If I were to say the words “drug addict,” then follow it up with “substance abuser,” then finish up with talking about someone who “uses” a particular type of substance, what would you think? Does the same image pretty much pop into your head for all three? Or do you have different ideas in mind? There’s absolutely no question that these things are inextricably linked. But it’s probably best to think of these things as like a chart of concentric circles. This is to say, obviously everyone who is a substance abuser is also a substance user. But not all substance users actually abuse the substance. Likewise, all substance addicts are also substance users. But there are lots of substance users who never come anywhere close to addiction. In fact, there are a lot of substance addicts who never even abuse the substance they’re addicted to. But that’s enough already with the logic puzzles. Let’s actually break this down, piece-by-piece, before we make things entirely too confusing.
What is Substance Use?
This is the easy one to define. Substance use means exactly what it sounds like it does. It means somebody is using a substance with psychoactive properties. That substance can be legal or illegal, prescribed or simply bought off a shelf somewhere. Having a sip of wine counts as substance use. So does shooting heroin. Those aren’t the same thing by any stretch of the imagination, but that should give you an idea of how broad this umbrella is. Some looser interpretations will even include eating chocolate as a form of “substance use,” since it contains caffeine. There’s a good chance that everyone reading this right now has had wine, beer, or chocolate at some point. And therefore, everyone reading this has, at some point, probably been a substance user. There’s nothing wrong with that at all. Substance use, in its broadest sense, is simply a part of normal human life. Where we run into trouble is when the wrong substances start to get used, or substances are used outside of their intended contexts, or in too high of quantities. Those situations are what the American Psychiatric Association call substance use disorders. Substance use disorders are when substance use goes from normal, moderated and manageable to problematic and potentially dangerous.
What is Substance Abuse?
Technically, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, usually abbreviated “DSM-5,” no longer uses the words “substance abuse” to classify disorders. They now exclusively use the aforementioned term “substance use disorder,” which they classify as mild, moderate or severe based on the number of diagnostic criteria met in the evaluation. Previously, “substance abuse” and “substance dependence” were classified separately, but now they are combined in the “substance use disorder” category. Regardless of its technical classification, “substance use disorder” is what is generally meant by substance abuse. Substance abuse is often used interchangeably with the words “drug abuse.” The World Health Organization (WHO) classifies substance abuse as “the harmful or hazardous use of psychoactive substances, including alcohol or illicit drugs.” This is an important distinction. Substance abuse refers almost exclusively to substances that affect the brain and can lead to dependence. In other words, drugs, and alcohol. The biggest difference between substance use and substance abuse is regularity. Substance use can be something as simple as drinking half a beer at a football game. Substance abuse is when someone starts consuming substances regularly, and it starts causing issues in their life. It seems like a simple thing, but it’s actually really important. Substance use becomes abuse when it starts causing problems. These can be financial problems, relationship problems, or even health problems. Many times, someone under the influence of drugs or alcohol will fail to see a problem or deny its existence until it becomes unmanageable. But that doesn’t mean it isn’t a problem. In fact, the denial of a problem that seems obvious is, if anything, evidence of an even more severe problem. Substance abuse is still a fairly broad canopy, though, and it can include abuses of a number of different substances, both legal and illegal, including
- Cannabis (marijuana)
- Stimulants (methamphetamine and cocaine, for instance)
Most of these are substances that can be obtained legally under the right circumstances, but each of them can be a catalyst for substance abuse.
What is Substance Addiction or Dependence?
Substance abuse – or substance use disorder, depending on whose definition you’re using – is defined as a person’s ongoing willingness to use a substance, even when it begins doing damage to their life. The willingness to use a substance when it clearly goes against your self-interest is indeed a key sign of addiction as well. But not all substance abusers become addicts, and not all addicts got hooked because they were substance abusers first. Addiction is closely related, but still notably different. The American Society of Addiction Medicine (ASAM) qualifies addiction in an almost purely neurological way. They call it a “chronic disease of brain reward, motivation, memory, and related circuitry.” Some of the highlights of addiction are:
- inability to abstain from substance use
- dysfunctional emotional reactions
- lack of behavioral control
- denial of problems with behavior
- inability to recognize negative consequences, even after they’ve occurred
- a lack of empathy for people around them – even loved ones
These are primarily the psychological symptoms of the mental disorder of addiction itself. It doesn’t even begin to cover the physical drawbacks of each individual drug, which are harmful, frequently disabling, and sometimes even fatal. But it’s important to recognize what sets addiction apart from use or abuse. While a substance abuse problem tends to share some characteristics with addiction, the core of these problems is different. Addiction is a classified disease. It exists when the brain’s reward center is so accustomed to reacting to a certain activity or substance, it starts manufacturing an artificial demand for it. This demand grows in intensity, with the brain eventually forcing the body to believe the activity or substance is absolutely essential for survival. The desire eventually outpaces the need for things that are actually essential, like food and water. This is a dysfunctional feedback loop that affects everything in a person’s brain, forcing them to evaluate every situation through the lens of whether it helps them further their addiction, and ignore potentially negative consequences. And it’s that feedback loop that sets addiction apart from abuse, though the two are closely linked.
Use, Abuse and Addiction: What are the Real Differences?
The simplest way to understand the difference between use, abuse, and addiction is perhaps a bit too simple. But at the risk of oversimplifying a complicated issue, here are the basics. Substance use is just using a mind-altering substance any number of times, in any quantity, for any reason. It could mean smoking a cigar, drinking a beer, even taking a prescribed painkiller – none of which are illegal. Substance abuse is a level of substance use that becomes consistent and starts causing problems. When the use of a substance starts to affect the user’s personal life or health, it becomes abuse. Abuse generally means that the substance is being consumed on a fairly consistent basis and that the use is becoming problematic in a number of ways. But abuse is not necessarily addiction. It is possible to be a substance abuser who is not addicted – it just means that a person is making a conscious, controlled decision to use their preferred substance and that they haven’t really been faced with serious consequences yet. For example, someone may be a “problem drinker” – someone who occasionally binge drinks and damages their health, while also endangering those around them with poor decisions. This would be classified as substance abuse, but they may not be considered an alcoholic who is addicted to the substance. Maybe that person is completely sober almost every day of the year and only drinks on a couple of specific occasions per year. But if they cause problems when they do drink, they’re a problem drinker, and that counts as substance abuse. This, too, may be something that requires treatment, but it isn’t what we’d call “addiction” in the truest sense. Addiction carries many of the same features as abuse. Consistent usage of a substance that causes problems for a user and those around them is a feature of both substance addiction and abuse. But the big difference is neurological. Addicted people have their whole mental decision-making process upended by chemical changes in the brain. They abuse substances not because they want to, but because their body chemistry is making them believe they have to. They’ve lost the ability to control their own actions, and are effectively slaves to their impulses. This chemical change is why addiction is classified as a disease and a serious mental health disorder. It’s also why substance abuse and addiction are classified as notably different things. We should also address the issue of addiction without abuse. As we’ve discussed, substance abuse means someone is using a substance in a way that is harmful to themselves or to the people around them. But what about if someone is using a substance in moderation? What if they’re using a substance that is intended to help them, or at least be relatively harmless? What if they’re using a substance exactly as prescribed to them by a doctor? Can those people still become addicted? They most certainly can. Addiction isn’t a choice, nor is it simply a result of a person’s bad decisions. Some of the most healthy, good-natured, law-abiding people in the world fall victim to addiction just by doing exactly as they were told. Prescription opioids are a major offender in this category. These are drugs that are prescribed by doctors, usually as painkillers. And although drugs like Oxycontin can do a lot of good for people in extreme pain, the reality is also that they are opioids, which carry an extremely high risk of addiction, even when taken properly. Lots of people who fall into opiate addiction never did anything but take what they were instructed to take, in exactly the way they were instructed to take it. But addiction isn’t a choice, and it isn’t an issue of moral fortitude. It’s an issue of brain chemistry that people have no control over, and it can sink its hooks into anyone.
Use, Abuse, and Addiction: What to Do About It
While it’s certainly true that drug use, abuse, and addiction are separate issues, they are closely linked, and by comparing their characteristics, we certainly don’t intend to downplay the severity of any of these conditions. One can lead to the next in a very short time frame, and it’s never a bad time to seek help if you sense yourself losing control. Have you experienced a time when use evolved into abuse or abuse into addiction? What were the signs, and how did you know there was a change? We want to hear from you, so tell us your story in the comments below.