How does substance use develop into substance abuse

- [Instructor] When we talk about substance use and substance abuse, we have to remember that these are two different things, although they are obviously related. And although majority of people who use substances will never develop a substance abuse problem, it is true that everyone who develops a substance abuse problem starts as a user. And so, it's really important for us to figure out exactly how a substance use develops into substance abuse. The first theory that I want to discuss is the gateway model. And this theory might be familiar to you. It says that some substances act as gateway drugs, meaning that their use can lead to the use of other, more dangerous substances. So here we have John. And when John was a teen, or maybe a pre-teen, he started experimenting with alcohol and cigarettes. And from there, maybe he starts smoking pot. He starts using marijuana. And eventually, he winds up using drugs like heroin and cocaine. So here, alcohol and cigarettes would be a gateway that leads to marijuana use, which is itself a gateway for heavier drug use. So, John's early experience with less dangerous substances led him to use more dangerous substances later on. And the implication of all of this seems to be that if you can prevent people, specifically teens and pre-teens, from experimenting with smoking and drinking and marijuana use, then they will never move onto harder drugs. And this is the basis of a lot of anti-drug programs in the US that are targeted at pre-teens. And there is some support for this idea. First, the order of drug use that I've described here is pretty typical. People who use substances generally do use alcohol and cigarettes before they use marijuana. And it's also true that individuals who use heavier substances did, in fact, use alcohol, cigarettes and marijuana first. But there are a few problems with this theory. The first is that correlation does not imply causation. Just because individuals have the tendency to follow a certain path for drug use doesn't mean that one causes the other. It could be that there's a third factor that's more important. Maybe any of the risk factors that we mentioned earlier. So maybe some individuals who use heroin and cocaine would have wound up using them even if they didn't have alcohol and cigarettes first. Second, this actually might be about availability. Because even though alcohol and cigarettes are not legal for minors, they are readily available, perhaps more readily available than illegal substances, like heroin and cocaine. So, maybe alcohol and cigarettes are used first because they're easier for individuals to get a hold of. And lastly, only a very small percentage of those who use alcohol, cigarettes and marijuana wind up using other substances. So it might not be accurate to say that marijuana causes harder drug use, when that's true only for a very small number of cases. A different way to think about how substance use might progress to substance abuse is a theory that focuses on a continuum of drug use. So rather than saying that one drug leads to the use of another, this theory states that a change in the pattern of substance use is what moves someone from use to abuse. So this could be a change in the amount of the substance used, or in the availability of the substance, or in the consequences of substance use. And this theory also holds that there is no one direct pattern from substance use to substance abuse. Instead, there are many twists and turns along the way. So let's talk about John again. And maybe John uses cocaine once at a party, and in one scenario, he uses and then never uses again. But in a second scenario, maybe he uses once at that party, and maybe he intends to never use again, but maybe it turns out that one of his friends brings cocaine to a party a few years later, and he uses again. And from then on, he uses it every few years. Only in specific social situations and only when other people are bringing the substance. And we would define this as non-problem use. All right, now let's talk about a third scenario. And this one is kind of a longer story. So in this scenario, he uses at that first party. And then, just as in scenario two, he moves onto non-problem use. But let's say that something changes. Maybe he finds someone who is willing to sell him a steady supply. So whereas before, he only used when someone else brought cocaine to parties, now he buys on his own. So there's been a change in availability and a change in supply, and that has led John to use the substance more often. And remember, as this is going on, John probably has a lot of other life changes as well. Maybe he has a new job that requires a lot of energy, like maybe he's a bartender or a business man, and he needs a lot of energy to work late into the night. So maybe instead of using cocaine socially at parties, now he starts using it for work purposes. So that pattern of drug use changes as well. And because of all of these things, including the fact that he's using more often, maybe John moves from non-problem use to substance abuse, which, if he keeps following this pattern, can lead to a state of substance dependence. So, a state where he is addicted to the substance, and would experience withdrawal symptoms if he tried to quit. So this figure shows us the different pathways that people can take in terms of substance use, and also, how different patterns of use might move someone from use to abuse. But I actually think that the most interesting part of this theory is that it says that people can move back and forth along these paths. So maybe John begins to realize that his drug taking is becoming out of control, and so, he moves back from substance abuse to non-problem use, so he decides he's not going to use cocaine for work anymore and he's only going to use it in social situations. And maybe after awhile, he stops using entirely. Or maybe he just continues with non-problem use. Or let's say that John gets into a car accident. And after that, he's moved into a treatment program, so there's forced abstinence. And after a period of abstinence, maybe he starts to use infrequently again, until he has a health scare, maybe a heart attack, that may or may not be related to cocaine use, he isn't sure. But this possible change in drug use consequences moves him to abstinence again. And so, depending on all of these different circumstances, all of these different life changes, drug availability, the amount that someone is using, why they're using that substance, even things like whether or not they have money or being put in prison or moving to a new town, all of these changes in patterns of drug use can lead to either an increase or a decrease in the amount of drug used, depending on what those changes are. Another interesting thing that you can notice about this theory by looking at this figure, is that it says that someone can't move from a single use directly to problem use. Instead, they have to pass through non-problem use first. So this theory is pretty clear in its statement that addiction is a process. It's not something that happens right away. And one other very important part of this theory is that it holds that this cycle is repeated individually for each substance. So maybe John tries cigarettes once and then never uses them again, and maybe he used to drink alcohol once in awhile, but then stopped when he reached middle age. And maybe his cocaine use, as we've been talking about, follows a more complicated path along this figure. So this is very different from the gateway theory, which holds that using one substance can lead to the use of another substance, because in this model, each substance is considered individually. And because of this, this continuum model winds up being a lot more complicated than the gateway model. But because it has this added complexity, it might be a more realistic way of looking at how people move from use to abuse.