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U.S. Department of Health and Human Services

Archival Content: 1999-2005

HIV Prevention Among Drug Users:
A Resource Book for Community Planners & Program Managers

Drug Use, Abuse, and Dependence

As noted previously, drug use encompasses a wide range of substance-related behaviors that have varying effects on the individual and his or her HIV risk exposure. Understanding the nature of drug use, abuse, and dependence can help HIV prevention planners and program managers better target high-risk drug users and support HIV prevention programs that accommodate the recurrent and variable nature of the drug use problem. Such an understanding can also provide insight into the ways users are viewed and treated by service providers and by the community in general. Service providers' orientation can have a powerful impact on how drug users are treated in prevention programs, and the community's view can strongly affect the response to and acceptance of a program designed for drug users.2

In a medical orientation, drug-using behaviors are viewed as symptoms of a chronic medical disorder that can be treated but not cured. Drug users are not blamed for their use. Rather, as with other chronic diseases, they are helped to manage their illness. In this orientation, substance-related disorders are classified into two broad categories-substance abuse and substance dependence-that form a continuum. Abuse may result in specific recurrent personal and social problems, while dependence results in an established pattern of consequences. Exhibit B presents the medical criteria by which each of these disorders is recognized and diagnosed. The criteria give a clear idea of the range of behaviors, their potential consequences, and environmental implications. All of these can affect prevention strategies and interventions. However, not everyone who uses drugs develops substance-related disorders. Why this is so is still unclear, although researchers have identified a number of biological, psychological, and environmental factors that may have a role.

Exhibit B: Definitions of Substance Abuse and Substance Dependence

Substance Abuse

For an individual to be diagnosed with substance abuse, s/he must have experienced one (or more) of the following in the same 12-month period:

  • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences, poor work performance, neglect of children or household).
  • Recurrent substance use in situations in which it is physically hazardous (e.g., driving a car or operating machine while impaired).
  • Recurrent substance-related legal problems (e.g., substance use-related arrests).
  • Continued substance use despite having persistent or recurrent social or interpersonal problems caused by effects of substance (e.g., arguments, physical fights).
Substance Dependence

For an individual to be diagnosed with substance dependence, s/he must have experienced three (or more) of the following in the same 12-month period:

  • Tolerance, defined as either: a) a need for markedly increased amounts of the substance to achieve the desired effect; or b) a markedly reduced effect with the continued use of the same amount of the substance. A cocaine user experiences drug tolerance when s/he seeks more cocaine to recapture the "high" initially derived from smaller amounts (Ray et al., 1996).
  • Withdrawal, defined as: a) the occurrence of a withdrawal syndrome when the substance is not used or there is a reduction of use after heavy, prolonged use (e.g., with crack, becoming irritable and/or depressed; with heroin, becoming shaky and/or nauseous); b) the use of the same or related substance to relieve or avoid withdrawal symptoms.
  • The substance is often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control substance use.
  • A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors, driving long distances), use the substance (e.g., chain-smoking), or recover from its effects.
  • Important social, occupational, or recreational activities are given up or reduced because of substance use.
  • The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by the substance (e.g., continued alcohol consumption despite a known ulcer).

Source: American Psychiatric Association,1994.

Substance Dependence as a Chronic, Relapsing Disorder

Drug dependence is considered chronic because there is no cure. An integral element of this disorder is a common pattern of remission followed by relapse. Many of those who are dependent stop using drugs but later resume their use and continue to have alternating periods of remission and relapse.

Many persons dependent on drugs want to stop or control their substance use. Those who are in drug treatment programs or who, on their own, are successfully abstaining from drug use are said to be "in remission" or "in recovery." Recovery from drug use is a delicate balancing act. Most initial attempts to stop drug use are unsuccessful, and individuals in recovery may relapse one or more times, particularly early in the treatment process. As a result of high relapse rates among those in drug treatment, relapse prevention strategies have become an important component of many drug treatment programs. These strategies involve helping the patient identify personal "triggers"-situations, locations, or objects-that prompt a desire to resume drug use. Helping a person "talk through" or learn how to manage this craving prompted by a trigger may be an effective technique in reducing relapse potential.

Substance Abuse and HIV Risk

Persons who use, abuse, or are dependent on drugs often engage in behaviors, including HIV risk behaviors, that can negatively affect their health. This may caused by the effects of the substance itself. For example, people who use or abuse drugs or alcohol sometimes report being so high or intoxicated that they forget to use a condom. Or, risk behavior may result from the desire to avoid withdrawal symptoms. An individual who is dependent on heroin may choose to share a syringe in order to avoid the painful effects of withdrawal. In both of these examples, the individuals involved may be well educated about HIV transmission and deeply concerned about the risks of HIV infection and ways to protect themselves. Yet, the effects of the substance override this knowledge and place them at risk. Even given these powerful effects, some studies show that drug users will change their behaviors to reduce their risk of HIV and other health problems. For example, when heroin purity increases, users switch from injecting to snorting the drug. One reason given for this change is the fear of needle-acquired HIV infection (Johnson, Bassin, and Shaw, Inc., 1995, vol. I).

It is important that prevention planners and program managers understand the powerful effects of drug dependence, particularly as they relate to HIV risk behaviors, and accept the fact that knowledge alone will not protect a community from the transmission of HIV. This has important implications for the design, type, number, and compatibility of programs, and the frequency and number of support or "booster" sessions needed to maintain behavior change that lowers HIV risks. It also has implications regarding the need to increase the availability of prevention supplies, such as bleach kits, sterile syringes, and condoms, so that they are easily accessed at the times and in the locations where individuals are most vulnerable.

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  1. These orientations and attitudes are discussed more fully in PART 4: PUBLIC POLICY ISSUES.

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