits in 2009 (SAMHSA [DAWN], 2010).